Meningitis refers to inflammation of the protective layers around the brain and spinal cord, often triggered by infections. This condition is a critical emergency, demanding quick identification and intervention to avoid serious outcomes like hearing impairment, brain damage, or even death. In Ghana, bacterial forms are frequent, particularly among young children and during the dry season, with potential outbreaks in northern areas.
π¦ Overview and Pathophysiology
Meningitis commonly stems from infectious agents, though non-infectious causes like cancer or certain medications can also play a role. Contributing factors include crowded living conditions, lack of vaccination, weakened immunity, and seasonal changes in Ghana.
Main Causes
- Bacterial: Streptococcus pneumoniae (common, with growing resistance to penicillin), Neisseria meningitidis (linked to epidemics in northern Ghana), Haemophilus influenzae type b (in unvaccinated kids), Mycobacterium tuberculosis, Listeria monocytogenes (in newborns or those with weak immunity), Staphylococcus aureus, Escherichia coli (neonates), and others like Gram-negative bacilli or Pseudomonas in hospital settings.
- Viral: Enteroviruses, herpes simplex, mumps, or other herpes viruses.
- Fungal: Cryptococcus neoformans, especially in people with HIV.
- Parasitic/Protozoal: Uncommon, but includes cases mimicking cerebral malaria or toxoplasmosis in HIV patients.
π Clinical Presentation
Manifestations differ by age group and disease severity, but early recognition is vital.
Symptoms
In Adults and Older Children (>5 years): Abrupt high fever, intense headache that persists, neck discomfort or rigidity, vomiting without relation to meals, sensitivity to light, nausea, confusion, irritability, drowsiness, or behavioral shifts.
In Infants and Young Children (1-5 years): Refusal to feed or suckle, irritability, lethargy, convulsions, altered tone (floppy or stiff), high-pitched or weak cry.
Severe Cases: Fits, unconsciousness, skin rashes (non-fading spots in meningococcal infection).
Signs
In Adults and Older Children: Elevated temperature, rigid neck (pain when bending forward), positive Kernig's (resistance/pain extending knee with hip bent) or Brudzinski's sign (hip flexes involuntarily when neck is bent), reduced awareness (Glasgow Coma Scale <15), light aversion, focal nerve issues, or shock indicators like rapid heart rate and low blood pressure.
In Infants: Arched neck, bulging soft spot on head, fever presence, tone changes, seizures, coma.
Other: Spotty or bruised rash in meningococcal cases.
π§ͺ Diagnosis
Key tests focus on cerebrospinal fluid analysis, but start treatment without delay if needed.
Investigations
Essential: Lumbar puncture for CSF examination (avoid if signs of high brain pressure like swollen optic disc or comaβbegin antibiotics and image first).
CSF Findings:
- Bacterial: Turbid fluid, elevated white cells (>1000/ΞΌL, mostly neutrophils), reduced glucose (<40% blood level), high protein (>1 g/L).
- Viral: Clear fluid, moderate white cells (lymphocytes), normal glucose, slight protein rise.
- Fungal: Similar to viral but low glucose; use India ink or antigen test for Cryptococcus.
- TB: Lymphocyte dominance, very low glucose, high protein; acid-fast stain for bacilli.
Additional: Full blood count (high white cells in bacterial), blood culture/sensitivity, Gram stain/CSF culture, malaria test (RDT/film) to rule out mimic, blood sugar for CSF comparison, HIV screening in at-risk groups, brain imaging (CT/MRI) if focal signs or LP contraindicated.
π Treatment
Goals include eliminating the pathogen, easing symptoms, avoiding long-term issues, supporting life functions, and curbing transmission.
Non-Pharmacological
Isolate patients with droplet precautions, especially for meningococcal types. Provide rest in a calm, dim environment. Track vital signs, brain function, and fluids hourly. Elevate head to 30 degrees to lower pressure inside the skull. Ensure proper hydration and nutrition, using tube feeding if required. Avoid excessive fluids to prevent brain swelling. Supply oxygen if breathing is compromised, and position to safeguard during seizures. Use drains or repeated taps for ongoing high pressure. Offer rehab post-recovery.
Pharmacological
Begin IV antibiotics right after samples, based on age and suspected bug, adjusting per results. Duration varies by cause. Use steroids alongside for certain bacterial types to lessen inflammation.
| Age Group | Drug and Dose | Duration | Evidence |
|---|---|---|---|
| Adults/Adolescents | Ceftriaxone 2-4 g IV every 12 hours | 7-14 days | [A] |
| Children >1 month | Ceftriaxone 100 mg/kg/day IV divided every 12 hours (max 4 g/day) | 10-14 days | [A] |
| Neonates | Ceftriaxone 50-100 mg/kg/day IV divided every 12 hours | 14-21 days | [A] |
| Suspected Pneumococcal | Add Vancomycin 15-20 mg/kg IV every 8-12 hours | 7-14 days | [A] |
Empirical Bacterial Therapy
Alternative Empirical
- Benzylpenicillin: Adults 4 MU IV every 4-6 hours; Children 0.2-0.3 g/kg/day divided every 6 hours [B]
- Plus Chloramphenicol: Adults 25 mg/kg IV every 6 hours (max 4 g/day); Children 25 mg/kg every 6 hours [B]
Adjunctive
- Dexamethasone: Adults 10 mg IV every 6 hours for 4-7 days; Children 0.15 mg/kg every 6 hours for 4 days [A]
Viral (HSV)
- Aciclovir: Adults 10 mg/kg IV every 8 hours; Children 10-20 mg/kg every 8 hours for 14-21 days [B]
- Do not delay antibiotics for LP or results.
- Monitor for hepatotoxicity and other side effects.
- For contacts in meningococcal cases: Ciprofloxacin 500 mg oral single dose (adults).
π€° Special Populations
Adapt approaches for different groups:
Children and Neonates
Higher doses per weight; watch for fontanelle bulging and seizures. Use gentamicin with ampicillin for Listeria suspicion in newborns.
Pregnancy/Lactation
Avoid chloramphenicol; prefer ceftriaxone. Monitor closely for maternal and fetal impacts.
π¨ Referral Criteria
- Suspected epidemics or CSM outbreaks
- Complications like hydrocephalus or abscess
- Persistent symptoms or treatment failure
Notify authorities and transfer to specialized units.
π§ Key Takeaways
- β Emergency: Treat as urgent; start antibiotics immediately
- β Diagnose: LP for CSF analysis if safe
- β Bacterial Therapy: Ceftriaxone first-line [A]
- β Adjunct: Dexamethasone for bacterial cases [A]
- β Prevent Spread: Isolate and prophylax contacts
- β Refer: For outbreaks or complications