Meningitis

Clinical Description

Clinical syndrome characterized by inflammation of the meninges.

Causes:

• Viruses: Herpes simplex Virus, enteroviruses
• Bacteria: Streptococcus Pneumoniae, Staphylococcus Aureaus, Haemophilus

Influenza, Meningococcal TB

• Fungal: Cryptococcus Neoformans

Signs and Symptoms

• Headache, Photophobia, Fever, Neck stiffness, Seizures, Altered mental status, Positive Babinski, Positive Kernig’s sign

Investigations

• FBC, Blood glucose, HIV status, Lumbar Puncture, Microscopy, chemistry and culture (CSF for gene X-pert if suspect TB meningitis), India ink and Cryptococcal antigen, Blood culture

Pharmacological

• Assess and manage Airway, Breathing, Circulation and Disability
• Treat seizures as per protocol
• Neuroprotective measures
• Analgesia as per WHO pain ladder
• Bacterial meningitis
• Ceftriaxone 100mg/kg IV q24h (maximum dose 2g) for 10 to 14 days
• Adjust treatment as guided by culture results
• Viral encephalitis
• Acyclovir 10mg/Kg IV 8 hourly for 10 days if suspecting Herpes

Simplex or Varicella encephalitis

• Cryptococcal meningitis
• Induction Phase
• Option 1: Liposomal Amphotericin B + Flucytosine for 7 days
• Amphotericin B 6mg/kg IV over 6 hours daily
• Flucytosine 100mg/kg/day PO divided into 4 doses
• Option 2: Fluconazole + flucytosine for 14 days
• Fluconazole 12mg/kg (max 800mg) q24h
• Flucytosine 100mg/kg/day PO divided into 4 doses
• Option 3: Liposomal Amphotericin B + fluconazole for 14 days
• Amphotericin B 3-4 mg/kg IV over 6 hours daily. Use up to 6 mg/kg for treatment failure or serious disease
• Fluconazole 12mg/kg (max 800mg) q24h
• Consolidation Phase
• Fluconazole 12mg/kg PO (maximum 800mg) daily for 8 weeks
• Maintenance Phase
• Fluconazole 6mg/kg PO daily, life long
• TB meningitis
• Intensive treatment HRZE for 2 months
• RH for 10 months
• Prednisolone 2-4mg/kg/day for 3 weeks, taper dose over 3 weeks
• Pyridoxine 25mg daily

Non-pharmacological

• Hearing assessment
• Refer for Intensive Medical rehabilitation Services.
• Serial head circumference measurement

Complications: Brain abscess, Cranial nerve palsies, Seizures, SIADH, Stroke, Learning disability, Developmental regression, Hearing loss, Hydrocephalus

Complications and Referral Criteria

• Suspected brain abscess
• Signs of raised intracranial pressure
• Not responding to treatment