CSF and Meningitis

A neonate acquires meningitis during delivery. Which of the following organisms should be suspected? A) Escherichia coli and Streptococcus agalactiae B) Haemophilus influenzae and Neisseria meningitidis C) Haemophilus influenzae and Streptococcus pneumoniae D) Listeria monocytogenes and Neisseria meningitidis E) Staphylococcus aureus and Staphylococcus epidermidis

A

What is the typical Order of Collection for CSF fluid into tubes?

Tube 1:◦ Chemistry and immunological testing. [Most contaminated fluid]∙ Tube 2:◦ Microbiology∙ Tube 3:◦ Hematology, Cell Count [Usually least contaminated]∙ Tube 4:◦ Optional, Micro

How does neonatal GBS acquisition usually occur?

Vertical transmission from mother to infant

What is KERNIG'S sign?

When the thigh is flexed at 90 degrees, the KNEE is incapable of straightening

What is the best medium for growth of S. pneumoniae ?

blood agar plate (BAP), which is a trypticase soy agar (TSA) plate containing 5% sheep blood. Human blood is NOT an acceptable substitute for the blood in the agar because the antibodies contained in human blood may inhibit bacterial growth

Haemophilus etymology

haemo, "blood" ; hilos, "lover" ("blood lover"; requires blood for growth on media)

What is Waterhouse-Friderichsen syndrome?

Particular form of disseminated meningococcus with death resulting from adrenal insufficiency due to hemorrhage into the adrenal glands when bacteria attacks adrenal glands mortality is 30%

A false positive CAMP test for the presumptive ID of GBS may occur if the plate is incubated in a: A) Candle jar or CO2 incubator B) Ambient air incubator C) 35C incubator D) 37C incubator

A

Children (>2yrs) What are the typical agents of Bacterial Meningitis in this age group?

Streptococcus pneumoniae Neisseria meningitidis SNot nosed kids and their meningitis music

Why is GBS quick to cause infection?

-acquired at birth causing ---bacteremia ---pneumonia ----meningitis WITHIN FIRST WEEK

What are the typical laboratory values of NORMAL CSF?

-clear -colorless Protein: (15-45mg/dL) Glucose: 40-80 mg/dL -only a few WBC present

What is the normal range for leukocytes in CSF?

0-5cells/mm^3

LEVELS to this s*** young boy (3 starting with most outward)

1) Dura mater 2) Subarachnoid space 3) Pia mater

Describe the situation where one of these organisms could cause neonatal acute meningitis: 1) Elizabethkingia (Chryseobacterium) meningisepticum 2) E. coli K-1 3) Chronobacter (Enterobacter) sakazakii.

1. Elizabethkingia (Chryseobacterium) meningisepticum: in hospitals, found in water system and wet surfaces. Premature babies often get this kind of meningitis 2. E. coli K-1: acquired from mom during the birth process (vertical transmission) 3. Chronobacter (Enterobacter) sakazakii: in 2011 it was found in formula, causing babies to get infected; highly virulent

What are the typical laboratory findings in Acute Bacterial meningitis?

-CSF turbid -PMN: Increased -Low Glucose -Increased protein -Increased WBC

What are Listeria virulence factors?

-Cell attachment factors (internalins) -hemolysins(listeriolysin O, two phospholipase Cs) -Protein that mediates actin-directed intracellular motility (ActA) Ability to grow at 4C can lead to high concentrations in foods

Haemophilus influenzae Diseases

-Genitourinary infections -Meningitis(to 6 years old) -Epiglottitis

Streptococcus agalactiae Characteristics

-Group B -can be part of normal vaginal and oral flora -Capsule -Inhibits complement

What is the normal range for CSF protein?

15-50mg/dL

Which CSF tube specimen # is used to diagnose and treat meningitis?

2

How many layers of meninges are in the brain? What are they?

3: Dura mater Arachnoid mater Pia mater

What is a normal Glucose CSF range?

45-100mg/dL

What is the normal range for CSF glucose?

45-100mg/dL

What percent of the US population is colonized by H. influenzae?

85% of adults 60% of daycare children

Haemophilus influenzae which requires X and V factors for growth, can be differentiated from H. aegypticus by which two tests? A) Indole and Xylose B) Glucose and Urease C) Oxidase and Catalase D) Indole and Oxidase

A

Repeated Neisseria meningitidis septicemias in an individual should raise physician awareness of what underlying condition? (A) C5 to C8 deficiencies (B) Chronic hepatitis B infection (C) Ketosis-prone diabetes (D) Multiple myeloma (E) Severe neutropenia"

A

A baby born at 32 weeks, gestation with Apgar scores of 2 and 7 was placed in the neonatal intensive care unit. She developed a fever and leukocytosis; lumbar puncture revealed pleocytosis with increased protein, decreased glucose, and Gram POSitive Rods. Which of the following organisms was most likely isolated from the CSF? A) Escherichia coli B) Listeria monocytogenes C) Neisseria meningitidis D) Streptococcus agalactiae E) Streptococcus pneumoniae

B

The normal concentration of proteins in cerebrospinal fluid, relative to serum protein, is: A) <1mg/dL B) 5-10mg/dL C) 25-35mg/dL D) 50-60mg/dL

A) <1mg/dL Consider that a normal serum protein is approximately 7g/dL, and a normal CSF protein is 15mg/dL. The units are different by 3 orders of magnitude. This indicates that the CSF protein is <1% of serum protein. [Strasinger 2014, p193]

A turbid cerebrospinal fluid is most commonly caused by increased: A) white blood cells B) protein C) glucose D) bacterial organisms

A) white blood cells Protein and glucose are dissolved substances and don't contribute to turbidity. Bacteria and WBCs are solids that make the CSF turbid. When bacteria are present, so are WBCs. The large WBCs contribute more to turbidity than the smaller bacteria. [Strasinger 2014, p183]

A small, gram-negative coccobacillus recovered from CSF of a 2-year old child gave the following results: Indole:POS X requirement: POS Urease: POS Sucrose: NEG Glucose : POS (acid) V requirement: POS Lactose : NEG Hemolysis: NEG What is the most likely identification? A) H. parainfluenzae B) H. influenzae C) H. ducreyi D) H. aphrophilus

B

An autopsy performed on an 8-year-old child revealed Waterhouse-Friderichsen syndrome. Blood and throat cultures taken just prior to death were positive for which organism? A) Neisseria gonorrhoeae B) Neisseria meningitidis C) Haemophilus influenzae D) Klebsiella pneumoniae

B

Blood cultures (two) on a newborn grew beta-hemolytic streptococci with the following reactions: CAMP test: POS Bile Solubilitiy:NEG PYR: NEG Bacitracin: RESistant Hippurate hydrolysis: POS 6.5% Salt: POS (growth) Bile Esculin hydrolysis: NEG SXT: RESistant Which is the most likely ID? A) Group A streptococci B) Group B streptococci C) Group D streptococci D) none of the above

B

Which of the following plates should be used in order to ID H. haemolyticus and H. parahaemolyticus? A) Sheep blood agar and chocolate agar B) Horse blood agar and Mueller-Hinton agar with X and V strips C) Brain-heart infusion agar with sheep red cells added D) Chocolate agar and Mueller-Hinton agar with X factor added

B

The appearance of normal CSF is: A) pale yellow and clear B) colorless and clear C) opalescent D) xanthochromic

B) colorless and clear CSF looks like water. If it is yellow or pink it is called xanthochromic. This indicates a previous bleed into the CNS. Opalescence is a haziness, usually due to the presence of lipids. [Strasinger 2014, p183]

What is Brudzinski's neck sign?

Bending of neck causes flexion of knees and hips

presumptive ID of Streptococcus pneumoniae

Bile Solubility: Soluble Catalase: NEG GPDC ----lancet shaped

What locations in the body are generally sterile?

Blood CSF Deep Tissue

A nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate the patient is developing meningitis as a complication of surgery? A) A Negative Kernig's sign B) Absence of nuchal rigidity C) A Positive Brudzinki's sign D) A Glasgow Coma Scale score of 15

C

A 3-week-old child develops fever and lethargy, has a full fontanelle, and just about one hour ago had a seizure. Cultures of the blood and of the CSF grew the same organism. The most likely pathogen is: A) Neisseria meningitidis B) Streptococcus pneumoniae (pneumococcus) C) Gram-negative bacilli D) Staphylococci E) Haemophilus influenzae

C) Gram-negative bacilli Among children one month of age and younger, gram-negative bacilli, mainly E. coli and other enteric bacilli, are the most common cause of meningitis. Group B streptococci and Listeria monocytogenes also cause meningitis in this age group of children, but not as often as do the gram-negative bacilli. Group B streptococci septic infections that occur very early do so as a result of spread of the organism to the newborn from the maternal genital tract. Neisseria meningitidis is a common cause of meningitis in children older than one month of age, and among older children, adolescents, and adults, Neisseria meningitidis and Streptococcus pneumoniaeare the two most common pathogens of meningitis. Haemophilus influenzae is a common cause of meningitis among older children and adolescents. (Levinson, 7/e, pp 114, 121.)

Which of the following organisms causes neonatal sepsis? A) Enterococcus faecalis B) Streptococcus pneumoniae C) Group B streptococci D) Viridans streptococci

C) Group B streptococci GBS cause neonatal sepsis in two forms: an early onset form, occurring in infants from birth to 4 days old, and a late onset form, occurring in infants from 7 days to 4 months old

A CSF Specimen was sent to the laboratory for analysis. A glucose, protein, and cell count were performed. Based on the following results, what would be the probable cause? Glucose: 15mg/dL Protein: 150mg/dL Leukocytes: 1,000 cells/mm^3 neutrophils A) Normal CSF B) Viral infection C) Purulent infection D) Tuberculosis or fungal infection

C) Purulent infection Purulent infection is correct. For a CSF to be considered purulent, the glucose value should be <45mg/dL, the protein value should be >100mg/dL, and the leukocyte count should average 800 cells/mm^3 (range 5020,000cells/mm^3) with polymorphonuclear cells predominating. The glucose value is low because bacterial organisms are using the glucose as an energy source for growth and the protein value is elevated due to an increase in cellular presence. Normal CSF is incorrect. To be considered normal, the glucose value must be within 45-100mg/dL, the protein must be within 15-50gmg/dL, and the leukocyte count must be within 0-5cells/mm^3 with no predominant cell line Viral infection is not correct. In a viral infection, the spinal fluid will have a normal glucose value (range 45-100mg/dL), a slightly elevated protein value (range 15-50mg/dL), and an average leukocyte count of 80 cells/mm^3 (range 0-5cells/mm^3) with mononuclear cells predominating. Tuberculosis of fungi is incorrect. In this type of infection, the glucose value is low to normal, the protein value is >50mg/dL, and the leukocyte count is around 100cells/mm^3 with mononuclear cells predominating.

What is the subarachnoid space filled with?

CSF (cerebrospinal fluid)

What are the expected findings consistent with Bacterial meningitis?

CSF: Turbid, Cloudy Protein CSF: Elevated (>45mg/dL) WBC: elevated NEUTROPHILS: Elevated Glucose CSF: very low(<40% of serum glucose concentration")

What are the virulence factors of S. pneumoniae?

Capsule Autolysin Hyaluronidase IgA protease

What does normal CSF look like?

Clear, colorless Protein CSF: 15-45mg/dL WBCs: Few or none Glucose CSF: 40-80mg/dL

Physical Examination of CSF based on Color/Appearance:

Cloudy/Turbid = WBCs, Increased protein or Lipid Milky = WBCs, Increased protein or Lipid Xanthochromic = Pink to orange color, RBC degradation, increase bilirubin, carotene, increased protein, melanoma pigment Hemolyzed = Inter-cranial hemorrhage or traumatic tap

What deficiency helps to facilitate infection via N. meningitidis?

Complement C5-9 deficiency OR Properdin deficiency

All of the following substances are T-independent antigens EXCEPT: A) endotoxin B) lipopolysaccharide C) polymerized flagellin D) phytohemagluttinin E) Epstein-Barr virus

D

Normal CSF contains all of the following proteins EXCEPT: A) Transferrin B) Transthyretin C) Albumin D) Fibrinogen

D) Fibrinogen Normal CSF contains protein fractions similar to those found in serum such as transthyretin (prealbumin), albumin, transferrin, haptoglobin, ceruloplasmin, IgG, IgA, etc., but does not contain IgM fibrinogen, or beta lipoprotein. [Strasinger 2014, p193]

Where is Elizabethkingia meningisepticum found?

DIRRRTTYYYY Hospital Water

Fill in The Blank In bacteria meningitis, the glucose levels in CSF are _________

Decreased

All of the following statements about Listeria monocytogenes infection are correct EXCEPT: A) abscess and granulomas occur in many different tissues B) laboratory isolation involves cold enrichment media C) neonatal infections have a poor prognosis D) bacteria parasitize neutrophils and monocytes E) neonatal infections occur ONLY during passage through the infected birth canal

E

Fill in The Blank ______________ and _______________ are the most common causes of neonatal meningitis

E.coli K1 Group B Streptococcus (Streptococcus agalactiae)

Hippurate POS

GBS

Neonates (<1mo) What are the typical agents of Bacterial Meningitis?

Group B Strep (Streptococcus agalactiae) Escherichia coli K1 Listeria monocytogenes Find Babies with Ultrasound GEL

Name that Haemophilus Species! Beta Hemolysis on Horse BAP: Yes Requires X Factor (Hemin): Yes Requires V Factor (NAD): Yes

H. haemolyticus

Name that Haemophilus Species! Beta Hemolysis on Horse BAP: No Requires X Factor (Hemin): Yes Requires V Factor (NAD): Yes

H. influenzae

Name that Haemophilus Species! Beta Hemolysis on Horse BAP: No Requires X Factor (Hemin): No Requires V Factor (NAD): Yes

H. parainfluenzae

Fill in the Blank ________________ colonies on a CHOC

Haemophilus influenzae

Infants (1-23Mo) What are the typical agents of Bacterial Meningitis for this age group?

Haemophilus influenzae Escherichia coli Neisseria meningitidis Streptococcus pneumoniae Streptococcus agalactiae (GBS) Mother HENSS don't want baby chickees to get bacterial meningitis

Fill in The Blank In bacterial meningitis, the protein levels in CSF are _______

Increased

Listeria monocytogenes has specific receptors for what cell?

Monocytes

E. coli K1

K1(capsular) antigen Neonatal meningitis

Fill in The Blank Infection caused by ___________ ____________________ is more commonly seen in neonates, older patients, alcoholics, and immunosuppressed individuals

Listeria monocytogenes

Older Adults (>65yrs) What are the typical Bacterial Meningitis agents?

Listeria monocytogenes Aerobic gram negative bacilli Neisseria meningitidis Streptococcus pneumoniae "You kids GET OFF MY 'LAwNS'"

Fill in The Blank Individuals who are deficient in terminal components of complement (C5-C9) are at higher risk for _____________________ infection

Neisseria meningitidis

Gram stain of?

Neisseria meningitidis

Streptococcus agalactiae Diseases

Neonatal sepsis (early and late onset) Meningitis

What type of WBC is associated with BACTERIAL meningitis?

Neutrophils "Neuts"

Fill in The Blank Replication in the subarachnoid space results in INCREASED ________________ in the skull, harming the brain

Pressure

Fill in The Blank Patients with Sickle Cell Anemia, splenectomy or asplenia, malignancy, malnutrition, and chronic renal or liver disease are more likely to develop serious __________________ infection

S. pneumoniae

What are some common etiological agents of Acute Meningitis ?

Streptococcus pneumoniae Neisseria meningitidis Streptococcus agalactiae (GBS) Haemophilus influenzae Listeria monocytogenes

Where do bacteria that cause meningitis replicate?

The subarachnoid space

Name the 3 ways that pathogenic bacteria can cross the blood brain barrier?

Transcellularly Paracellularly Via the Trojan horse mechanism

A 15-month old child living in a religious community that does not vaccinate their children develops meningitis. A gram-negative rod is seen in the CSF. What is the most likely causative agent? a. An enterovirus b. Escherichia coli c. Haemophilus influenzae d. Neisseria meningitidis e. Streptococcus agalactiae

c

What is the first event in a patient who ultimately develops Neisseria meningitidis meningitis? a. Crossing the blood-brain barrier b. Meningococcemia c. Skin lesions d. Upper respiratory colonization e. Waterhouse-Frederichsen syndrome f.Traumatic implantation directly into the brain

d

N. meningitidis etymology

meningis, "the covering of the brain"; itis, "inflammation" (inflammation of the meninges as in meningitis)