MBBS
Meningitis refers to an infection of the meninges – the layers surrounding the brain and the spinal cord. It is a disease that requires prompt attention and action by the healthcare staff. In this article, we will discuss meningitis, its causes, destruction, complications, the role of nurses, diagnosis, and management of a patient with meningitis.
The meninges comprise the dura mater, the arachnoid mater, and the pia mater, closely linked to the brain. Meningitis usually occurs because of an infection spread from different body sites, such as a respiratory infection, sinusitis, or mumps. Open wounds can also facilitate the entry of microorganisms, resulting in meningitis.
Mostly, viruses and bacteria cause meningitis. Some fungi can also cause meningitis, but fungal meningitis is rare.
The course of the illness and the prognosis differ by the causative organism. Bacterial meningitis is severe and is considered a medical emergency. Viral meningitis, on the other hand, is self-limiting and is considered benign. Viral meningitis is also known as aseptic or serous meningitis.
The most common bacteria causing meningitis in newborn children is Streptococcus pneumoniae. In older adults, it is Streptococcus pneumoniae and Neisseria meningitis. In unvaccinated individuals, Hemophilus Influenza is the most common cause.
Viral meningitis can be caused by various organisms, such as mumps virus, Herpes virus, influenza virus, arbovirus, or West Nile virus.
Bacterial meningitis is a serious, potentially life-threatening type of meningitis. In this type, bacteria enter the meningeal space and trigger an inflammatory response. This inflammatory response is the beginning of the damaging effects of meningitis. As a result of inflammation, purulent exudate is released. If left untreated, the CSF gets thick, and its normal drainage is blocked, which results in increased intracranial pressure and hydrocephalus.
Further deleterious effects of meningitis manifest by altered blood flow due to increased ICP and toxins released by the bacteria.
The infection can invade the brain tissue, a condition known as encephalitis. This can cause visual impairment, cranial nerve palsies, deafness, chronic headaches, paralysis, and even coma.
Any of the complications can also end in death. Talking about deaths, pneumococcal meningitis has the highest death rate, between 20% to 30% in adults and 10% in children.
Severe neurological impairment is a hallmark of dismal prognosis in pneumococcal meningitis. If noted in early assessment, the mortality rate soars up to 50% to 90% despite the institution of antimicrobial therapy.
Nurses should take a detailed and comprehensive history of the patient suspected of meningitis.
The history differs in acute and subacute type. Patients with subacute meningitis present with vague symptoms, such as headache, irritability, and loss of appetite.
Acute meningitis presents with progressively worsening headaches, vomiting, confusion, or delirium. It may be accompanied by photophobia, fever, and chills. Some patients may present with seizures, too.
As mentioned, meningitis usually manifests because of infection spread from other sites. Patients with meninga disease have a positive history of an infection at a different site.
Patients with pneumococcal meningitis may have had a recent ear infection, sinusitis, lung infection, or endocarditis. H. Influenza meningitis is also associated with lung and ear infections.
A patient with meningitis shows many signs on physical examination. The classic signs of meningitis include:
Other signs may include:
Nuchal rigidity refers to a stiff neck that creates pain when flexed towards the chest. To assess nuchal rigidity, have a patient lie flat on a bed. Place your hand behind the patient’s head and slowly bend their neck towards the chest. If nuchal rigidity is present, doing this will cause pain, and the patient will show resistance in flexion.
A positive Kernig’s sign is the inability to extend legs fully while lying supine. To check for it, have the patient lie supine and flex the hip and knee to a right angle. Slowly extend their knees. In a positive Kernig’s sign, the patient will experience pain while doing this maneuver.
Brudzinki’s sign works on the principle that the hips and knees will flex upon flexion of the neck from the supine position in the presence of meningeal irritation. To test for Brudzinki’s sign, ask the patient to lie supine. Put one hand under the patient’s neck and the other on their chest or shoulder to prevent them from rising. Slowly flex the neck and observe for reflex flexion of the hips and knees upon flexing the neck, which constitutes a positive Brudzinki’s sign.
Apart from the above-mentioned signs, the patient may manifest signs of raised ICP that may include:
In the pediatric population, the symptoms of meningitis may include:
While examining a child for meningitis, check for bulging fontanelles. If the fontanelles are not closed, nuchal rigidity may not be present.
Inquire the child’s guardian for any history of upper respiratory tract infection. Most children develop meningitis after a URTI and may present with respiratory distress along with signs of meningitis.
The following tools can be useful in the diagnosis of meningitis:
As soon as meningitis is suspected, a lumbar puncture is done to draw CSF for analysis.
The CSF can be sent for the following analyses:
While drawing the CSF sample, the pressure should also be noted.
A lumbar puncture should not be done in patients with signs of raised intracranial pressure or if a space-occupying lesion is suspected. Those conditions can show up with the following signs:
In patients suspected of having a space-occupying lesion, it is best to do neuroimaging such as a CT scan or MRI first to exclude such possibility. After exclusion, a lumbar puncture can be performed.
Carrying out a lumbar puncture in patients with raised ICP or a mass lesion can result in brain herniation, which can be fatal.
Lumbar puncture is also contraindicated in patients with bleeding disorders. To carry out an LP, the bleeding disorder should be controlled first.
In the presence of infection at the needle insertion site, the needle can be inserted at a different site, usually at the C2 level of the cervical spine.
Blood should be sent simultaneously with LP to compare the glucose levels of CSF and the blood.
Blood should also be obtained for culture, especially in patients in whom lumbar puncture is not done due to contraindications. Empirical therapy should be started after sending blood for culture.
The following findings in the CSF indicate a bacterial infection:
The following findings in CSF indicate a viral infection:
To manage a patient with meningitis, the most critical primary aspects are to check the ABCs (Airway, Breathing, and Circulation) and rapidly administer antibiotic therapy.
If the patient’s airway is at risk, it can be supported by mechanical ventilation, intubation, or hyperventilation. Start antibiotics simultaneously. If the patient is seriously ill, antibiotics and corticosteroids are started immediately before lumbar puncture.
If a person is suspected of having meningitis and a lumbar puncture is delayed for neuroimaging, treatment with antibiotics and corticosteroids should not be delayed.
Other measures for caring for your patient with meningitis include ICP monitoring. The physician may prescribe osmotic diuretics like mannitol to bring down the ICP. For seizures, the physician will prescribe anticonvulsant medications.
Sometimes, you may need to involve the surgical team for the drainage of hydrocephalus or abscess. That is required to prevent permanent neurological deficits.
There are various things you should do to care for your patient with meningitis.
As the patient is admitted to the hospital, check the airway, breathing, and circulation. To maintain airway patency, you can intubate the patient.
Monitor the patient’s response to therapy. Check for improvement or deterioration in the patient’s health status. Patients with meningitis require a periodic assessment of vital signs and neurological examination.
Encourage the patient to have complete bed rest. Elevate the head at a 30-degree angle to relieve the intracranial pressure.
To prevent seizures, control the environment and keep noise and light stimuli low.
Control hyperthermia to prevent shivering. Assess the patient for fever periodically.
A patient with increased ICP may need clarification. If a patient is restrained and fights them, the ICP Institute implements safety precautions to prevent injury from raised ICP or seizures.
Reorient the patient to time, place, and person as they are. Patients may need help with increased ICP. Communicate with them and explain the disease process. Allow the family to meet with the patient to help them reorientate.
As the patient is on bed rest, implement measures to limit the effects of immobility. Skin care, range of motion exercises, and periodic turning and positioning of the patient are needed.
Once the acute phase settles, the need for rehabilitation begins. Assess the patient for any signs of permanent neurological deficits. If any dysfunction is present, a multidisciplinary rehabilitation program is needed to help the patient with rehabilitation.
Also, check the vision and hearing senses of the patient.
The treatment and care for the pediatric population are similar to that of adults. However, children may be agitated and irritable. To soothe a child, encourage the family to be around them. Familiar voices of parents and the soothing touch of mother helps them calm down. To comfort them, their favorite toys can be brought for them.
In children, growth and development are essential. After the acute phase, the child should move into rehabilitation. Observe the developmental progress in a child, and if the child lags in it, make appropriate referrals.
Meningitis is a serious infection that requires prompt management. If left untreated, it can have long-lasting effects. Mostly, it occurs due to bacterial causes, which have an aggressive course. Urgent antibiotic therapy helps in treating meningitis.
A patient with meningitis may be anxious and irritated. Sometimes, the family members may also be excessively worried. Therefore, counsel your patient and the attendant and explain the nature of the disease.
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