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MENINGITIS
NUR ASILAH ATHIRAH BINTI GHAZALI
DIPLOMA IN MEDICAL IMAGING
FACULTY OF HEALTH SCIENCES
APRIL 2013
ACKNOWLEDGEMENTS
Alhamdulillah, firstly thanks to Almighty Allah for giving me a lot of strength and effort to keep doing and finally able to finish this clinical study until the end. Special thanks to my dedicated supervisor, Miss Alice Demi Anak Numpang in her support, guidance, concern and encouragement in producing my clinical study. I would also like to thank to all my supportive friend and colleagues for sharing any information regarding to this clinical study. I would also like to extend my special thanks to my lovely parents and a family member. They were always supporting me and encouraging me with their best wishes. Last but not least, I would like to thank everyone who assisted directly and indirectly in the success this clinical study.
TABLE OF CONTENTS
ACKNOWLEDGEMENTS…………………………………………………………………………………………… iLIST OF TABLES……………………………………………………………………………………………………… iiCHAPTER 1: INTRODUCTION………………………………………………………………………………….. 11. 1 Historical Background of Meningitis……………………………………………………………………….. 11. 2 An Overview of the Meningitis……………………………………………………………………………….. 11. 2. 1 Definition……………………………………………………………………………………………… 21. 2. 2 Anatomical Part involved……………………………………………………………………… 3
CHAPTER 2: LITERATURE REVIEW………………………………………………………………………..
2. 1 Histopathology……………………………………………………………………………………………………. 2. 2 Causes………………………………………………………………………………………………………………. 2. 3 Incidence…………………………………………………………………………………………………………… 2. 4 Mortality/ Morbidity………………………………………………………………………………………………. 2. 5 Pathophysiology…………………………………………………………………………………………………. 2. 6 Signs and Symptoms…………………………………………………………………………………………..
CHAPTER 3: IMAGING MODALITIES……………………………………………………………………..
CHAPTER 4: IMAGE FEATURES OF MENINGITIS……………………………………………………….
CHAPTER 5: DISCUSSION………………………………………………………………………………………..
CHAPTER 6: CONCLUSION……………………………………………………………………………………..
6. 1 Treatment………………………………………………………………………………………………………… 6. 2 Prognosis………………………………………………………………………………………………………. 6. 3 Conclusion…………………………………………………………………………………………………… REFERENCES…………………………………………………………………………………………………………
CHAPTER 1: INTRODUCTION
1. 2 An Overview of the MeningitisMeningitis is one of the diseases that need early diagnosis and should be treated as soon as possible. If not, it will lead to fatal. It is serious and always views as medical emergency. The following are general introduction about meningitis. 1. 2. 1 DefinitionAnything ending in ‘ itis’ means an inflammation. In the case of meningitis, Kowalczyk and Mace (2009 pg 210) define that it is an inflammation of the meningeal coverings (meninges) of the brain and spinal cord. Meningitis mostly purulent and involves the fluid in the meninges which found in the subarachnoid space that called cerebrospinal fluid (CSF). The meninges contain cerebrospinal fluid (CSF) fluid protective membrane that surrounds the brain and spinal cord. 1. 2. 2 Anatomical Part InvolvedIt is good to understand meningitis by knowing anatomical part involved. Meningitis refers to medical term that used when the meninges and the cerebrospinal fluid (CSF) that encircles the brain and spinal cord become inflamed (Williams, 2010). With this definition, we can identify that the meninges and the CSF are the anatomical structure that involved in meningitis. jpg0103f1. jpgFigure 1. 2. 2. 1: Anatomical parts involved in meningitis. Meninges is a protective membrane that covers are the organ of central nervous system; the brain and spinal cord. When meninges become infected, it is called meningitis. (Leslie & Lovett, 2010.)According to Tortora and Derrickson, (2009, pg. 461) the meninges are three connective tissue coverings that surround the brain and spinal cord. The three layers are the pia mater, the arachnoid and the dura mater (Figure 1. 2. 2. 2). Bolker (2011) says that meninges not only protects and covers brain and spinal cord but it also help to prevent CSF from leaking. http://t2. gstatic. com/images? q= tbn: ANd9GcTVXr12ajffW0g0XM50_J_rt0TV-44LRTtW1Lwf-XW3NiWnbaUqFigure 1. 2. 2. 2: Meninges consist of three layers called, the pia mater, the arachnoid and the dura mater. (Understanding Meningitis: Basics, 2012)The most superior of the three meninges, the dura mater, is a composed of dense, irregular connective tissue. This corresponds to its name, dura mater, which means ” tough mother”. The dura mater adheres to the skull and spinal canal. The epidural space located between dura mater and skull is filled with fat and connective tissue to protect the spinal cord. The middle layer of the meninges is an avascular covering known as the arachnoid mater or arachnoid because of its spider’s web like appearance or cobweb of delicate fibers and some elastic fibers. The arachnoid mater and dura mater are separated by the subdural space that contains interstitial fluid. The pia mater is the innermost layer of three meninges (coverings) of brain and spinal cord. This thin transparent connective tissue layer adheres closely to the surfaces of brain and spinal cord. The subarachnoid space that lies between arachnoid and pia mater contains CSF, which acts as a shock absorber and suspension system for brain and spinal cord. FIGURE 1. 2. 2. 3: This diagram illustrates the location of meninges. In general, the CSF always related with meningitis because meningitis occur when this fluid becomes infected. According to articles from KidsHealth entitled ‘ meningitis’, the infection from elsewhere in body can spread via the bloodstream and reach the meninges through CSF. A clear and colorless liquid, called cerebrospinal fluid protects and serves to cushions the central nervous system from injury and it is produced within cavities in the brain called ventricles. In addition, it also carries nutrient such as oxygen, glucose, and other needed chemicals from the blood to neurons and neuroglia. This fluid circulates and occupies in the cavities in and around the brain and spinal cord in the subarachnoid space.
CHAPTER 2: LITERATURE REVIEW
2. 1 HistopathologyFigure 2. 1. 1 (A) shows purulent leptomeningitis resulting in pus, which consists of neutrophils, fibrin, germs, proteins, necrotic debris. Besides, there is congestion of blood vessels in subarachnoid as well as intracerebral, and also existence of neutrophil margination. In the Figure 2. 2. 1 (B) at the left one can clearly see meningeal exudates rich in neutrophils as well as prominent vessels because of dilation. Meanwhile at the right, the focal inflammation and edema is seen spreads down through Virchow-Robin space in cortex. Bacterial infections usually lead to the production of this type of acute meningitis. This edema may contribute to herniation and fatal. In patients resolving infection, some progress to obstructive hydrocephalus which may be due to adhesive arachnoiditis coming together with obliteration of subarachnoid space. BAhttp://1. bp. blogspot. com/-zg7evsafJEo/Tyvck14Ho7I/AAAAAAAADuo/uFRjsXND16Q/s320/purulent_meningitis. jpg http://2. bp. blogspot. com/-6RiOT28si7E/TyveeDFfjCI/AAAAAAAADvQ/7AMpXpGdDtw/s320/CNS190. jpgFigure 2. 1. 1: Purulent leptomeningitisFigure 2. 1. 3 shows a result of post-mortem study in pneumococcal meningitis by apply hematoxylin-eosin staining; where there is an inflammatory infiltration of the leptomeninges, including neutrophilic granulocytes as displayed at high magnification in boxed region. (Marvin, 2010)File: Meningitis Histopathology. jpgFigure 2. 1. 3: Histopathology of bacterial meningitis (Marvin, 2010)Figure 2. 1. 4 shows streptococcus pneumonia which is one of the bacteria that can cause meningitis. http://pathmicro. med. sc. edu/infectious%20disease/s%20pneumoniae. jpgFigure 2. 1. 4: Positive blood culture for patient with streptococcus pneumonia. http://pathmicro. med. sc. edu/infectious%20disease/n%20meningitidis. jpgFigure 2. 1. 5: 2. 2 CausesMeningitis mainly caused by variety of infectious agent, but meningitis may also result from non-infectious agent. (Gulati, 2012) According to Kowalczyk and Mace (2009), meningitis can be caused by bacteria, viruses or other organism that reach the meninges from somewhere else in the body via blood or lymph or can occur as a result of trauma and penetrating wounds or from adjacent structures. 2. 2. 1 Infectious AgentInfective causes can be divided by bacterial meningitis, viral meningitis and fungi meningitis. Viral (aseptic) meningitis is the most common and luckily can be the least life-threatening than bacterial cause. Most people who suffer from viral meningitis would make full recovery. The Centers for Disease Control and Prevention (CDC; 2012) research shows that enteroviruses are major cause of viral meningitis during the summer months in the United Stated but, the numbers of people who have enteroviruses infection can develop into meningitis are few. According to Wikipedia (2012), enteroviruses are the most common cause of viral meningitis. However, other viral infection can also cause viral meningitis. Krause, 2012 state that viral meningitis that cause by viral infection are mumps, Herpesvirus, herpes simplex viruses, varicella-zoster virus (virus that responsible to cause both chicken pox and shingles (Wikipedia, 2012) ), measles, and influenza. Besides that, arboviruses which are viruses spread through mosquitoes and insects can also caused viral meningitis. Wan (2011), notes that Lymphocytic choriomeningitis virus (LCMV) is a rare cause of meningitis, which is spread by rodent including hamster, mice and rate or their excretory product. According to the CDC (2012), transmissions of enteroviruses are usually spread to person through an infected person’s stool. This may happen when changing the diapers or improper hand washing practices especially after going to the toilet. In addition, spreading of enteroviruses and other viruses (mumps and varicella-zoster virus) can also occur through respiratory secretions such as sputum, saliva, nasal mucus of a person who is infected. Bacterial meningitis, on the other hand is extremely dangerous. The most common form of bacterial meningitis is caused by Meningococcus bacterium. Meningococcal meningitis has no boundaries because it can affect anyone at any age. The CDC (2010), has reported that the Haemophilus influenzae type b (Hib), Streptococcus pneumoniae, and Neisseria meningitidis are three most frequent causative agents which together cause 90% of cases of acute bacterial meningitis in infants and children less than one month of age. Schoenstadt (2012) states that before Hib vaccine being introduced in 1990s, Hib becomes the leading cause of meningitis until vaccine introduce and nowadays, Streptococcus pneumoniae and Neisseria have replace Hib as leading cause of bacterial meningitis. It is stated that the common pathogens that cause bacterial meningitis are vary by patient age group. (Wikipedia, 2012)
AGE GROUP
COMMON BACTERIA CAUSING BACTERIAL MENINGITIS
Premature babies and newborns (until the age of three month old)Group B streptococcus, Escherichia coli (carrying K1 antigen)NewbornListeria monocytogenes (serotype IVb)Children under five years oldHaemophilus influenzae type B (without vaccine)Older childrenNeisseria meningitidis (meningococcus), Streptococcus pneumoniae (serotypes 6, 9, 14, 18 and 23)AdultsNeisseria meningitidis, Streptococcus pneumonia, Listeria monocytogenesCommon cause of bacterial meningitis by patient age. (Wikipedia, 2012)Bacterial meningitis is contagious as it capable to transmit from one person to other by infection. (CDC, 2012) The CDC (2012) says that although meningitis is a contagious disease, but it is not easily spread because it is not spread through casual contact such as being near or just breathing the same air with an infected person. The CDC (2012) also states that the ways of contagious are through exchanging respiratory and throat secretion. This is because according to Singha (2011) the direct contact of meningitis’s patient secretion from throat and nose with other person; for example via kissing, sneezing, coughing, and sharing the same toothbrush can increase the risk of having bacterial meningitis by spreading the bacteria. Risk factor for bacterial meningitis includes age, community setting, certain medical condition, travel and working condition. In terms of age, infants are more susceptible to bacterial meningitis. Besides that, the CDC (2012) note that infectious diseases spread more rapidly in community settings especially at crowded place such as college dormitories and military personnel. People at weakened immune system due to certain diseases, medication, surgical procedures are also at greater risk according to CDC (2012). In addition, individuals who travel to places where meningococcal meningitis is common such as sub-Saharan Africa and Mecca, Saudi Arabia may be at greater risk. This is why the Government of Saudi Arabia requires all the pilgrimage to Hajj or Umrah must have been vaccinated and it is mandatory for them in order to have a certificate proving of vaccination against four different strains of meningitis A, C, W and Y strains to obtain a visa before their departure. (Meninigitis UK, 2012) In case of working conditions, the CDC (2012) notes that those who are regularly work with pathogens causing bacterial meningitis such as microbiologist may have a significant risk of being infected. Last but not least, meningitis infection can also occur due to fungi. There are variety types of fungus that can cause fungal meningitis and Gulati (2012), states that the most common is Cryptococcus Neofarmans in those with deficiency of immune system. Candida Albicans is one of the fungus that cause fungal meningitis. According to Meningitis Research Foundation, Candida is the fungus that can cause thrush and in rare cases, premature babies with low birth weight at greater risk. Besides that, according to CDC 2012, a fungus called Histoplasma that is found in soil or bird/bat droppings in the Midwest United State can also cause meningitis. Coccidiodes is another fungus that lives in soil in Southwestern US and parts of Central and South America which also cause fungal meningitis. (CDC, 2012) CDC (2012), notes that in the Midwest United States, especially the northern Midwest, other types of fungi that cause meningitis may be found in soil rich decaying organic matter is blastomyces. Fungal meningitis is not contagious; therefore it cannot be spread from one person to other. A person can become infected through inhalation of fungal spore when there is a disruption in the environment. The blood infections that travel to the spinal cord are believed to cause the spread of meningitis. 2. 2. 2 Non-Infectious AgentOther than infectious causes, meningitis can also be caused by non-infectious causes. Non-infectious causes include cancers, systemic lupus erythematosus (lupus), certain drugs that allergies, head injury, and brain surgery. 2. 3 IncidenceThe difference between the incidence rate of meningitis occur in developing countries and developed countries is ten times more higher due to precaution step that are still undeveloped (Abd Nasir et al., 2011). Hafizah (2009) report, in Britain, the incidence of meningitis is 3000 cases per year whereas in Malaysia, on the average, there is less than 50 cases of meningitis per year have been recorded. Wikipedia, 2013 notes that the incidence of bacterial meningitis occurs approximately 3 cases per 100, 000 populations in western countries while the incidence of viral meningitis is more frequently than bacterial meningitis, at 10. 9 per 100, 000 people and most common occur in the summer. Data from 2003 to 2007 shows that a total 4100 cases of bacterial meningitis per year were reported in United State(US) (Krause, 2012). The attack rate of bacterial meningitis per year in Brazil is higher at around 45. 8 per 100, 000(Attia et al. 1999, cited in Wikipedia 2013). It is stated that the largest recorded epidemic of meningococcal meningitis occurred in Africa with more than 250, 000 cases were reported and a total of 25, 000 people reportedly died from the disease in 1996(World Health Organization 2003, cited in Wikipedia 2013). Luckily, Abd Nasir et al. (2011) states that the incidence of bacterial meningitis developing countries has shown a decrease from 1998 to 2003, from 1. 9 to 1. 5 per 100, 000 since the vaccine were introduced in that area. Virus that causes meningitis much commonly is enteroviruses which account about 90% (Rothman, 2009). The Meningitis Angels (n. d), which reports more than 10, 000 cases of viral meningitis in the US annually state that the exact incidence of viral meningitis probably high as 75 000. In addition, viral meningitis causes among 25, 000 to 50, 000 people being admitted to hospital each year(CDC, 2011). In Finland, the incidence among young children is higher than older children. Studies have shown as much as 219 cases per 100, 000 children less than one year compared to 19 cases per 100, 000 population of children aged between 1-4 years (Meningitis Angels n. d.). In Malaysia, the incidence of meningococcal infection is unidentified because it has not been reported(Lum, 2008). However, E-Fatwa (2012) states that, comparison of the incidence of meninggococcal meningitis in Malaysia occur occasionally which is 50 cases per year when compared with the high incidence rate in North Africa. We are lucky as compared to US because in there, there were approximately 1400-2800 cases of meningococcal meningitis per year(Rice University Student Health, n. d.). A fungal meningitis case is rare compared to bacterial and viral meningitis (Cool, 2012). In general population, the incidence of cryptococcal meningitis is 0. 4 to 1. 3 cases per 100, 000 annually (MD Guidelines n. d.). According to CDC (2012), the global prediction for one of the fungal meningitis cause which is Cryptococcus neofarmans (cryptococcal meningitis) is around 1 million new cases per year and kills 625, 000 people. Cryptococcal meningitis occurs mostly in place which the number of people living with weakened immune system such as human immnodeficiency virus (HIV)/ acquired immune deficiency syndrome (AIDS) as what is happening in the Sub-sarahan Africa. According to MD Guidelines, those infected with AIDS resulting in slightly higher incidence of cryptococcal meningitis from 2 to 7 cases per 1000 annually. A similar situation occurred in Malaysia which is proved by the results of studies that have been conducted. The study involving cryptoccocus meningitis in Malaysia was carried out and research on 96 patients from 2003 to 2004 found that, people infected with HIV are more likely to get cyptococcus meningitis with a total of 36 people over 96 were reported. Besides, 74 among of them were males and 45 were between the ages of 30 to 39. This study also found that Malay patients dominate cryptococcus meningitis at 57 people while Chinese patients only 23 people (Tay et al. 2010). In 2009, there is one death and 20 cases of meningitis among trainees of the Road Transport Department (JPJ) Academy in Tiang Dua, Malacca have been reported (Bernama, 2009). Hafizah (2009), says that a case of meningitis in the Academy Road Transport Department is not the first case in Malaysia. This is because there is a similar case occurred at Universiti Putra Malaysia in 2002 before. The exact cause of meningitis cannot be identified accurately in Malaysia because of the attitude of parents who refuse to allow their children to undergo Lumbar Puncture procedure (Hafizah, 2012). So, we can conclude that the incidence of meningitis by cause among children in Malaysia cannot be identified accurately. 2. 4 Mortality and MorbidityA total of 8000 cases of meningitis and 2, 000 deaths each year indicate the disease have high morbidity and mortality (Abd Nasir et al., 2011). Morbidity refers to number of people become ill while mortality is defined as If meningitis continues to develop without any treatment, the mortality rate can rise above 50% (Advanced Immunization Management (AIM) 2009, cited in World Health Organizations (WHO) 2005). Generally, with adequate treatment also still causing minimum 10% mortality within 24 to 48 hours of symptoms begin to start. About 10% to 20% of patient who survive meningitis develop permanent damage or complication such as mental retardation, loss of hearing (deafness), epilepsy and other neurological disorders. The AIM (2009) states that, a completely or partial amputation of limb will occur if meningococcal meningitis presence together with necrosis and gangrene. Data from 2003 to 2007 shows that a total 4100 cases of bacterial meningitis per year were reported in United State. Bacterial meningitis kill one in ten people(Krause, 2012). Mortality or the number of death from bacterial meningitis between children and adults can be describing as Table 2. 4. 1.
PATHOGEN
CHILDREN
ADULTS
Streptococcus pneumoniae15%20-37% -High income51% – Resource-Poor areaNeisseria meningitidis4-8%7%Listeria monocytogenes15-17%17-27%Group B streptococcus7-27%25-30%Table 2. 4. 1: Mortality rate of bacterial meningitis according to age group. (Brouwer et al., 2010 cited in Salinas 2012)Based on the Table 2. 4. 1, percentage of mortality rate among adults is higher compare to children. The number of death in adults that cause by bacteria is pneumococcal disease (Streptococcus pneumonia) especially at low-income area which account for 51% is the highest one. In most cases, the morbidity rate in low-income area or remote area is higher due to the difficulty in obtaining medical care that not yet developed well like Gambia which resulted in 26% of infected kill, and as many as 88% of patients die in between 24 hours before able to access the medical care (Greenwood et al., 1987, cited in AMI 2009). On the other hand, the highest mortality among children is caused by group B streptococcus with 7-27%. The mortality and morbidity rates for viral meningitis is 8. 3% and 8. 6 per 100, 000 respectively(Arias, 2012). Dar (2009), notes that infants younger than one year old have up to 20 times higher incidence rate than older children and adults reveal that infants face the greatest risk as well as higher risk of morbidity and mortality in viral meningitis cases. Cool (2012) note that, the most common cause of fungal meningitis is Cryptococcus. In cases of fungal meningitis, there are approximately more than 500, 000 deaths per year due to cryptococcal meningitis accompanied with people affected with HIV were reported around the world (Park et al., 2009, cited in University of Washington n. d.) MD Guideline (n. d.) state that mortality rate of cryptococcal meningitis is about 5% to 25% despite of medical aid.(AMI )2. 5 PathophysiologyAccording to Day, Paul and Williams (2009, p. 2155), meningeal irritation occurs in two ways: it is either via the bloodstream from other infections and the other spread by way of direct extension for example by traumatic injury to facial bone or may result from secondary to invasive procedure. When the causative agents enter the bloodstream, the infection can diffuse across the blood brain barrier and proliferates in the CSF (Day, Paul and Williams 2009, p. 2155). This will cause inflammation in meninges to occur. Day, Paul and Williams (2009), notes that inflammation of subarachnoid space and pia mater occur as the result from the host immune response that stimulates the release of cell wall fragments and lipopolysaccharides. Since there is little room for expansion within cranial vault, raised intracranial pressure (ICP) will arise when there is an inflammation (Day, Paul and Williams 2009, p. 2155). Then, when CSF enters and circulates in the subarachnoid space where infected cellular material from affected meningeal tissues also enters and accumulates in it, thus resulting in increased CSF cell count (Spach 2003, cited in Day, Paul and Williams 2009, p. 2155). An articles from Nursing Articles entitled ‘ Meningitis’ states that as meningitis occurs, result from lumbar puncture test showed an increase in white blood cell count, increase in protein and low glucose levels. 2. 6 Signs and SymptomsSmadi (2009), observes that many people have mistaken the early signs and symptoms of meningitis for just symptoms of the common flu due to the flu-like symptoms can be similar to meningitis. 2. 6. 1 Signs and Symptoms Accordance to Type of MeningitsThe signs and symptoms of meningitis according to their type are described as follow. According to the CDC (2012), the most common symptoms of bacterial meningitis that occur on sudden onset may include stiff neck, woarsening headache, and the most common sign is high fever. 1. Stiff neck- Extreme pain occurs during movement of neck because the lining of the spinal cord that connects to the brain lining becomes infected and inflamed (Sears W and Sears M, 2012). 2. Woarsening headache- The pressure and woarsening headache occurs due to inflammation (Melton, 2012) and brain swelling( Irene, 2010)3. High fever- Fever present with temperature at 38°C (100. 4F) or higher(The National Health Service, 2012). This may accompanied with chills and skin flushing and presence of complication such as joints ache and febrile seizure (Irene, 2010)McCoy (2012) says that it can develop in a few hours or in one to two days for these symptoms to appear. These three common symptoms may also accompanied by nausea and vomiting, dislike of bright lights (photophobia), confusion or other altered mental status. According to Haroon (2010), the symptoms of stiff neck and photophobia occur due to irritation of meninges. ” In cases of bacterial meningitis, CSF is under increased pressure and can contribute to hydrocephalus” (Kowalczyk and Mace, pg 210, 2009)The CDC (2012) states that newborns and young infants may not have the classic signs and symptoms of fever, headache and stiff neck, but instead may show inactivity, irritability, vomiting or eat poorly like refused to eat, bulging frontanelle (soft spot) or abnormal reflexes. As the illness progresses, seizure, coma and possibly death can occur. (CDC, 2012)The symptoms of viral meningitis are said to be same as bacterial meningitis and what makes a differences is symptoms of viral meningitis last for about seven to ten days. The CDC adds some symptoms of bacterial meningitis to be viral meningitis symptoms in adult, which include sleepiness and lack of appetite while for infant is hard to wake up. Haroon (2010) in his article says that the symptoms such as fever, chills, severe headache, vomiting, nausea, deterioration of consciousness and convulsions are due to due to inflammation and raised intracranial pressure. The symptoms of fungal meningitis are largely same to that bacterial meningitis. Zhang (2012), mentioned that about one to four weeks are take for symptoms began to visible. The non-infectious meningitis also tend to share similar symptoms as bacterial meningitis. 2. 6. 2 Physical ExaminationSome of physical examinations that can be done as two classic meningeal sign are Kernig and Brudzinski sign. (Figure 2. 6. 1). However these tests are not completely accurate to prove patient having meningitis. The study by Thomas et al (2002, as cited in Mehndiratta et al, 2012) by using the Kernig’s and Brudzinski’s signs on 297 adults who are likely has meningitis found that percentage for sensitivity only 5 percent and for specificity is 95 percent. Signs of meningeal irritation. (A) Kernig’s sign. (B) Brudzinski’s sign. Figure 2. 6. 2. 1: A. Kernig’s sign B. Brudzinski’s sign (Nervous System Disorder, n. d.)Gibson (2012), notes that positive Kernig’s sign demonstrate when patient unable to straighten leg without accompanied pain when the hip is flexed 90 degree angle. Positive Brudzinki’s sign as mentioned in post by Prakasam (2012) is indicated when patient’s leg spontaneously flexed when the patient’s neck is being flexed toward the chest. 2. 6. 3 Laboratory TestBesides physical examination toward patient, laboratory test can also be done to confirm meningitis. Therefore, the procedure to investigate CSF, called lumbar puncture should be performed (Sacks, 2011). According to article from Nursing Articles entitled ‘ Meningitis’, someone who have raised white blood cell count, raised protein content and low glucose level is suspected to have meningitis. Table 2. 6. 3. 1 below shows the result of CSF analysis in different type of meningitis. http://lifeinthefastlane. com/wp-content/uploads/2010/05/CSF-Analysis. jpg Table 2. 6. 3. 1: Cerebrospinal fluid findings in meningitis. (CSF Analysis, n. d.)(Imaging modalities bawah ni)
CHAPTER 3: IMAGING MODALITIES
Computed tomography (CT) scan, magnetic resonance imaging (MRI), ultrasound and x-rays are diagnostic tool that may be used to diagnose suspected meningitis. Unfortunately, these modalities alone are not enough to confirm meningitis disease. This is because according to Macnair (2009), meningitis can be confirmed by performing lumbar puncture and blood test. 3. 1 CT Scan and MRIA CT scan may used to reveal swelling, inflammation or infection of meninges and may show the presence of other problems like brain tumour, size of the ventricles, brain edema (Sachdev, 2012). If there is abscess of the brain, CT scans can also show it (Lights and Boskey, 2012), while MRI can detect other complications of meningitis like empyema or effusion, venous thrombosis, venous and arterial infarcts, ventriculitis and hydrocephalus (Arun’s MRI Protocols, 2012). Besides, what makes CT scan helps in detecting meningitis is its ability to reveal if there is inflammation of the skull or sinuses or not(Rothman, 2009). Same goes to postcontrast MRI; it can detect subarachnoid inflammation of the mastoids or sinuses(Kowalczyk and Mace, 2009 pg 211). A CT scan and MRI scans help to identify shift in brain contents which probably cause by increase intracranial pressure that will carry potential risk of herniation if lumbar puncture is performed (Smeltzer et al., 2010). This means performing CT scan before lumbar puncture may able to determine any abnormalities that would contraindicate lumbar puncture(Kowalczyk and Mace, 2009 pg 210). According to Razonable and Keating (2012), one should undergo CT scan prior to lumbar puncture if having greater risk of brain herniation especially those with risk factors such as new onset seizures, an immunocompromised state, have papilledema or focal neurologic findings, and deterioration in consciousness from moderate to severe. Currently, MRI is more sensitive in diagnose meningitis compare to CT scans. The study found a total of 62 HIV-seropositive with suspected cryptococcal meningoencephalitis who underwent CT scan and MRI, reported appearance of an abnormality in CT scans is 53% but in MRIs is 92% (Berger, n. d.). In addition, MRI is sensitive in detecting the complication and also the presence and extent of inflammatory changes in the meninges (Incesu and Khosla, 2011). CT scans usually do not able to reveal very small abnormalities in size as MRI show (Sachdev, 2012). 3. 2 X-rays and UltrasoundsA single dimension produce by X-rays are very good if it is used to look at bones, but less obvious to see tissue (Rothman, 2009). That is why x-rays is not used in screening meningitis. On 11th December 2012, a study was conducted on 439 patients with meningitis and the results show no one among of them showing chest x-ray (CXR) abnormalities (E Health Me, 2012). However, sometimes CXR is performed to pneumoccal meningitis patients because most of them reveal pneumonia findings in radiograph (Slowik, 2012). Ultrasound is another imaging modalities which also unhelpful in diagnosed meningitis as it cannot pass through the bone but it can be used to examine baby’s brain since their fonatelle still not close yet(Rothman, 2009). These imaging are done just to ensure there is no brain damage that result from pressure or accumulation of fluid.
CHAPTER 4: IMAGE FEATURES OF MENINGITIS
4. 1 Bacterial MeningitisCT brain plain often reveals no abnormalities, but it can also show increased density in subarachnoid space frequently in children, and small ventricles due to diffuse cerebral edema also can be seen. Contrast-enhanced CT scans may show curvilinear meningeal enhancement over cerebrum, interhemispheric, sylvian fissures and most often obliteration of basal cistern with enhancement. Mostly, MRI scan without contrast often looks normal. Dahnert (2007), note that obliterated basal cisterns on photon-density appear hyperintense and on T1WI image appear intermediate intensity. Besides, hyperintense plaques can be seen on T2WI and induce enhancement of leptomeningeal after administration of gadolinium-diethylenetriamine penta-acetic acid (Gd-DTPA) also may present in chronic infection of meningitis. http://thehealthscience. com/image/2011091000481512154. jpgImage 4. 1. 1: Contrast-enhanced axial T1WI demonstrate enhancement of leptomeningeal marked with arrow. (The Health Science, 2011)ABHead (Meningitis – MRI, )Image 4. 1. 2 Contrast-enhanced T1WI (A: axial, B: coronal) shows diffuse leptomeningeal enhancement obviously in the posterior fossa, paramesencephalic and the basilar cisterns(ImageB), sylvian fissures, and interhemispheric fissure(Image A). (On Call Radiology-Emergency Radiology Findings on Call, n. d.)4. 2 Viral MeningitisContrast-enhanced MRI can reveal lumbosacral polyradiculopathy with enhacement of meningeal that cause by cytomegalovirus especially in AIDS patients (Naidich et al 2010). Erasmus (2011) state that cytomegalovirus is one of the cause of viral meningitis. However, there is no specific imaging finding in viral meningitis(Naidich et al 2010). 4. 3 Fungal MeningitisDahnert (2007) has listed radiologic findings in fungal meningitis on CT scan, including obliteration of basal cistern, sylvian fissure, suprasellar cistern which usually appear isodense due to cistern be filled with debris, meningeal calcification and show decrease attenuation of white matter. CT scan with contrast will show intensely enhancing of gyri and subarachnoid spaces. On MRI, the radiological findings include the basal cistern demonstrate hyperintensity on T2WI and to obtain enhancement in MRI scans, gadopentetate dimeglumine should be used.
CHAPTER 6: CONCLUSION
6. 1 TreatmentThe effective way to treat bacterial meningitis is by giving intravenous antibiotics. Sometimes the physician will combine different type of antibiotics, however it depend on bacteria causing meningitis. Ampicillin, cefotaxime, ceftriaxone, gentamicin penicillin G, rifampin, vancomycin are antibiotics treatment for bacterial meningitis (Web MD, 2010). Antibiotics are given based on age group and the bacteria causing meningitis as shown in Table 6. 1. 1. Table 1: Treatment of bacterial meningitisTable 6. 1. 1: Antibiotics treatment for bacterial meningitis. Unlike bacterial meningitis, viral meningitis is usually less severe and mostly can recover without antiviral therapy (Dugdale and Vyas , 2012) in seven to ten days (CDC, 2012). Treatments may include bed rest, consume plenty of fluid, and pain medication to reduce the symptoms like fever and headache such as acetaminophen or ibuprofen (Kaplan and Pentima, 2012). http://www. uptodate. com/contents/meningitis-in-children-beyond-the-basics In serious conditions or individuals who have poor immune system must be hospitalized (CDC, 2012)Fungal meningitis typically requires high-dose intravenous antifungal medications for a long time in order to treat the disease (CDC, 2012). Cool (2012) mentioned that, examples of medicine are amphotericin B which administer intravenously or flucytosine which given by orally. The CDC (2012) notes that, the state of immune system as well as what kind of fungi cause meningitis will determine how long the treatment is. Gulati (2012), believed that cortisone-like medications might be useful to cure non-infectious meningitis caused by allergic reaction or autoimmune disease. Cancer cause meningitis can be treated with chemotherapy (Schaub, 2012), http://prezi. com/krgtufkoc7tt/meningitis/ however according to Gulati (2012), meningitis can improve itself if cancer is treated. 6. 2 Prognosis6. 2. 1 Bacterial MeningitisBacterial meningitis, if left untreated can lead to death and disability. However, according to Kowalczyk and Mace (2009 pg 210), if antibiotic given immediately, it will result mortality rate less than 10%. There are many factors that determine prognosis status includes, treatment given, patient age, secondary to others disease, etiologic agent, and severity of illness(Sachdev, 2012). The risk of death varies according to age group. Neonates and adult have greater risk, at 20% to 30% and 19% to 37% respectively (Wikipedia, 2012). Bacterial meningitis is treated by antibiotics while viral meningitis can be treated at home and will be better within two weeks. 6. 2. 2 Viral MeningitisThe prognosis of viral meningitis is more good when compare to bacterial meningitis because mostly can clear up in seven to ten days with treatment (Sachdev, 2012). However, prognosis tend to be worse if presence in neonate and infants, and existence of possible outcome such as encephalitis, pericarditis and hepatitis. 6. 2. 2 Fungal MeningitisFungal meningitis, if left without appropriate treatment may lead to death and even though being treating with antifungal drug, the mortality is still unreasonably high. The prognosis of most common fungal meningitis; cryptococcal meningitis among HIV-infected patients is poor because they experience alter mental status (Brouwer et al. 2004, cited in Best Practice 2012) while for non-infected patient typically die due to chronic renal failure, liver failure, or hematologic malignancy, absence of headache and altered mental status (Pappas 2001, cited in Best Practice 2012)6. 3 ConclusionAn inflammation of the meninges of the brain and spinal cord is called meningitis. It can be divided into two sources; infectious and non-infectious. If an individual complaining of fever, stiff neck and headaches, it indicates the presence of meningitis. Lumbar puncture and laboratory test can be done to diagnose meningitis with the aid of imaging modalities. The mortality rate among meningitis patient is quite high but it can be prevent with appropriate treatment. Prevention of meningitis is recommended in order to decrease the number of cases. For example, vaccination and immunization can be given to prevent infection of meningococci, Hib, pneumococci or mumpd virus (Sáez-Llorens and McCracken 2003, cited in Wikipedia 2013).