Meningitis and Encephalitis in the Older Patient

Posted by e-Medical PPT Sunday, April 8, 2012
Meningitis and Encephalitis: general features and causes
Diagnosis: review of CSF findings
Meningitis: specific causes
Encephalitis: specific causes
Zoom in on important arboviruses and tick-borne illnesses
Summary of diagnosis and treatment
Review of the cases

Inflammation of the meninges
Classic triad:
Severe, frontal, photophobia, n/v
Jolt accentuation
Meningismus/altered mental status

Meningeal signs
Kernig sign: one leg with hip flexed, pain in back with extension of knee
Brudzinski sign: flexion of legs and thighs when neck is flexed

Inflammation of the cerebral cortex
Fever, HA, altered mental status
Key: early mental status changes
More commonly viruses
Behavioral or speech problems, neurological signs, seizures
Difference from meningitis: less likely fever, more likely personality/behavioral changes

Meningitis in the Elderly
Decreased total incidence; increased in elderly
Increased prevalence of Listeria (25%)
30-50%: S. pneumoniae
Less likely Neisseria and Haemophilus
Less likely fever and meningeal signs; more likely neurological symptoms, seizure, coma
More often complicated by pneumonia
Older patients with neurological impairment: 50% mortality

Risk Factors
Age (bimodal peak)
Prior neurosurgery, alcoholism, malignancy, steroids, HIV, sinusitis, DM

Clinical suspicion
Triad: fever, nuchal rigidity, altered mental status: only seen in 40% elderly
Only 59% of elderly patients with acute bacterial meningitis had fever
Most have at least ONE symptom

The Diagnosis
LP if suspicion
Do not delay antibiotics if suspected!
CT prior to LP in patients with focal neurological deficits, seizures, HIV, or elderly
MRI: to identify areas of CNS involvement
Temporal involvement with HSV
Basilar meningitis with TB

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