ΜΗΝΙΓΓΙΤΙΔΕΣ. Ι. Γ. Ρούτσιας Επίκουρος καθηγητης Μικροβιολογίας/Ανοσολογίας

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1 ΜΗΝΙΓΓΙΤΙΔΕΣ Ι. Γ. Ρούτσιας Επίκουρος καθηγητης Μικροβιολογίας/Ανοσολογίας

2 Τι είναι η μηνιγγίτιδα? The brain and spinal cord are covered by 3 connective tissue layers collectively called the meninges which form the blood-brain barrier. -Χοριοειδής μήνιγγα (closest to the CNS) -Αραχνοειδή χώρο -Σκληρή μήνιγγα (farthest from the CNS). Σκληρή μήνιγγα Αραχνοειδής χώρο Χοριοειδής μήνιγγα The meninges contain cerebrospinal fluid (CSF) «Meningitis is an inflammation of the meninges, which, if severe, may become encephalitis, an inflammation of the brain» Εγκέφαλος

3 Μήνιγγες

4 Αίτια της Μηνιγγίτιδας Bacterial Infections Viral Infections Fungal Infections (Cryptococcus neoformans) Inflammatory diseases (SLE) Cancer Trauma to head or spine.

5 Αίτια της Μηνιγγίτιδας 24% 22% 54% Bacterial Viral Non-Infectious

6 Συμπτώματα

7 Symptoms of meningitis. Adults and children

8 Meningitis Clinical Manifestations Nuchal rigidity Kernig s Pt supine with flexed knee has increased pain with passive extension of the same leg Brudzinski s Supine pt with neck flexed will raise knees to take pressure off of the meninges Present in 50% of acute bacterial meningitis cases

9 Pt supine with flexed knee has increased pain with passive extension of the same leg

10 Supine pt with neck flexed will raise knees to take pressure off of the meninges

11 Είναι η μηνιγγίτιδα μεταδοτική? Some forms of bacterial meningitis are contagious, through respiratory or throat secretions such as coughing or kissing. However, it is not as contagious as the cold or flu, and the disease cannot live outside the body very long.

12 Διάγνωση της μηνιγγίτιδας : Οσφυονωταία παρακέντηση. A lumbar puncture collects cerebrospinal fluid to check for the presence of disease or injury. A spinal needle is inserted, usually between the 3rd and 4th lumbar vertebrae in the lower spine. Permits the urgent distinction of bacterial meningitis from viral meningitis and examination of the CSF allows precise diagnosis

13 Τυπικά ευρήματα της ΟΝΠ Bacterial meningitis 1. Presence of neutrophils in the CSF is associated with infection by N. meningitidis, S. pneumoniae etc. 2. CSF protein level reflects the degree of meningeal inflammation:- 10 X in bacterial infections 3. CSF glucose levels :- very low in bacterial infections Viral meningitis 1. Presence of lymphocytes is associated with infection by viruses or mycobacteria. 2. CSF protein level reflects the degree of meningeal inflammation:- 2-3 X in viral CNS infection 3. CSF glucose levels :- normal with viral infections

14 Βακτηριακή Μηνιγγίτιδα.. Δεδομένα: Potentially life threatening disease. One million cases per year world wide. 200,000 die annually. Can affect all age groups but some are at higher risk. Treatment available : antibiotics as per causative organism Humans are the reservoir. Pneumococcal meningitis is the most common type. Approximately 6,000 cases/yr Haemophilus meningitis: Since 1985 Incidence has declined by 95% due to the introduction of Haemophilus influenza b vaccine. Other bacterial meningitis caused by E-Coli K-1, Klebsiella species and Enterobacter species are less common overall, but may be more prevalent in newborns, pregnant women, the elderly and immunocompromised hosts.

15 Βακτηριακή Μηνιγγίτιδα.. Αίτια: -Pneumococcal, Streptococcus pneumoniae (38%) -Meningococcal, Neisseria meningitidis (14%) -Haemophilus influenzae (4%) -Staphylococcal, Staphylococcus aureus (5%) -Tuberculous, Mycobacterium tuberculosis

17 Μηνιγγιτιδοκοκκική μηνιγγίτιδα Etiological Agent: Neisseria meningitidis Clinical Features: sudden onset. Reservoir: Humans only. 5-15% healthy carriers Mode of transmission: direct contact with patients oral or nasal secretions. Saliva. Petichial Rash Incubation period: 1-10 days. Usually 2-4 days Infectious period: as long as meningococci are present in oral secretions or until 24 hrs of effective antibiotic therapy Epidemiology: Sporadic cases worldwide. Meningitis belt sub-saharan Africa into India/Nepal. Μost cases seen during late winter and early spring. Children under five and adolescent most susceptible. Overcrowding predispose to spread of infection.

18 Neisseria meningitides

19 Αιμορραγικό εξάνθημα

20 Αιμορραγικό εξάνθημα

21 Εγκέφαλική βλάβη

22 Οίδημα οπτικής θηλής

23 Ο.Ν.Π.

28 Άσηπτη μηνιγγίτιδα Ορισμός: A syndrome characterized by acute onset of meningeal symptoms, fever, and cerebrospinal fluid pleocytosis, with bacteriologically sterile cultures. Εργαστηριακά κριτήρια: No evidence of bacterial or fungal meningitis Επιβεβαιωμένη: a clinically compatible illness diagnosed by a physician as aseptic meningitis, with no laboratory evidence of bacterial or fungal meningitis Σχόλιο Aseptic meningitis is a syndrome of multiple etiologies, but most cases are caused by a viral agent.

29 Ιογενής μηνιγγίτιδα Etiological Agents: Enteroviruses (Coxsackie's and echovirus): most common. Adenovirus Arbovirus Measles virus (ιός της ιλαράς) Herpes Simplex Virus Varicella Reservoirs: Humans for Enteroviruses, Adenovirus, Measles, HS, and Varicella Natural reservoir for arbovirus not known but may be birds, rodents etc. Modes of transmission: Primarily person to person and arthopod vectors for Arboviruses Incubation Period: Variable. For enteroviruses 3-6 days, for arboviruses 2-15 days Treatment: No specific treatment available.

30 Μηνιγγίτιδα: Επιπλοκές -Σηψαιμία; advanced disease with high mortality. -Οι νευρολογικές επιπλοκές είναι σπάνιες. Deafness or other cranial nerve lesions most likely and may improve or recover during convalescence. -Η αρθρίτιδα στα δάχτυλα και στα γόνατα είναι πιο συχνή; due to immune complexes in the synovium, resolves spontaneously. - Η νέκρωση του δέρματος και το εξάνθημα μπορεί να είναι επώδυνο ή να αφήσει ουλές.

31 Non Polio Enteroviruses Types:62 different types known: 23 Coxsackie A viruses, 6 Coxsackie B viruses, 28 echoviruses, and 5 other How common? 90% of all viral meningtis is caused by Enteroviruses Second only to "common cold" viruses, the rhinoviruses. Estimated million/ more symptomatic infections/yr in US Who is at risk? Everyone. How does infection spread? Virus present in the respiratory secretions & stool of a patient. Direct contact with secretions from an infected person. Parents, teachers, and child care center workers may also become infected by contamination of the hands with stool.

32 Non Polio Enteroviruses contd. Can it be prevented? No vaccine available for the non-polio enteroviruses. Prevention difficult because most infected not sick. General cleanliness and frequent handwashing critical. Dilute solution of chlorine-containing bleach to clean washing soiled articles inactivates the virus, especially, in institutional settings such as child care centers.

33 Reported Cases of Aseptic Meningitis by Month of Onset, West Virginia, ; N = Number of Cases Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month Seasonal Pattern

34 HIV Infection of the Nervous System Neuropsychological Factors

35 Classification of HIV Nervous System Disease Primary (caused by HIV alone) HIV Dementia Secondary (opportunistic infections associated with immunodeficiency) Fungal, Parasitic, Viral, TB, Bacterial, Cancer

36 How Does HIV Affect the Nervous System? General immunosuppression can lead to: Opportunistic Infections Fungal (Cryptococcal Meningitis) Parasitic (Toxoplasmosis) Viral (Progressive Multifocal Leukoencephalopathy) HIV-Related Tumors

37 Changes in Incidence of Cryptococcal Meningitis 5 4,5 4 3,5 3 2,5 2 1,5 1 0, (monotherapy) (dual therapy) (HAART) Incidence rates are number per 1000 person-years. (Sacktor et al., 2001)

38 The syndrome of chronic meningitis Some combination of fever, headache, lethargy, confusion, nausea, vomiting, and stiff neck Frequent elevation of CSF protein, predominantly lymphocytic pleocytosis, low CSF glucose Process fails to improve or progresses during at least 4 weeks of observation.

39 Causes of chronic meningitis Infections: Tuberculosis, cryptococcosis and other fungal infections, syphilis, brucellosis, and miscellaneous agents that more commonly cause brain abscess Other: tumors, sarcoidosis, granulomatous angiitis, uveomeningoencephalitis, Behcet s disease, chronic benign lymphocytic meningitis

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