Dr. IA. Ratih Wulansari M,SpPD-KR,M.

Kes
Lahir : Surabaya, 21 April 1970
Pendidikan:
S1 Fak. Kedokteran Univ.
Udayana (1995)
SP1 Spesialis Penyakit Dalam
FK Univ. Udayana (2003)
S2 Magister Manajemen Rumah
Sakit, FK Univ. Gadjah
Mada (2006)
SP2 Konsultan Rheumatologi, FK
Univ. Indonesia (2009)

Kegiatan :
Praktek : RS Manuaba, RS Prima Medika, RS Puri Raharja
Dosen Tamu: Univ. Pendidikan Nasional, Stikes Bina Husada
MENINGITIS
 Meningitis
• Inflammation of the meninges
• Classic triad:
– Fever
– Headache
• Severe, frontal, photophobia, n/v
• Jolt accentuation
– Meningismus/altered mental status

• Meningeal signs
– Kernig sign: one leg with hip flexed, pain in back with
extension of knee
– Brudzinski sign: flexion of legs and thighs when neck is flexed
 Meningitis
• Risk Factors
– Age (bimodal peak)
– Prior neurosurgery, alcoholism, malignancy, steroids, HIV,
sinusitis, DM

• Clinical suspicion
– Triad: fever, nuchal rigidity, altered mental status: only
seen in 40% elderly
– Only 59% of elderly patients with acute bacterial
meningitis had fever
– Most have at least ONE symptom
 Causes of Meningitis
• Bacterial
• Viral
• Fungal: cryptococcus
• Mycobacteria: MTB
• Parasitic/protozoa: Naegleria fowleri
• Noninfectious
– Medications
– Paraneoplastic
 Acute Bacterial Meningitis
• Streptococcus pneumoniae
• Neisseria meningitidis
• Listeria monocytogenes
• Haemophilus influenzae: nearly unheard of
since vaccinations
• Less common: Gram negatives (Klebsiella, E.
coli)
• History of procedure: Staphylococcus
 Strep Pneumoniae Meningitis

• Now most common cause (H flu rare)

• 30-50% cases of bacterial meningitis in elderly
• Otitis 30%, sinusitis 8%, pneumonia 18%
• Elderly more often have pneumonia (bad)
• Bad markers: older age, low platelets, dec CSF glucose, no
otogenic focus
• Vaccination: recommended in all over age 65
– Efficacy in elderly/immunocompromised NOT clear
– Decrease bacteremia/meningitis
 TB Meningitis
– Tuberculous meningitis (most common)
– Intracranial tuberculomas
– Spinal tuberculous arachnoiditis
• Meningitis: inflammation from rupture of
subependymal tubercle into subarachnoid space
• Basilar meningitis, CN palsies, hydrocephalus
• Subacute or chronic
• Initial neutrophilic pattern on CSF
• Very high CSF protein may be seen
• AFB smears often neg; need HIGH volume sent to lab
 Viral Meningitis
• Aseptic meningitis
• Enteroviruses
• HSV
• VZV
• Arboviruses (arthropod borne viruses)
– West Nile, Eastern Equine, Western Equine, St.
Louis, California, Japanese Encephalitis
• HIV
• Rabies virus
• Adenovirus
• CMV, EBV
 Viral Meningitis

• Aseptic meningitis
• May be difficult to initially separate
from partially treated bacterial
meningitis (obligates empiric treatment
for bacterial)
• Differentiate from true aseptic (drug
related such as NSAIDs, paraneoplastic)
 Viral Meningitis
• Finland study: etiology found in 66%
patients with aseptic meningitis
• Viral encephalitis: etiology only found
in 36% cases
• Viral prodrome, sore throat, myalgias,
ill contacts, GI complaints; summer/fall
season
• Most common= enteroviruses (25%)
–Echoviruses
–Coxsackievirus
 Meningitis in the Elderly
• Decreased total incidence; increased in
elderly
• Increased prevalence of Listeria (25%)
• 30-50%: S. pneumoniae
• Less likely Neisseria and Haemophilus
• Less likely fever and meningeal signs; more
likely neurological symptoms, seizure, coma
• More often complicated by pneumonia
• Older patients with neurological
impairment: 50% mortality
 The Diagnosis
• LP if suspicion
• Do not delay antibiotics if suspected!
• CT prior to LP in patients with focal
neurological deficits, seizures, HIV, or
elderly
• MRI: to identify areas of CNS
involvement
–Temporal involvement with HSV
–Basilar meningitis with TB
 The LP
• Opening Pressure
– Important data
– Only in lateral decubitus (not position
usually done under radiology)

• Xanthochromia
– Yellow/orange color of centrifuged CSF
– RBC lysis – oxyhemoglobin, bilirubin
– Blood in subarachnoid space at least 2-4 hrs
– More likely due to blood in CSF and less
likely traumatic tap
 CSF Findings
Normal Bacterial Viral Fungal TB other

WBC 0-5 100- 5-3000 5-500 5-500 paraneo

(TNC) 10,000
Cell type >50% >50% >50% >50% Monoclon
PMN lymphs lymphs lymphs al, atypia
Protein 50-80 >200 Nl/slight Nl/slight Increase increased
mg/dL increase increase
Glucose 70-80 <40, Normal normal <40 or nl decrease
mg/dL <60% of
>60% serum
serum glucose
Gm stain 60% + Neg 50% AFB +
india ink 25-35%
+ crypto
Pressure 75-200 Inc Nl Inc Nl/inc
mm Hg
 The Lumbar Puncture: Risks
• Headache: 10-25%
– Typical: appears suddenly upon standing
– Decrease CSF pressure with small leak
– Decrease risk: small (<20 g) needle, leave
patient prone after procedure
– Blood patch
• Infection (small)
• Local bleeding: traumatic tap to epidural
hematoma
• Brain herniation