Makindo Medical Notes

👥 Contacts: Chemoprophylaxis is not required for pneumococcal meningitis (unlike meningococcal). 🌟 Classic point: Pneumococcal meningitis usually has no rash.

📖 About

• Second most common cause of bacterial meningitis in the UK (after meningococcal in young adults; most common in the elderly).
• Caused by Streptococcus pneumoniae, a Gram-positive capsulated diplococcus.

⚠️ Risk Factors

• Older age, chronic alcoholism.
• Anatomical: skull fracture, CSF leak, cochlear implants.
• Immunocompromised states: splenectomy/asplenia, immunosuppressive therapy, HIV.
• Post-otitis media or sinusitis spread.

🩺 Clinical Features

• Headache, fever, photophobia, neck stiffness.
• Confusion, reduced GCS, seizures.
• No purpuric rash (unlike meningococcal).
• May present subacutely in elderly or immunocompromised.

🚨 Complications

• Sensorineural hearing loss (up to 50%).
• Hydrocephalus, cerebral oedema.
• Seizures, focal neurological deficits.
• Sepsis, pneumonia, arthritis.

🔎 Differentials

• Meningococcal meningitis (usually with purpuric rash).
• Viral meningitis (milder, lymphocytic CSF).
• TB meningitis (subacute, basal meningeal enhancement).
• Encephalitis (confusion + seizures prominent).
• Intracranial abscess (focal neurology, raised ICP).

🧪 Investigations

• CT head before LP if focal signs, seizures, or raised ICP → exclude mass, hydrocephalus, or fracture.
• CSF (LP): cloudy, high protein, low glucose, neutrophilia; Gram-positive diplococci in pairs.
• Blood cultures before antibiotics.
• Consider HIV/splenectomy screen in recurrent cases.

💊 Management

• 🏥 Admit HDU/ITU; ABC resuscitation.
• Empirical antibiotics: – Cefotaxime 2 g IV q6h OR Ceftriaxone 2 g IV q12h. – Add Vancomycin ± Rifampicin if resistant strain suspected (per microbiology advice). – If anaphylaxis to β-lactam: Chloramphenicol or Vancomycin IV.
• Dexamethasone: 0.15 mg/kg q6h for 2–4 days (give before/with first dose of antibiotics to reduce risk of hearing loss).
• Supportive: fluids, seizure control, ICP management.

🧾 Clinical Case Example

A 72-year-old woman with a history of splenectomy presents with 2 days of headache, fever, and confusion. She is febrile (38.9 °C), GCS 11/15, and photophobic. 🧪 CT head: no mass lesion, mild cerebral oedema. 🧪 LP: cloudy CSF, neutrophils 1,200/mm³, glucose 1.0 mmol/L (serum 6.0), protein 2.8 g/L. Gram stain: Gram-positive diplococci. 👉 Diagnosis: Pneumococcal meningitis. 👉 Management: IV ceftriaxone + dexamethasone, escalate to ITU, infection control notes no need for contact prophylaxis.

📚 References

• NICE: Bacterial meningitis and meningococcal septicaemia
• UKHSA: Guidance on meningitis and meningococcal disease