ZSFG AM Report Pearls 7.11.17 – Does Bacteremia Cause Meningitis and Seizure?

Thank you to Kenny and Annsa for presenting the case of a women who presented with altered mental status and falls who was found to have severe sepsis secondary to a urinary source, who also developed seizures.

******************************************************

Top Peals:

  • Gram negative rod bacteremia (except for H. flu) does not typically cause meningitis in adults.
  • Meningitis from bacteremia should be considered in staph aureus bactermia in the setting of endocarditis.
  • New-onset seizures (even in the setting of severe sepsis), merits an independent work-up (See DDx and Approach below).
  • Lumbar puncture can still provide meaningful cell counts, chemistries and cytology up to 48-72 hours after antibiotics (and possible beyond, but this is the timeframe that has been studied).

*******************************************************

Bacterial Meningitis:

  • Typical Organisms:
    • Streptococcus pneumoniae (most common for all ages)
    • Neisseria meningitides
    • Haemophilus influenze
    • Listera monocytogenes (increasing prevalence with age)
    • Group B streptococcus

 

  • Mechanisms for Developing Meningitis
    • Direct entry of organisms into the CNS from a contiguous infection (e.g. sinuses, mastoid), trauma, neurosurgery, a CSF lead or medical device
    • Colonization of the nasopharynx, with subsequent bloodstream invasion followed by CNS invasion
    • Invasion of the CNS following bacteremia due to a localized source, such as infective endocarditis

Causes of Bacterial meningitis

  • What If The LP is Delayed?
    • REMEMBER: Don’t delay antibiotics to get the LP
    • You can still get blood cultures, even if you cannot get the LP
    • Antibiotics have MINIMAL effect on chemistry and cytology findings (up to 48-72 hrs) BUT can reduce the yield of gram stain and culture
    • However, a pathogen can still be cultured several hours after antibiotics (except meningococcal infxn which has dramatically lower yield)

 

New Onset Seizure:

  • Etiology:
    • New onset epilepsy is most common
    • Only 1 in 6 have identifiable cause
    • Pre or peri-natal brain injury
    • Cerebrovascular disease
    • Head trauma
    • Brain tumor
    • EtOH use
  • Neuroimaging:
    • Warranted in all adults with new seizure
    • Head CT done 1st to eval for bleed or large mass
    • MRI is more sensitive and may be needed afterwards
  • Prognosis:
    • 1/2 or pts with single unprovoked seizure and 3/4 of those with multiple seizures will have another seizure in the next 9 years
    • Need to consult neuro and evaluate case by case if new seizure

Courtesy of Rachel Stern, here is an approach to first seizure.

Suspected Seizure

 

Sources:

 

Evernote:

 

 

 

 

 

 

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s