If you have meningitis with trauma

If you have meningitis with trauma, post-op or shunt situation, make sure you are giving vancomycin. Now steroids in childhood meningitis is still a little bit controversial but I think most people now recommend a few days of steroids, especially children with meningitis. Especially if you happen to have H. influenza. Two, three or four days. Some people recommend two days of Decadron. This is basically to reduce the morbidity, brain edema, ICT due to tumor necrosis factor. So there is a lot of inflammation that can trigger brain edema. So steroids are supposed to reduce that.

What about contacts for Neisseria meningitidis? Rifampin for a few days. Family members, school contacts. Rifampin is the way to go. For H. influenza Rifampin is for the contacts also. Here’s a list for strep, Neisseria, H. influenza, Listeria. Ampicillin. If you have a gram-negative situation a whole lot of different combinations there, including metronidazole. Proteus, Pseudomonas, gentamycin. Staph aureus, vancomycin. So this again is pretty easy. This may vary from this list to your people. Nothing is carved in stone. Talk to your ID people. There may be some subtle variations on the theme. TB meningitis is associated with a very high risk of stroke, compression of optic nerve, extremely high protein, big time risk of hydrocephalus, basal adhesions. So steroids in TBM is accepted by most people.

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Viral meningitis. Patients are less sick, no focal features. CSF shows lymphocytes, glucose is normal. Easy. Here is a list of some of the common causes you look for. Enteroviruses, echo, Coxsackie B, polio, mumps, Herpes simplex I and II, Varicella zoster, Epstein-Barre, adenovirus, lymphocytic choriomeningitis, occasionally Influenza A and B. Now the differential diagnosis of viral meningitis includes partly treated bacterial meningitis. Look for cultures, look for how sick the patient is, look for antigens. Continue, in many cases, as if the patient has bacterial meningitis if you are not sure. One of the very important diagnostic helps in partly treated bacterial meningitis is EEG. EEG in viral meningitis is essentially normal but in bacterial meningitis, even if partly treated, often shows slow waves. So the EEG can be a very helpful test when you want to differentiate the two phenomena. Fungal meningitis produces a lot of lymphocytes. What’s the one important CSF change, the difference between virus and fungus? Glucose. In fungus, the glucose is low. In TB meningitis glucose is low.

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