Meningitis & Encephalitis Nursing

⚠ EMERGENCY: Bacterial meningitis mortality 20-30% without prompt treatment. Do NOT delay antibiotics for LP or imaging.

Classic Triad

Present in only 44% of patients. Absence does NOT rule out meningitis.

Headache — severe, sudden onset
Fever — temperature >38°C
Neck stiffness (nuchal rigidity)

Additional Features

Photophobia / phonophobia
Nausea, vomiting, confusion
Petechial/purpuric rash — NON-BLANCHING = EMERGENCY
Seizures (20-40% of cases)

Clinical Signs

Kernig's Sign

Hip flexed to 90° — knee extension is painful/resisted due to meningeal irritation

Brudzinski's Sign

Passive neck flexion → involuntary hip and knee flexion

Rash — Glass Test

Press glass on petechial rash. Does NOT blanch = meningococcal septicaemia. Give ceftriaxone NOW.

CSF Findings

Parameter	Normal	Bacterial	Viral	TB / Fungal
Appearance	Clear	Turbid/Purulent	Clear	Clear/Fibrin web
WBC	<5/mm³	100-50,000 (neutrophils)	10-1000 (lymphocytes)	100-500 (lymphocytes)
Glucose	2.5–4.5 mmol/L	<2.2 mmol/L	Normal	Very low
Protein	0.15–0.45 g/L	Raised >1 g/L	Mildly raised	Markedly raised

Empirical Treatment Protocol

Give antibiotics BEFORE LP if LP delayed >30 min or patient unstable.

Ceftriaxone 2g IV 12-hourly (N. meningitidis + S. pneumoniae)
Dexamethasone 0.15mg/kg IV BEFORE or WITH first antibiotic dose
Add Ampicillin 2g IV if Listeria risk (age >50, immunocompromised)
Blood cultures BEFORE antibiotics — but do not delay for cultures

Causative Organisms by Age

Age	Key Organisms
Neonates (<3 months)	GBS E. coli Listeria
Children (3m–5y)	N. meningitidis H. influenzae
Adults (16–50y)	N. meningitidis S. pneumoniae
>50y / immunocomp.	S. pneumoniae Listeria
Hajj / GCC pilgrims	N. meningitidis W135

Nursing Emergency Actions — First 60 Minutes ▼

0–5 min
Call senior/MET
IV access x2
Blood cultures
Give antibiotics NOW

5–30 min
FBC, CRP, coag, LFT
Blood glucose
CT if indicated
LP when safe

Ongoing
Neuro obs hourly
Droplet precautions
Contact tracing
Notify public health

HSV encephalitis: Untreated mortality 70%. Start IV aciclovir IMMEDIATELY on clinical suspicion — do not wait for MRI/EEG.

HSV Encephalitis

Classic: Temporal lobe involvement → personality change, bizarre behaviour, complex partial seizures, olfactory hallucinations, aphasia

Aciclovir 10mg/kg IV TDS (every 8 hours) for 14–21 days
Adjust for renal function. Ensure adequate hydration (nephrotoxic).

MRI: T2/FLAIR hyperintensity in temporal lobes
EEG: Temporal lobe PLEDs (periodic lateralised epileptiform discharges)
CSF PCR for HSV-1 (sensitivity 96%, specificity 99%)
CSF: lymphocytosis, mildly raised protein, normal glucose

Anti-NMDA Receptor Encephalitis

Young females, psychiatric prodrome mistaken for schizophrenia

Psychiatric prodrome (psychosis, agitation)
Orofacial dyskinesias (lip smacking, chewing)
Seizures, autonomic instability
Screen for ovarian teratoma (USS/CT pelvis)
Tx: IVIG, plasmapheresis, steroids; tumour removal
Diagnosis: anti-NMDA receptor antibodies in CSF/serum

GCC-Relevant Viral Encephalitides

Virus	GCC Relevance	Key Features	Treatment
West Nile Virus	Vector-borne Culex mosquito, Gulf region	Flaccid paralysis, tremors, fever	Supportive
Enterovirus	Faeco-oral, common in children	Aseptic meningitis, HFMD	Supportive; IVIG if immunocompromised
Japanese Encephalitis	Migrant workers from Asia	Extrapyramidal / Parkinsonian features	Supportive; JE vaccine available
Rabies	Animal bites; GCC animal exposure	Hydrophobia, aerophobia, agitation	Post-exposure: HRIG + vaccine
VZV	Reactivation in elderly/immunocomp	Zoster rash + neurological features	IV aciclovir 10–15mg/kg TDS

Encephalitis vs Meningitis — Key Differences ▼

Feature	Meningitis	Encephalitis
Brain parenchyma	No (meninges only)	Yes
Consciousness	Usually preserved early	Often impaired
Focal neurology	Uncommon	Common
Psychiatric features	Uncommon	Common
MRI changes	Meningeal enhancement	Parenchymal (temporal lobe HSV)

Rabies Post-Exposure Prophylaxis Protocol ▼

Category III (deep bite, mucous membrane): HRIG 20 IU/kg + vaccine (days 0,3,7,14)
Category II (minor bite, scratches): Vaccine only
Wound wash with soap and water for 15 minutes IMMEDIATELY
No proven treatment once symptomatic — 100% fatal
GCC: Vaccinate animal care workers, outdoor workers, travellers

Before LP: Always check for contraindications. LP in raised ICP can cause fatal brainstem herniation.

Contraindications — CT Brain First

Absolute — CT Required Before LP

Papilloedema (raised ICP)
Focal neurological deficit
GCS <13 or deteriorating
New onset seizures
Immunocompromised status

Relative

Coagulopathy / anticoagulation (INR >1.5, platelets <50)
Local skin infection at LP site

Patient Positioning

Lateral Decubitus (Preferred)

Left lateral, knees drawn to chest (fetal position)
Chin to chest — maximises intervertebral space
Nurse holds patient — reassure and keep still

Seated (Alternative)

Seated on edge of bed leaning over pillow
Cannot measure opening pressure accurately
Useful in obese patients

Interspace: L3/L4 or L4/L5 (level of iliac crests). Conus ends at L1–L2 — LP below is safe.

CSF Sample Collection & Labelling

Label tubes in order. Do not mix up — cell count degrades within 1 hour.

Tube	Volume	Test	Lab
Tube 1	1–2 mL	Cell count, RBC (traumatic tap vs true blood)	Haematology
Tube 2	1–2 mL	Glucose, protein, lactate	Biochemistry
Tube 3	1–2 mL	Culture, Gram stain, PCR, India ink	Microbiology
Tube 4	1 mL	Spare — cytology, virology, special tests	Spare/Cytology

Opening Pressure: Normal 6–18 cmH₂O. >25 cmH₂O = raised ICP. Measure in lateral decubitus before draining fluid.

Post-LP Care

Bed rest 4 hours post-procedure (flat/slight head-down)
Vital signs + neuro obs every 30 min × 2 hours
Encourage oral fluids (2–3 L/day)
Assess for post-LP headache (positional — worse upright)
Warn: headache may develop 24–48h later
Check site for bleeding, CSF leak, haematoma

Post-LP Headache Management

Positional frontal/occipital headache, worse upright, relieved by lying flat. Occurs 10–30% of LPs.

1st line: Bed rest, hydration, paracetamol, NSAIDs
Caffeine 300mg oral/IV — effective in 80%
Epidural blood patch 15–20 mL autologous blood — 98% effective for refractory PDPH
Use smaller gauge needle (22G/25G pencil-point) to reduce incidence

LP Procedure Checklist — Nursing Role ▼

Confirm written informed consent obtained
Check coagulation, platelets; review anticoagulants/antiplatelets
Gather equipment: LP kit, sterile gloves, drapes, LA, manometer
Position patient correctly; maintain sterile field
Assist doctor — pass equipment using sterile technique
Record opening pressure on manometer
Label tubes 1–4 correctly and in order
Transport to lab immediately
Document: time, pressure, tube appearance, patient tolerance

Key principle: Early detection of deterioration allows intervention before irreversible injury. Hourly neuro obs are standard in CNS infections.

GCS — Glasgow Coma Scale

Component	Response	Score
Eyes (E)	Spontaneous	4
	To voice	3
	To pain	2
	None	1
Verbal (V)	Orientated	5
	Confused	4
	Words	3
	Sounds	2
	None	1
Motor (M)	Obeys commands	6
	Localises pain	5
	Withdraws	4
	Abnormal flexion	3
	Extension	2
	None	1

Report immediately: Any drop of 2+ GCS points

Pupil Assessment — PEARL

Pupils Equal And Reactive to Light

Abnormal — Report Immediately

Unilateral dilated & fixed — CN III compression (herniation)
Bilateral fixed dilated — severe brainstem dysfunction
Pinpoint pupils — opiate overdose / pontine lesion
Anisocoria >1mm — investigate

Document Every Hour

Size in mm (2–6 normal)
Reaction: brisk (+++) / sluggish (+) / absent (-)
Consensual light reflex

Raised ICP Management

Head Positioning
Elevate HOB 30°
Midline head position
Avoid neck flexion
Avoid tight collar

Osmotherapy
Mannitol 0.25–1g/kg IV over 20 min
OR 3% hypertonic saline
Monitor Na⁺, osmolarity
Avoid hyponatraemia

Avoid
Hypotension (CPP = MAP−ICP)
Hypercapnia (CO₂ raises ICP)
Hypoxia (SpO₂ <94%)
Hyperthermia

Cushing's Triad (LATE SIGN — EMERGENCY): Hypertension + Bradycardia + Irregular breathing = Imminent brainstem herniation → Call emergency team, prepare for intubation

Seizure Management

Protect airway — lateral position, oxygen
Time the seizure; do NOT restrain
Lorazepam 0.1mg/kg IV (max 4mg) — first line
No IV access: Midazolam 10mg buccal/IM
2nd line: Levetiracetam 60mg/kg IV or Phenytoin 20mg/kg IV
Status (>30 min): RSI, ICU, general anaesthesia

Temperature & Fluid — SIADH

Temperature Control

Hyperthermia worsens outcome — increases CMRO₂
Paracetamol 1g IV/oral QDS; cooling blanket if >38.5°C
Target normothermia 36.5–37.5°C

Fluid — SIADH Common in Meningitis

Restrict fluids if Na⁺ <135 mmol/L
Correct Na⁺ slowly: max 10 mmol/L per day
(Risk: central pontine myelinolysis if corrected too fast)

Meningococcal meningitis: Droplet precautions until 24 hours AFTER effective antibiotics. Notify public health immediately.

Isolation Precautions

Organism	Precaution	Duration
N. meningitidis	Droplet	24h after antibiotics
S. pneumoniae	Standard	No isolation
HSV encephalitis	Standard	No isolation
Enterovirus	Contact	Duration of illness
TB meningitis	Airborne	3 negative sputum
Varicella zoster	Airborne + Contact	Until crusted over

Chemoprophylaxis for Contacts

Close contacts of meningococcal meningitis need prophylaxis within 24 hours of index case.

Who Needs Prophylaxis?

Household contacts / kissing contacts
HCW performing unprotected intubation or mouth-to-mouth

Regimens

Drug	Dose	Duration
Rifampicin	600mg BD (adult)	2 days
Ciprofloxacin	500mg single dose (adult)	Single dose
Ceftriaxone	250mg IM (adult)	Single dose

Hajj / Umrah — GCC Mass Gathering Meningitis Risk

Saudi MOH Mandatory: MenACWY vaccination is COMPULSORY for all Hajj and Umrah pilgrims.

Why High Risk?

2+ million pilgrims from 180+ countries
Close proximity in Masjid al-Haram, tents, transport
N. meningitidis serogroup W135 outbreak — Hajj 2000
Novel strains, elderly/immunocompromised pilgrims

Saudi MOH Nursing Role

Verify vaccination certificate at port of entry
MenACWY at least 10 days before Hajj
Screen pilgrims for fever/neck stiffness on arrival
Report clusters to Saudi MOH immediately
Stock ceftriaxone and rifampicin in Hajj clinics

Vaccination Schedule

Vaccine	Target Group	GCC
MenACWY	Hajj/Umrah pilgrims, students	Mandatory Hajj
MenB	Infants, adolescents	Recommended
PCV13/PCV23	Age >65, immunocomp., asplenia	Recommended
Hib	Children <5y, asplenic	National schedule
BCG	Neonates	Mandatory

Public Health Notification

Meningococcal meningitis is a NOTIFIABLE DISEASE in all GCC countries.

Notify public health within 24 hours of diagnosis
Complete notifiable disease form (MOH form)
Provide contact list for prophylaxis follow-up
Cluster of 2+ cases = immediate outbreak response
Document vaccination status of all contacts

GCC Exam Focus: DHA/DOH/SCFHS frequently test meningitis protocols, LP complications, and Hajj health requirements.

TB Meningitis — GCC Migrant Worker Risk

High risk: Migrant workers from TB-endemic regions — large population in UAE, Saudi Arabia, Qatar.

CSF Findings in TB Meningitis

Lymphocytes (not neutrophils)
Very low glucose (<2.2 mmol/L)
Markedly raised protein (>1 g/L)
Fibrin web in CSF
CSF PCR for M. tuberculosis (rapid, 70% sensitivity)

Treatment: RIPE x 2 months → RIP x 10 months + dexamethasone

Cryptococcal Meningitis

Setting: Immunocompromised — HIV (CD4 <100), transplant, high-dose steroids

Subacute onset (weeks) — headache, fever
India ink stain — encapsulated budding yeast
Cryptococcal antigen (CrAg) serum/CSF sensitivity >95%
Very raised opening pressure (>40 cmH₂O)

Treatment

Induction: Amphotericin B + Flucytosine × 2 weeks
Consolidation: Fluconazole 400mg daily × 8 weeks
Serial therapeutic LPs to control raised ICP

DHA / DOH / SCFHS Exam MCQs

Q1. A 22-year-old Hajj pilgrim presents with fever, severe headache, and a non-blanching petechial rash. What is the MOST appropriate immediate nursing action?

A. Perform a lumbar puncture immediately

B. Obtain CT head before any treatment

C. Administer IV ceftriaxone 2g immediately and apply droplet precautions

D. Isolate and wait for blood culture results

Non-blanching rash with meningism = meningococcal septicaemia. Antibiotics IMMEDIATELY. Do NOT delay for LP, CT, or cultures. Droplet precautions until 24h after antibiotics.

Q2. When performing a lumbar puncture, which tube is sent to the microbiology laboratory?

A. Tube 1

B. Tube 2

C. Tube 3

D. Tube 4

Tube 1 = cells (haematology), Tube 2 = biochemistry (glucose, protein), Tube 3 = microbiology (culture, Gram stain, PCR), Tube 4 = spare/cytology.

Q3. A patient is diagnosed with HSV encephalitis. Which feature is MOST characteristic?

A. Basal ganglia calcification on CT

B. Cerebellar ataxia and nystagmus

C. Temporal lobe involvement with complex partial seizures and behavioural change

D. Symmetrical flaccid limb weakness

HSV-1 encephalitis classically involves the temporal lobes. Features: personality change, bizarre behaviour, olfactory hallucinations, complex partial seizures. MRI: T2 hyperintensity temporal lobes. EEG: PLEDs.

Q4. A post-LP patient develops a severe positional headache 24 hours later, relieved by lying flat. What is the FIRST-LINE treatment?

A. Epidural blood patch

B. Bed rest, oral hydration, paracetamol, and caffeine

C. Repeat lumbar puncture

D. IV morphine infusion

Post-dural puncture headache (PDPH): treat conservatively first — bed rest, hydration, paracetamol, NSAIDs, caffeine 300mg. Epidural blood patch is 2nd line (refractory cases), 98% effective.

Q5. Which CSF finding is MOST consistent with TB meningitis in a migrant worker?

A. Neutrophil pleocytosis, very low glucose, turbid CSF

B. Normal cells, normal glucose, raised protein

C. Lymphocyte pleocytosis, very low glucose, markedly raised protein, fibrin web

D. Lymphocyte pleocytosis, normal glucose, mildly raised protein

TB meningitis: lymphocytic pleocytosis, very low glucose, markedly raised protein, fibrin web. Option D = viral meningitis. Option A = bacterial meningitis.

🚨 Meningitis Red Flag Emergency Checker

Select all signs and symptoms present, then press "Check Urgency" to determine response level and nursing actions. Assessment saved automatically.

Non-blanching rash (petechiae/purpura)

GCS <13 or deteriorating consciousness

Seizure (current or recent)

Focal neurological deficit

Signs of raised ICP (papilloedema)

Immunocompromised patient

Fever + Neck stiffness + Photophobia