Encephalitis and Meningococcal Infections

8/6/2019 Encephalitis and Meningococcal Infections

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Encephalitis

(Brain Fever)

Definition

Encephalitis is an acute inflammatory condition or infection of the brain usually

occurring as a complication or sequel to some viral diseases characterized by various

degrees and manifestations of cerebral dysfunction.

Etiologic Agent

The causative factor generally remains unknown or maybe caused by a variety of

pathologic agents including bacteria, viruses, fungi, rikettsia, toxins, chemical

substances or trauma.

Rikettsia - Rickettsia are bacteria, which are obligate intracellular parasites

many disease-causing, that live in vertebrates and are transmitted by bloodsucking

parasitic arthropods such as fleas , lice and ticks. Rickettsias unlike other

bacteria, but like viruses, they require a living host (a living cell) to survive

1. Virus

Virus encephalitis can be due to the direct effects of an acute infection, or as one

of the sequelae of a latent infection. A common cause of encephalitis in human is

herpes (HSE). It causes inflammation of the brain.

Herpes (HSE) - Herpes of the brain is called herpes simplex encelpalitis and is a

very serious health disorder. HSE is caused by HSV-2 and is asscoiated with

repeated outbreaks of genital herpes.

HSE causes inflammation of the brain and can affect people of any age although

typically it will appear in the person who already has genital herpes and who has

had repeated outbreaks.

2. Bacteria

It can be caused by a bacterial infection such as bacterial meningitis spreading

directly to the brain (primary encephalitis), or may be a complication of a current

infectious syphilis (secondary encephalitis).


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3. Certain parasitic or protozoal infestations, such as toxoplasmosis, malaria or

primary amoebic meningoencephalitis, can also cause encephalitis in people with

compromised immune systems. Lyme disease and/or Bartonella henselae may

also cause encephalitis.

The virus of Arthropod-borne viral encephalitis belongs to the group of

arboviruses. The natural habitat of these viruses appears to be many species of wild

birds and some domestic birds that live in a symbiotic relationship with several knownspecies of mosquitoes, many of which belong to the culex group.

Toxoplasmosis - disease caused by the sporozoan Toxoplasma gondii, especially:

a. A congenital disease characterized by lesions of the central nervoussystem that can cause blindness and brain damage.

b. An acquired disease characterized by fever, swollen lymph nodes, and

lesions in the liver, heart, lungs, and brain.

Arbovirus Arbovirus is short for arthropod-borne virus. Arboviruses are a large

group of viruses that are spread by certain invertebrate animals (arthropods),

most commonly blood-sucking insects.

Culex group subgroup of mosquito

Incubation period

The incubation period is 5 - 15 days, with a range from 4 21 days.

Mode of Transmission

It is transmitted to human by a bite of an infected mosquito. The mosquito

becomes infected by biting an infected bird and after incubating the virus in its own body

for five to seven days, the mosquitoes carry the virus to healthy birds, horses, pigs and

humans. Infection of man is the end of the cycle, since the infection is not transmitted

from man to man and mosquitoes do not carry the virus from humans.

Classification


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1. Primary Encephalitis an infection caused by direct invasion of the CNS by the

virus resulting to an inflammatory reaction. These arthropod-borne viruses as

follows:

a. Eastern Equine Encephalitis (EEE)

Considered as a serious epidemic diseases of the horses

Principally affecting children under 5 years of age.

The virus can multiply in the Aedes sullicitans mosquito

b. Western Equine Encephalitis (WEE)

Milder and usually affecting adults

c. St. Louis Encephalitis

The organism believed to gain entrance through the olfactory tract

Caused by bite of an infected mosquito Culex tarsalis

d. Japanese Encephalitis

A potentially severe viral disease that is spread by bite of an infected

mosquito, Culex triteaniorhyncus, that live in rural rice growing and pig

farming regions. The mosquito breeds in flooded rice field and standingwater around planted fields. Once the mosquito is infected, it will carry

the virus and capable of transmitting the disease for life. There is no

evidence of human to human transmission.

Affecting children 5 10 years old; more in male than in female with

the ration of 3:1

Case fatality rate is 30 35%

Peak season for JE is March April; September October where ricefields are flooded to hasten growth of the plants that also favor the

breeding place for the mosquitoes.


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2. Secondary Encephalitis

a. Post Infection Encephalitis usually a complication or a sequelae to some

viral diseases like measles, chicken pox and mumps.

b. Post Vaccinal Encephalitis most common is anti-rabies vaccine

Clinincal Manifestations

A. Japanese Encephalitis

Flu-like symptoms (fever, chills, headache, nausea, vomiting)

Stiff neck, confusion, neurologic manifestations occur within 72 hours(drowsiness, seizures, bizarre, coma)

Decreased IQ

Serious brain damage

B. General Manifestations

During the prodromal period (1 - 4 days), patient experience fever,

headache, vomiting and apathy.

Prodromalperiod: the time during which a disease process has begun but is not yet

clinically manifest.

Chills, sore throat, conjunctivitis, arthralgia, myalgia and abdominal pain.

Athralgia joint pain

Myalgia means "muscle pain" and is a symptom of many diseases and disorders. The

most common causes are the overuse or over-stretching of a muscle or group ofmuscles.

Nuchal rigidity - stiffness in the nape of the neck, often accompanied by pain and


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spasm on attempts to move the head; the most common sign of meningitis.

Ataxia - is a neurological sign and symptom that consists of gross lack ofcoordination of muscle movements

Stupor - is the lack of critical cognitive function and level of consciousness

wherein a sufferer is almost entirely unresponsive and only responds to basestimuli such as pain.

Ptosis - is a (drooping) of the upper or lower eyelid.

Occularpalsy Paralysis of 2/3 of face due to cavernous sinus thrombosis

Flaccid- lacking firmness, resilience, or muscle tone ; lacking vigor or energy

Phonation voicelessness

Later, the patient go through encephalitic signs, manifested by nuchal

rigidity, ataxia, tremors, mental confusion, speech difficulties, stupor or

hyperexcitability, convulsion, coma and death.

Ocular palsy, ptosis, and flaccid paralysis

Disturbances in swallowing, mastication, phonation, respiration and

movements of the muscles of the eyes or face.

Uncontrollable contraction or twitching of the muscles of the different partsof the body.

Diagnostic Exams

1. CSF Analysis

2. Serologic Tests 90% confirmatory, usually done on the 7th day of illness

3. ELISA (IgM)

4. Polymarase Chain Reaction


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Sequelae

I. Motor Disturbances

Persistent convulsions

Parkinsonian syndrome or paralysis agitans

Epylepsy-like manifestations

II. Mental Disturbances

Mental dullness

Mental retardation

Lethargy

Mental depression

Sleep disturbances

III. Endocrine Disturbances

Patient may grow fat or thin

Sexual interest or activity is lost

Nursing Management

1. Symptomatic and supportive

2. Control of convulsion (Diazepam and Barbiturates) as ordered

3. Sanitary disposal of nose and throat secretions


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4. TSB or alcohol sponges maybe given if the temperature is exceedingly high

5. Unless is patient is comatose, oral fluid should be encouraged

6. Oral care should be strictly done

7. A mouth gag and protective devices, such as bedrails, should be available in

case convulsion occurs.

8. Intake and output records are closely monitored

9. Patient should be observed for neurologic signs involving speech, swallowing

difficulty, twitching, eye movements and indications of paralysis.

10. The beginning, duration and frequency of all convulsions should be carefully

observed and recorded.

Prevention and Control

1. Preventive measures are directed toward the identification of mosquito vectors.

2. Elimination of breeding places, destruction of larvae, screening of homes, use of

repellents

3. A broad public education program is an important phase of all preventive

program.


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Meningococcal Infections

There are two major types of meningococcal infections: meningitis and

meningococcemia

I. Meningitis (Cerebrospinal Fever)

Definition

The inflammation of the meninges of the brain and spinal cord as a result of viral

and bacterial infection

Such inflammation may involve the three meningeal membranes, the dura

matter, the arachnoid and the pia matter

Etiologic Agent

The disease can be caused by several kinds of organisms, which include the

pneumococcus, staphylococcus, streptococcus and tubercle bacillus. The specie

Neiserria meningitides (meningococcus) is the organism causing most epidemics of

meningitis which also can cause primary pneumonia, purulent conjunctivitis,

endocarditis, sinusitis and genital infections.

Incubation Period

Incubation period is variable, the extreme limits being set from 1 10 days.

Mode of Transmission

Respiratory droplets through nasopharyngeal mucosa

By direct invasion through otitis media

May also follow skull fracture, a penetrating head wound, lumbar puncture or

ventricular shunting procedures

Viral meningitis is usually a result of a complication of an existing viral infection.


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Diagnostic Procedures

1. Lumbar Puncture (CSF)

Purpose of Lumbar Puncture

a. Diagnostic purpose

To obtain specimen, the CSF

To take x-ray of the spinal canal and cord

b. Therapeutic purposes

To reduce intracranial pressure

To introduce serum and other medications

To inject an anesthetic agent

2. Gram Stain

3. Smear and blood culture

4. Smear from petechiae

5. Urine culture

Types of Meningitis

1. Aseptic Meningitis

A benign syndrome characterized by headache, fever, vomiting andmeningeal symptoms

Begins suddenly with fever up to 40C, alterations in consciousness

(drowsiness, confusion, stupor), neck and spine stiffness, which is slight at

first.


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Characteristic sign of meningeal irritation

a. Stiff neck or nuchal rigidity

b. Opisthotonus

- isa state of a severe hyperextension and spasticity in which anindividual's head, neck and spinal column enter into a complete

"bridging" or "arching" position.[1] This abnormal posturing is anextrapyramidal effect and is caused by spasm of the axial

muscles along the spinal column.

c. (+) Brudzinskis sign

Flexion of the hips when the neck is flexed from a supine

position.

d. (+) Kernig sign

A sign of meningeal irritation evidenced by reflex contractionand pain in the hamstring muscles, when attempting to extendthe leg after flexing the hip.


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e. Exaggerated and symmetrical deep tendon reflexes

Sinus arrhythmia, irritability, photophobia, diplopia and other visual

problems

Delirium, deep stupor and coma

Arrhythmia - An irregularity in the force or rhythm of the heartbeat.

Irritability is a state of extreme sensitivity to stimulation of any kind.

Photophobia is a symptom of abnormal intolerance to visual perception of light,sometimes additionally defined by abnormal or irrational fear of light

Diplopia double vision

Delirium- temporary state of mental confusion and fluctuating consciousness

resulting from high fever, intoxication, shock, or other causes. It is characterizedby anxiety, disorientation, hallucinations, delusions, and incoherent speech.

Signs of intra-cranial pressure

a. Bulging fontanel in infants

b. Nausea and vomiting (projectile)

c. Severe fontanel headache


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d. Blurring of vision

e. Alteration in sensorium

Sensorium: The totality of those parts of the brain that receive, process and

interpret sensory stimuli. The sensorium is the supposed seat of sensation, the

place to which impressions from the external world are conveyed and perceived.

The sensorium also refers to the entire sensory apparatus of the body.

In medicine, "sensorium" is sometimes used as a generic term for the intellectual

and cognitive functions.

Complications

1. Subdural effusion

2. Hydrocephalus

3. Deaf-mutism

4. Blindness of either one or both eyes

5. Otitis media and mastoiditis

6. Pneumonia or bronchitis

Subdural effusion is a collection of fluid beneath the outer lining of the brain. If

this fluid becomes infected, the condition is called a subdural empyema.

Causes, incidence, andrisk factors:

A subdural effusion is a rare complication of bacterial meningitis. Subdural

effusion is more common in infants and in persons who have meningitis caused by

Haemophilus influenzae.

Hydrocephalus, also known as "water on the brain," is a medical condition in which

there is an abnormal accumulation of cerebrospinal fluid (CSF) in the ventricles,


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or cavities, of the brain.

Deaf-mutism - congenital deafness that results in inability to speak

Mastoiditis is an infection of mastoid process, the portion of the temporal bone

of the skull that is behind the ear which contains open, air-containing spaces.[1][2]

It is usually caused by untreated acute otitis media (middle ear infection) and

used to be a leading cause of child mortality.

Modalities of Treatment

If meningitis is left untreated it has a mortality rate of 70% - 100%

Treatment includes appropriate antibiotic therapy and supportive care

management

Usually IV antibiotics are given for two weeks and are followed by oral antibiotics

such as:

y Ampicillin

y Cephalosporin (Ceftriaxone)

y Aminoglycosides

Digitalis glycosides ( digoxin) to control arrhythmias

Manitol to decrease cerebral edema

Anticonvulsant or sedative to reduce restlessness and convulsion

Acetaminophen to relieve headache and fever

II. Acute Meningococcemia

Most common among children, ages 6 months to five years old

Following an incubation period of 3 4 days meningococci invade the

bloodstream, the joints, the skin, the adrenal glands, the lungs, without invading

the mininges.


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Usually it starts with nasopharyngitis followed by sudden onset of spiking grade

fever with chills, nausea, vomiting, malaise and headache

Petechial, purpuric or ecchymotic hemorrhages scattered over the entire body

and mucous membrane, which could be due to acute vasculitis followed by

suppurative necrosis and hemorrhage into the dermal connective tissues.

Purpura is purple-colored spots and patches that occur on the skin, organs, and in

mucus membranes, including the lining of the mouth.

Purpura occurs when small blood vessels under the skin leak.

When purpura spots are very small, they are called petechiae. A petechia is a small

(1-2mm) red or purple spot on the body, caused by a minor hemorrhageLarge purpura are called ecchymoses.

Vasculitis is a term for inflammation of the blood vessels. The inflammation canaffect any of the vessels including capillaries, venules, arterioles and lymphatics.

The adrenal lesions start to bleed into the medulla which extends to the cortex.

The combination of the dermal manifestations and adrenal medullary

hemorrhage, is known as Waterhouse-friderichsen syndrome

Waterhouse-friderichsen syndrome is the rapid development of petechiae to

purpuric and ecchymotic spots in association with shock

The condition runs short course and is usually fatal. This frequently occurs in

fulminant type of meningococcemia.

Nursing Management for Aseptic Meningitis

1. Asses neurologic condition of the patient

Observe the patients level of consciousness and check for signs of

increased intracranial pressure (ICP) manifested by:


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y Plucking at bedcovers

y Projectile vomiting

y Seizures, changes in motor functions and vital signs

Watch for deterioration of patients condition, which may be a signal for an

impending crisis

Monitor fluid balance.

y Maintain adequate fluid to avoid dehydration, but avoid fluid

overload because of danger of cerebral edema.

y

y

Measure central venous pressure and intake and output

Watch for adverse reaction of antibiotics and other drugs. Avoid IV

infiltration and phlebitis.

Infiltration, or tissuing, describes leakage of fluids or blood fromdamaged blood vessels as a result of medical interventions.

Phlebitis, also called superficial venous thrombosis or superficialthrombophlebitis, is a blood clot that develops in a vein close to the

surface of the skin

Position the patient carefully to prevent joint stiffness and neck pain.

y Turn him often to avoid pressure sores and respiratory

complications

y Assist with ROM, passive or active.

y Maintain adequate nutrition and elimination

y Ensure patients comfort

y Provide reassurance and support to the patient and the family.


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y Follow strict aseptic technique when treating patients with head

wounds or skull fractures

y Isolation is necessary especially if nasal culture is positive.

Prevention

Several vaccines are available to protect against certain types of meningitis.

Teach clients with chronic sinusitis or other chronic infections about the

importance of proper and prompt medical treatment and diagnosis.

MCV4 should be used in people ages 2 through 55 years in these risk groups, but

MPSV4 can be used if someone has a permanent contraindication or precaution to

the use of MCV4. MPSV4 is the only licensed meningococcal vaccine product that

can be used in adults 56 years or older.


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Portals of entry resulting in meningitis, meningoencephalitis, andintracranial mass lesions.


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CULEX TARSALIS


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Bruzinskis Sign

Flexion of the hips when the neck is flexed from a supine position.

Kernig Sign A sign of meningeal irritation evidenced by reflex contraction and pain inthe hamstring muscles, when attempting to extend the leg after flexing the hip.

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Encephalitis and Meningococcal Infections

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