Meningitis

MENINGITIS

o   Inflammation of the meninges that surround the brain and the spinal cord.

o   Classified as Septic and Aseptic

o   Neisseria meningitidis (most common)

o   Haemophilus influenzae and streptococcus pneumoniae ((causative agents)

o   Neisseria and Streptococcus pneumoniae,most common cause ( Lippincott)

Pathophysiology

o   Infecting organism gains entry through bloodstream (2⁰ infection) or direct extension

o   Infecting organism produce an inflammatory response

o   Meningeal vessels becomes hyperemic and increasingly permeable

o   Blood cells (neutrophils) migrate to SAS, producing exudate

o   Exudate formation causes meningeal irritation and increased ICP

Clinical Manifestations

o   Initial/ Classic:  fever, headache

o   Systemic infection

§  Fever, tachycardia, chills and petechial rash

o   Meningeal Irritation

§  Nuchal rigidity  - early sign

§  Positive Kernig’s sign

§  Positive Brudzinski’s sign

§  Photophobia

o   Neurologic signs

§  Decrease in consciousness

§  Cranial nerve palsies (ptosis, diplopia, facial weakness, tinnitus, vertigo, and deafness)

§  Focal neurologic deficits (ataxia and motor weakness)

§  Seizures

o   Petechial or purpuric rash to large area of ecchymosis from coagulopathy, especially with N. meningitidis.

o   Disorientation and memory impairment

o   Behavioral manifestation

o   Other signs f Increase ICP

o   Fulminating infection (10 % of Meningococcal meningitis)

Signs of septicemia

ü  Fever

ü  Extensive purpuric lesion over face and extrinmities

ü  Shock

ü  DIC

Diagnostic Evaluation

o   LP: elevated CSF pressure; cloudy, turbid, or clear in appearance; normal or increased protein; glucose decreased or normal; culture and sensitivity test; presence of polysaccharide antigen (supports bacterial meningitis)

o   Cultures: identify source of infection in blood, urine, and nose and throat secretions

o   X-rays: assess for fractures, abscesses, or signs of infection in chest, skull and sinuses

o   WBC count: elevated

Prevention

o   Vaccination: meningococcal meningitis (MCV4)

• Antimicrobial prophylaxis for people in close contact with meningococcal patients

v  Rifampicin (Rifadin), Ciprofloxacin hydrochloride (Cipro), or ceftriaxone sodium (Rocephin)

• Vaccination as an adjunct to antibiotic (H. influenzae and S. pneumoniae)

Medical Management

A.) Early antibiotic therapy

          - Penicillin ( ampicillin and piperacillin)

          - Cephalosporin (ceftriaxone sodium,

             cefotaxime sodium)

          - Vancomycin hydrochloride – alone or

            with rifampicin **

B.) Dexamethasone

          - given 15 to 20 minutes before 1^st dose of

            antibiotic (q 6 hrs for 4 days)

C.) Fluid volume expanders – DHN and shock

D.) Phenytoin (dilantin)

E.) Meaures for increased ICP

F.) Diuretic, Isolation, and seizure precaution

Nursing Management

• Provide continuous or on-going neurological assessment, monitor Vital signs
• Pulse oximetry and ABG is monitored
• Take measure to address Fever immediatey
• Monitor body weight, serum electrolytes, and urine volume, specific gravity, and osmolality
• Protect the patient from injury (seizure precaution)
• Prevent complication secondary to immobility
• Institute droplet precautions until 24 hours after the initiation of antibiotic therapy (isolation technique)
• Report meningococcal meningitis to local health authority   

Brain Abscess

• Localized collection of pus within the parenchyma of the brain and spinal cord
• Relatively rare,  complication encountered by immuno-compromised patients

Pathophysiology

• Direct invasion from intracranial trauma or surgery
• Spread of infection from nearby sites (sinuses, ears, and teeth)
• Spread of infection from other organs(lung abscess, infective endocarditis)

Clinical Manifestation

• HEADACHE – worse in the morning (prevailing symptom)
• Vomiting
• Focal neurologic signs (depends on  the location of abscess)
• Change in mental status
• Fever may or may not be present

Diagnostics

ü  CT SCAN

ü  MRI

ü  Useful to obtain images of the Brain Stem and posterior  fossa

Medical Management

• Antimicrobial therapy & Surgical incision or aspiration

v  Penicilin G (20 million U) and Chloramphenicol (4-6 g/day given IV in divided doses)

v  Given preoperatively and postoperatively

• Corticosteroids
• Antiseizure medications (phenytoid, phenobarbital)

Nursing Management

• Focus is on Ongoing assessment
• Blood laboratory test result , blood glucose and serum potassium levels
• Patient safety is a key nursing responsibility

Encephalitis

• Acute inflammatory process of the brain tissue

• HERPES SIMPLEX VIRUS ENCEPHALITIS
• Herpes Simplex virus (HSV) is the most common cause of acute encephalitis (HSV – 1)

PATHO:

- Infxn of buccal mucosa --- retrograde spread along trigeminal nerve --- to brain

- Latent virus in brain tissue is reactivated 

Clinical Manifestation

• Inflammation and necrosis in the T – F – L (temporal, frontal and limbic system)

§  Initial : FEVER, HEADACHE, CONFUSION, and BEHAVIORAL ABNORMALITIES

§  Focal neurologic symptoms (within 7 days, last 14 – 21 days)

ü  Behavioral changes

ü  Focal seizures

ü  Dysphasia

ü  Hemiparesis

ü  Altered LOC

Diagnostics

• EEG
• CSF

§  High opening pressure

§  Low glucose and high protein levels

§  Viral cultures are almost always negative

§  PCR (polymerase chain reaction)

-          Identifies DNA bands of the HSV (3^rd and 10^th day of Sx onset)

• NEUROIMAGING

v  MRI – is the neuroimaging study of choice

Medical Management

v  ACYCLOVIR (Zovirax) – medication of choice

ü  Continued for 3 weeks (prevent relapse)

ü  Slow administration (over 1 hour)

ü  Usual dose is decrease in patient with Hx of renal insufficiency

• FOSCARNET SODIUM (Foscavir)

            - in rare cases of acyclovir resistance

Nursing Management

• ON – Going Neurological Assessment
• Comfort measure for headache:

§  Dimming of lights

§  Limiting noise

§  Administering analgesics

• Use opioid medication cautiously – mask signs
• Initiate injury prevention and safety
• Monitor for renal complication (labs and I & O)

Fungal Encephalitis

• Occur rarely in healthy people
• COMPROMISED IMMUNE SYSTEM

Common agents:

ü  Cryptococcus neoformans

ü  Histoplasma capsulatum

ü  Aspergillus

ü  Candida Albicans

PATHO:

o   Fungal  Spores enters the body via inhalation

o   Initially through the lungs and bloodstream

o   CNS --- Meningitis – Encephalitis – brain abscess

o   also causes abscess of the SC = SC compression

Clinical Manifestation

ü  Common: Fever, malaise, headache, nuchal rigidity, lethargy and mental status changes

ü  Symptom of increase ICP from hydrocephalus

Assessment and Diagnostics

o   Presence of a compromised immune system and history of living or travel to certain areas

o   Elevated WBC and ANEMIA

o   Fungal antibodies in serum

o   Neuroimaging – CT scan and MRI

CSF :

o   Elevated WBC, and protein

o   Culture of fungi

Medical Management

o   ANTIFUNGAL AGENTS

-          Specific period or indefinite period (maintenance dose)

o   AMPOTHERICIN B (Abelcet, AmBisome, Amphocin, Amphotec, Fungizone, and Fungizone IV)

        - standard antifungal treatment

        - dose high enough without causing renal toxicity

o   FLUCONAZOLE (diflucan) or flucytosine (5-FC, 5- fluorocytosine, Ancobon)

                 - may be administered in conjunction with ampothericin B

                 - causes transient increase in liver enzyme

                 - S/E: Nausea, abdominal pain, headache, dizziness, rash, reversible alopecia 

Nursing management

o   On – Going assessment

o   Provide patient comfort:

§  Administering non-opioid analgesics

§  Limiting environmental stimuli

§  Positioning

o   Give diphenhydramine (Benadryl) and acetaminophen (Tylenol) approx. 30 mins before amphothericin B (fever, chills and body aches)

o   Monitor creatinine and blood urea nitrogen

o   Provide support to patient and family to cope up with work