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Meningitis / Reading and Sharing

Meningitis is the inflammation of the dura mater, arachnoid, and pia mater, the layers that cover the brain and the spinal cord. There are two types of meningitis, the aseptic that is the most familiar form and the bacterial. In the United States, the incidence of meningitis is 1.3 to 3 cases per 100, 000 persons, more than 1 million cases annually worldwide and approximately 135,000 cases of deaths globally. It affects both male and female from the neonates to the geriatric patients (Ferri, 2018).

Aseptic meningitis is most of the time caused by viruses, taking of antibiotics, non-steroidal anti-inflammatory drug and tumor. Aseptic means there is no bacterial growth in the CSF culture that was done although there is swelling in the meninges of the brain. Bacterial meningitis is most of the time caused by Streptococcal pneumoniae and Neisseria meningitidis. Most of these bacteria settle in the host’s nasopharynx and then to move to the blood stream. Since the two bacteria mentioned were safely inside their bacterial capsule, it prevents them from being attacked by the body’s defense system in the blood stream. The bacteria then enter through the choroid plexuses in the ventricles and sometimes to the defective blood brain barriers. CSF is sterile and has few white blood cells and no antibodies. These conditions make the bacteria thrive. As they multiply in the layers of the brain, the bacteria release cytokines, interleukin I, tumor necrosis factor that are responsible for allowing the passage of large number of white cells in the blood brain barrier. As the WBC numbers grow it combines with the pro-inflammatory molecules increasing intracranial pressure and edema. Inside the meninges, a purulent exudate is formed which impedes the flow of the CSF. This impediment causes the neck stiffness and headache. Lumbar puncture would show increased WBC levels and that is crucial in diagnosing between aseptic versus bacterial meningitis (Winland-Brown & Keller, 2015).

Identification whether meningitis is aseptic or bacterial is important in the treatment of the disease. Most adult patients come in with complaints of photophobia, headache, pyrexia, nuchal rigidity and change in mental status. Blanchable trunkal rash may be or may not be present. Other symptoms include, nausea, vomiting, lethargy, seizures with posturing, fever and myalgias. Symptoms appear within 24 hours for bacterial meningitis while it takes more or less two days for these symptoms to fully present in viral meningitis. There would be + Kernig’s sign and + Brudzinski sign on exam. Young children manifest the symptoms with restlessness, lethargy or decreased feeding (Mount and Boyle, 2017).

In primary care setting there is no way of confirming that this patient has meningitis except for a suspicion of having one due to presenting symptoms of headache, fever, trunkal rash that are blanchable and sending the patient to the emergency room for further evaluation. Patients who present to the ED with acute symptoms should be placed in a droplet precaution. An intravenous line with a large bore needle should be established. Blood cultures, lumbar puncture (LP) with collection and testing of cerebrospinal fluid (CSF) should be done. According to the Infectious Disease of America as cited in Mount and Boyle (2017), it is advised that patients have a CT Head first before the LP to prevent brain herniation. The provider should initiate the administration of broad-spectrum antibiotic like a gram of Rocephin IV and vancomycin dosage is basing on weight per kilogram, pain control and corticosteroid while working on getting the patient admitted to the hospital for a suspicion of bacterial meningitis. Studies showed that intravenous fluid therapy in children and infants decrease irritability and chances of having seizures. Aseptic meningitis treatment is more focused on alleviating and treating the symptoms. Providers or relatives who have contact with patients should have prophylactic treatments within 24 hours of diagnosis. Physical contact of more than 14 days is not qualified for preventative treatment of rifampin, Rocephin and ciprofloxacin (Mount & Boyle, 2017).

It must be emphasized that Haemophilus influenzae B, meningococcal and conjugate pneumonia vaccination reduce the occurrence of having meningitis. Patients may need assistance with activities of daily living post hospital discharge until fully recovered. Adequate hours of rest and sleep in a quiet and darkened room are important in recovery period.  Eating soft balanced diet with emphasis on increasing fluid intake for patients who do not have cardiac problems is important. Over the counter analgesics like Tylenol 650 mg po q 4-6 hours is prescribed for aches and pains. Patients should finish the course of antibiotics even if they feel better. Any respiratory infection, recurrent fever or any concerning symptoms should be referred to the provider or if not available in the emergency room for re-evaluation (Winland-Brown & Keller, 2015). Referral to the neurologist is advised if there are still concerning neurological deficits noted and an Infectious disease provider for unresolved bacterial meningitis. Patients should coordinate with their primary care providers for advice (Ferri, 2018).

References:

Ferri, F.F. (2018). Ferri’s clinical advisor. Philadelphia, PA: Elsevier

Mount, H. R., & Boyle, S. D. (2017). Aseptic and bacterial meningitis: Evaluation, treatment, and prevention. American Family Physician96(5), 314-322.

Shrader, A. L. (2014). Meningitis : Symptoms, management and potential             complications. New York: Nova Science Publishers, Inc.

Winland-Brown, J.E. & Keller, M.B. (2015). Neurological problems. In L.M. Dunphy, B.O. Porter, D.J. Thomas & J.E. Winland-Brown (Eds.), Primary care The art and science of advanced practice nursing. (4th ed., pp.77-148). Philadelphia, PA: F.A. Davis Company

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