Meningitis and Seizures

Acute Bacterial Meningitis

Acute Bacterial Meningitis

Etiology:

• Strep. Pneumo. = MCC in adults

• Neisseria menigitidis = MCC in older children (10-19yrs)

  • Petechial rash

• Group B strep = MCC in neonates under 1 month.

• Listeria monocytogenes = increased in neonates, 50+yrs, and immunocompromised states.

Clinical Manifestations:

• Meningeal symptoms: HA, neck stiffness, photosensitivity, fever

• Meningeal signs: Nuchal rigidity, Brzezinski, Kernig sign

Dx: Lumbar puncture + CSF examination (decreased glucose and increased neutrophils. = BEST INITIAL TEST and definitive dx.

• Head CT scan = best initial test PRIOR TO LP ONLY if needed to rule out mass effect

  • Papilledema, seizures, focal neurologic finding

Management:

• Abx + Dexamethasone (started ASAP)

  • Dex shown to reduce mortality and sequelae

Management for N. Menigitidis:

• Droplet precautions for 24hrs after starting abx

• Post-exposure prophylaxis: Cipro or Rifampin

  • Only needed for close contacts w/ 8+ hrs of exposure.

General measures for Meningitis

Empiric for Neonates <1month: Ampicillin + Gemtamycin or Cefotaxime

Empiric for 1m to 50yrs: Vanco. + Ceftriaxone (or Cefotaxime)

Empiric for 50+: Vanco + Ceftriaxone + Ampicillin (for Listeria)

Aseptic Meningitis

-Clinical & lab evidence of meningitis w/ (-) routine bacterial cultures.

Etiology:

• Enterovirus = MCC (Coxsackievirus & Echovirus)

Clinical Manifestations:

• Classic Meningeal symptoms

  • HA, nuchal rigidity, photosen. fever

Dx: Lumbar puncture → normal glucose and lymphocyte predominance

Management:

• Supportive (Antipyretics, IV fluids, etc..)

  • If HSV → Acyclovir

• Most are self-limiting

Focal (partial) Seizures

Part of one half of brain affected.

• Simple → retained awareness

• Complex → (consciousness impaired)

• Clinical Manifestations: (depends on where it occurs i.e. visual symptoms → occipital lobe)

  • Automatisms: repetitive behaviors

  • Todd’s paralysis: weakness from affected muscles.

• EEG

  • Simple partial: Focal discharge @ onset of seizure.

  • Complex partial: Interictal spikes or w/ slow waves in the temporal/frontotemporal area.

Absence (Petit Mal) Seizures

-Generalized seizure (both hemisphere involvement), MC seen in childhood

• Often stops at puberty.

Clinical Manifestations:

• Pause/stare: Sudden marked impairment of consciousness w/o loss of body tone (staring episodes)

  • Typically last 5-10 seconds (eyelid twitching/lip smacking can happen w/ >10 seconds)

• No post-ictal phase, my be provoked by hyperventilation.

Dx: EEG

• Bilateral symmetric 3 hz spike & wave activity

Management;

• Ethosuximide = First line

• Valproic acid = second line

• Lamotrigine

• (Carbamazepine/Gabapentin can make it worse)

Generalized (Grand Mal) seizure

-Diffuse brain involvement, Generalized tonic-clonic → MC.

Clinical Manifestations:

• Tonic-clonic: Rigidity (1-2min) and then jerking (1-3min)

  • Followed by postictal confusion phase (cyanosis & urinary incontinence may occur)

• Myoclonic: Sudden, brief involuntary twitching

• TOnic: Loss of consciousness followed by rigidity

• Atonic: “Drop attacks” → loose all muscle tone.

Dx: Inital wrkup to r/o reversible causes (CBC, electrolytes, liver/renal function, RPR)

• Increased prolactin & Lactic acid immediately after seizures → r/o psuedoseizures

• MRI to r/o focal mass

• EEG: Bilateral symmetric 3 Hz spike & wave activity.

Management:

• Tx underlying causes if known.

• Can use basically any antiseizure meds

  • Pregnant → Levetiracetam & Lamotrigine

• Ethosuximide = first line for absence

Status Epilepticus

-A single, continuous epileptic seizure lasting 5 min. or greater than 1 seizure w/in 5 min period w/o recovery between.

-A neurologic emergency!

Etiology: Structural, infectious, meds, toxins.

Dx: Neuroimaging: once stabilized. (r/o intracranial mass/hemorrhage)

Management:

• Benzodiazepines = preferred initial agents (lorazepam) (Midazolam if IV cant be done)

• Second line:

  • Phenytoin/Fosphenytoin if does respond

• Third line:

  • Phenobarbital if no response to 2nd line (Refractory)