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Chapter52

Meningitis

Guideline: British Infection Association (The UK joint specialist societies

guideline on the diagnosis and management of acute meningitis or meningococcal sepsis in immunocompetent adults):

https://www.journalofinfection.com/article/s0163-4453(16)00024-4/fulltext

OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.

Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.

Overview

Meningitisisinflammationofthemeningeswhichcanbesecondarytobacterial,viral,or fungalinfection.Althoughrare,itisimportanttorecognizeandtreatearly,aspatientscan rapidly deteriorate. Meningococcal meningitis is one of the most severe forms, and is often associated with meningococcalsepticaemia, characterized by a petechial rash and sepsissecondarytoNeisseriameningitides.Otherformsofmeningitisaresummarizedin

Table52.1.

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Table52.1Commoncausesofmeningitisandpopulationsmostaffected

Commoncausesof meningitis

Populationmostaffected

HSV-1and-2, enteroviruses,andVZV

Youngadults

Neisseriameningitides Youngadultsorimmunocompromised

Streptococcuspneumoniae

(pneumococcus)

Age>50orimmunocompromised

Listeria Age>60orimmunocompromised(includesrelativeimmunocompromisecausedby

alcoholdependence,diabetesmellitus,ormalignancy)

Haemophilusinfluenzae Immunocompromised

Cryptococcus HIV-positivepatients

TB HIV-positivepatients

Diagnosis

History

Patientswithmeningitismaypresentwithanacutehistoryof:

Meningismcharacterizedbyaheadache,neckstiffness,andphotophobia Alteredconsciouslevelorfocalneurologyincludingseizures Feversandrigors Non-blanchingpetechialrash(Fig.52.1).

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Fig.52.1Non-blanchingpetechialrash.

ReproducedfromtheoriginalbyDrFO.Jr.TnundertheCreativeCommonsCC-BY-SA3.0license.See

colourplate2.

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Examination

AllpatientsshouldbeexaminedusingtheABCDEapproach.FindingsareshowninTable

52.2.

Table52.2Examinationfindings

A ConsiderairwaycompromiseifGCSscoredropsbelow8

C Signsofsepticshock(seeChapter122):

Hypotension Tachycardia Weakandthreadypulse Prolongedcapillaryrefilltime Coolextremities

D ↓GCSscoreorcoma

Motor M6Obeyscommands M5Localizestopain M4Withdrawalfrompain M3Flexiontopain M2Extensiontopain M1Nomotorresponse

Verbal V5Orientated V4Confused V3Inappropriatewords V2Incomprehensiblesounds V1Noverbalresponse

Eyes E4Openspontaneously E3Opentoverbalcommand E2Opentopain E1Noeyeopening

E Non-blanchingpetechialrash

Fever Meningism(headache,neckstiffness,andphotophobia)oftenwithassociatednauseaandvomiting Kernig’ssign(withthehipandkneeflexed,extensionatthekneecausespainandresistance)and/or Brudzinski’ssign(whentheneckisflexedthepatientshipsandkneesflexduetoneckstiffness)—bothare highlyspecificsignsbutpoorlysensitive

Investigations

Investigations aim to diagnose infectious meningitis and to identify the organism responsible:

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NasopharyngealswabformeningococcalcultureandenterovirusPCR Bloods: FBC, procalcitonin (if available—useful as it is specific for bacterial infections, if

unavailableuseCRP),LFT,U&E,coagulationprofile,glucose,pneumococcalandmeningococcal PCR,VBGwithlactateandbloodcultures CThead: should be undertaken prior to LP if any of the following (indicating ↑ intracranial pressure)arepresent:

Focalneurology Papilloedema Seizures GCSscore<12

LP:ideallywithinanhourofpresentationANDpriortoantibioticadministrationUNLESS:

ItisnotpossibletoperformwithinanhourofadmissionOR ThereisevidenceofrespiratoryorcardiaccompromiseOR PresenceofseveresepsisorarapidlyevolvingrashOR ThereisinfectionatthesiteofLPor Thereiscoagulopathy(seeBox52.1).

ThefollowingmustbemeasuredintheCSF:

Openingpressure Glucose Protein Lactate(ifantibioticshavenotbeengivenyet) MC&S PCRforpneumococciandmeningococci PCRforenteroviruses,HSV-1and-2,andVZV.

Table52.3showsLPfindingsinmeningitis.

Table52.3Lumbarpuncturefindingsinmeningitis

Normal Bacterial Viral TB

Appearance Clear Turbid Clear Cloudy

Openingpressure(mmHg) 10–20 High Normal/high High

Whitebloodcellcount(cells/µL) 0–5 >100 10–1000 50–500

Celltype Polymorphs Lymphocytes Lymphocytes

CSFprotein <45mg/dL High High Veryhigh

CSFglucose >60%serum Low Normal Low

AdaptedfromTable19.4fromWilkinsonIetal(2018)OxfordHandbookofClinicalMedicine.Oxford: OxfordUniversityPress,withpermissionfromOxfordUniversityPress.

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Box52.1Lumbarpunctureanticoagulationandantiplateletconsiderations

IfthepatientisbeingtreatedwithprophylacticLWMH,theLPshouldnotbeperformeduntil12 hoursafterthelastdose PostLP,prophylacticLWMHshouldnotbegivenuntilatleast4hourshaveelapsed For patients on warfarin, INR must be ≤1.4 before performing the LP. Patients on other anticoagulantsshouldbediscussedwithahaematologistpriortoperforminganLP AspirinandNSAIDsdonotneedtobeheldpriortotheLPbutclopidogrelshouldbeheldfor7 days prior to an LP unless a platelet transfusion or desmopressin has been administered followingdiscussionwithahaematologist.Intheacuteassessmentofmeningitis,theriskofa LP onclopidogrel mustbeweighedagainstthediagnosticbenefits.This should bediscussed withaseniorclinician

Plateletcountshouldbe≥40×109/L.

Management

Callforhelp?

Meningitis and meningococcal septicaemia are medical emergencies and should be escalatedtoaseniorclinicianearly.

Acutemanagement

Pre-hospital

If meningitis is suspected in the community, antibiotics should be given urgently, e.g. IM/IVbenzylpenicillin1.2g,IM/IVceftriaxone 2g,or IM/IVcefotaxime2g.Thisshould notdelaytransfertohospital.

Emergencydepartment

Themainstayofacutetreatmentismanagementofsepsiswith:

Fluidresuscitation

Use crystalloids. A urinary catheter should be placed for accurate fluid balance measurements.

Antibiotics

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Must be administered immediately after a LP and blood cultures, and at most within 1 hourofpresentation,asperlocalguidance,e.g.:

Standardregimen:

IVceftriaxone2gBDorIVcefotaxime2gQDS

Penicillin/cephalosporinallergic:

IVchloramphenicol25mg/kgQDS

Immunocompromisedor>60years:

As per EITHER standard OR penicillin/cephalosporin allergic regimen PLUS IV amoxicillin/ampicillin2g,4-hourly

Ifforeigntravelwithinprevious6months:

Discusswithmicrobiology.

Steroids

IV dexamethasone 10mg QDS within 12 hours of antibiotic administration. This should be continuedfor4daysifpneumococcaldiseaseisconfirmed.Forothercauses,itshouldbestopped.

Due to overlapping presentations, patients are often simultaneously tested and treated for meningitisandencephalitis(seeChapter49).

Criticalcareadmission

Escalation to critical care must be considered in all patients, particularly if they have:

Rapidlyevolvingrash GCSscore<12 Organsupportrequirements Uncontrolledseizures.

Don’tforgetthe‘SepsisSix’: oxygen,fluid,andantibiotics IN;lactate,bloodcultures,and urineoutputOUT.

Treatmentafterstabilization

Antibiotictherapy

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Liaisewithlocalmicrobiology/infectiousdiseasesteamsandrationalizeantibiotictherapyoncean organismisconfirmed Treatment is usually continued for 10–14 days unless a viral organism is found in which case antibioticsshouldbestopped.

Isolation

Allpatientswithsuspectedmeningococcalmeningitisshouldbeisolateduntiltheyhavereceived 24hoursoftherapyorasperlocalpolicy.

Secondaryprevention

Allcasesmustbenotifiedtopublichealthauthorities Contactprophylaxiswillbecommencedbytheconsultantinthenotifiedhealthprotectionteam.

Screeningforimmunosuppression

TestforHIV Inanypatient withmorethanoneepisodeofmeningitisorafamilyhistory ofmultipleepisodes, furtherimmunologicalinvestigationsshouldbecarriedout.

Complicationsofmeningitis

Subduralempyema(suspectifpersistentfeverandnewneurologydevelops) Seizures Hydrocephalus(suspectif↓consciousness) Cerebralvenoussinusthrombosis(suspectif↓consciousnessandnewneurologydevelops) Cerebralischaemia.

Complicationsofmeningococcalsepsis

Purpurafulminans(suspectifrapidlyprogressiverash) Septicshock.

Furtherreading

1.WilkinsonIB,RaineT,WilesK,etal.(2017).Meningitis.In:OxfordHandbookofClinicalMedicine, 10th ed (pp. 822–3). Oxford: Oxford University Press. Available at:

https://doi.org/10.1093/med/9780199689903.003.0019

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Chapter53

Metastaticspinalcordcompression

Guideline: NICE CG75 (Metastaticspinal cord compression in adults: risk

assessment, diagnosis and management):

https://www.nice.org.uk/guidance/cg75

Localtrustguideline:pleaserefertoyourlocalguidelinesasnecessary.

Overview

Metastatic spinal cord compression (MSCC) is compression of the spinal cord due to tumourgrowthorpathologicalvertebralcollapse.PathologybelowL1willproducecauda equinacompression.MSCCismorecommoninlung,breast,prostate,renal,andthyroid malignancies,especiallyinpatientswithbonemetastases.Itcanalsooccurinlymphoma andmyeloma.MSCCshouldbeconsideredinallpatientswithknowncanceranditmay beapresentingfeatureofapreviouslyundiagnosedcancer.

DiagnosisisviaMRIwholespine.TheurgencyofMRIisdependentonwhetherthere areneurologicalsymptomsor signs; the presenceoftheseconstitutesan emergency.All hospitals should have a point of contact available 24/7 to advise on MSCC (this is sometimesviatheacuteoncologyteam).

Diagnosis

History

Symptomssuggestiveofspinalmetastases:

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Paininthecervical,thoracic,orlumbarspine Suddenonset,progressive,severe,orunremittingpain Spinalpainworsenedbystraining(e.g.withpassingstool,coughing,sneezing) Nocturnalspinalpainpreventingsleep Localizedspinaltenderness.

NeurologicalsymptomsorsignssuggestiveofMSCC:

Limbweakness Difficultywalking Sensoryloss Bladderorboweldysfunction(e.g.retentionofurine,incontinence,orconstipation).

Otherimportantinformation:

Premorbidfunction(mobility,generalfitness,performancestatus) Underlying cancer (when diagnosed, histology, previous treatments and response, extent of metastaticdisease) Medicationhistory:steroids,anticoagulants,andantiplatelets.

Examination

Performafullneurologicalexamination.FindingsareshowninTable53.1.

Table53.1Neurologicalexaminationfindingsinspinalcordcompression

Tone

Initialsign—tone↓belowthelesion Latesign—spasticity

Power

Weaknessbelowthelesion

Reflexes

Initialsign—spinalshockphase—reflexesare↓ Latesign—reflexesare↑ Inmoregradualorincompletecompression,reflexesmaybe↑earlier Extensorplantars

Sensation

Lookforasensorylevel—pinprick,vibration,proprioception,andtemperature Theabsenceofasensoryleveldoesnotexcludecordcompression

Coordination

Impaired,maybeataxic

Perform a rectalexamination and specificallydocument anal tone (normal, reduced, or absent)andanysensoryimpairment.

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