Meningitis.
Meningitis is an infection of the pia matter and arachnoid. If you think the
patient is having meningitis nothing should delay prompt blind treatment.
Clinical features: meningeal signs: headache, stiff neck, kernig's sign may be positive: pain and resistance on passive knee extension when hips fully flexed. Brudzinski's sign, hips flex on bending head forward; opisthotonus.
ICP signs: headache, irritable, drowsy, vomiting, fits, pulse¯ , consciousness¯ , coma, irregular respiration and papilloedema.
Septic signs: fever, arthritis, odd behaviour, rashes - any, petechiae suggest meningococcus, shock DIC, pulse raised, tachypnoea, WCC- increased.
Tests: LP is the key test, and should be done at once unless signs of raised ICP, or focal CNS signs in which case do CT scan, or suspected meningococcaemia (epidemic area, petechial rash, hypotension and rapid progression) when benzylpenicillin must be given urgently. An early LP in Pyogenic Meningitis may be normal. Repeat LP if signs persist. Send 3 bottles of CSF for urgent gram stain, culture, virology and glucose.
Blood culture, FBC and U & E, plasma glucose, SXR if h/o head injury, culture urine and nose swabs for virology.
Treatment:Prompt antibiotics save life. Give penicillin before admission. If on LP
pus emerges from the needle, start a broad-spectrum agent, cefotaxime at once
while awaiting its analysis. Liaise early with a senior and a microbiologist.
Set up an IVI. Treat shock with plasma IVI until BP >80mmHg systolic and urine flows as guided by CVP on ITU. If ICP raised ask a neurosurgeon's advice, is dexamethasone indicated?
Diamorphine may be needed for severe pain, for nausea try domperidone.
Once the organism is known use most effective antibiotic after discussing with a microbiologist.
Continue parenteral antibiotics for 10 days. Follow with rifampicin to eliminate nasal carriage.
Look for complications: cerebral oedema, cranial nerve lesions, deafness, cerebral venous sinus thrombosis and mental retardation.
Meningococcal prophylaxis: to all household and nursery contacts, those who have kissed the patient's mouth. Give rifampicin or ciprofloxacin 500mg PO one dose for adults. Vaccination protects from group A and C strains and may be used for school contacts (if >2yrs) or for travellers to endemic areas.