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Hello, good morning. Hello, good morning everyone. Uh My name is Nadal Hajj. I'm a microbiology consultant at uh Queens Hospital at Barking Havering and Red Bridge Trust. And today I'll be talking to you about uh central nervous system infections. So the outline of my talk, I'll start by talking about um I'm going to divide it into community acquired, uh central nervous system infections and healthcare acquired. I'm going to focus more on the community acquired because that's what we see mostly. And that's what I believe you need to know more uh for the community acquired uh CNS infections. Uh meningitis, I will start talking about uh talking about meningitis, uh mainly bacterial and viral and I'll touch up on encephalitis, uh brain abscesses and then we'll briefly uh touch on uh healthcare acquired infections which are mostly neurosurgical infections. Um There will be some questions and uh quizzes in the middle of the talk. So the aim is to make it as interactive as possible. So please feel free um to, to share your, your answers. So, um starting with meningitis, the definition of meningitis is inflammation of the leptomeninges which uh are the uh tissue surrounding the brain and spinal cord. So the uh if I've got the uh um the Diaa diagram just on the right side of the uh of the screen. So you can see the skull bone which beneath uh are the uh uh cra cranial meninges. There is the Deraa Arachnoid meta and uh the P and in between the arachnoid mater and the PM is a space which is the subarachnoid space where you uh there is, which contains the uh uh cerebrospinal fluid. And uh meningitis is a feature is characterized by elevated white cell counts of the CSF and uh protein counts in, in certain, in, in bacterial infections, mostly. So, meningitis, um as I said, it can be a community or healthcare acquired, uh can be caused by different organisms, bacterial, bacteria, viruses or fungi and presentation differs according to the age groups and the causative organism and the setting of the infection. So, it is really important to get a good history and examination uh to be able to reach uh kind of a differential diagnosis, a diagnosis that helps you guide the treatment. And it's also really important to have good background knowledge of microbiology which again can help you in guiding the investigation and patient's treatment as well. So, uh in terms of bacterial meningitis, the most uh known causes or the major causes, you can divide them. Um I've divided them according to age. So in adults and all the Children, the most common causes or uh causative organisms are uh streptococcus pneumonia and ne meningitis. Listeria, monocytogenes is also a known cause but mostly affects uh people who are over 50 years and who have issues or uh deficiency in their cell mediated immunity. Those who have chronic uh conditions. Uh, diabetes is a risk factor, uh chronic kidney disease, chronic renal disease. So anyone who has long term illness, anything that affects the immunity can put patients or people at risk of getting listeria. Uh uh meningitis, haemophilus influenza was uh at one time a very common cause of uh meningitis. But uh since uh the introduction of, of vaccination or childhood vaccination, it has not uh become a major cause in, in areas where vaccination is, is, is uh offered to kids, to Children for younger uh age group. It mainly the preterm who are less than one month. And uh if I in Children who are in general, less than two years, uh the organisms, the main organisms or the main, most causative uh factors change or organisms change the most organism you would find for causing meningitis. Uh uh group B strep. This is because it is uh a colonizer of the vaginal tract. So the uh babies attract it from or get it from their mothers and e coli as well. Uh Other organisms gram negatives including klebsiella can cause meningitis as well. And again, the other causes that cause meningitis in the older group streptococcus and Neera are still seen uh in, in this age group, but uh less common than the other two, the group B strep and the E coli there are other many, many and Listeria as well as, again, sorry is another cause of meningitis in that age group, not uh common. Uh because it's not, it's not one of the things that you would see much in, in, in this age group. But it is because the immunity is not uh much developed at that age. And of course, there are other causes, many, many other causes. I've just mentioned a few mycobacterium tuberculosis which is common in areas or countries where M TB or uh my bacteria tuberculosis is, is more uh prevalent. And the Borrelia Beri which is the cause of Lyme disease again, depends on the, on, on the area or the country. So I've got a uh a picture here which is a uh a slide of a uh of, of a CF and um it's, it's a gram stain. The arrow is pointing to the organism. If anyone could tell me, what do they think? This is? Sorry, I'm just gonna going back. Um maybe strep also cause pneumonia. Uh It's uh because the shape is, is, is, is similar. But if I tell you this is a gram negative organism. OK. Well done. Yes. So that's ne meningitis. So if you can, it's um sorry, it's not a very clear picture, but you can see that it is uh gram-negative. So it's red in color and it occurs in pairs. So it's gram-negative dilia. So that's nice. Correct. Thank you. So, what is this one? Strep Coccus strep Cocos. Well done. Yes. So again, this is uh the gram stain, not a very good picture but the gram stain, it's a, it's a gram positive. So it's darker in color, usually purple and it occurs in pears mostly. So pears and short chains. So that's uh gram positives. Diplococcus strep pneumonia, well done. So this is um a blood aga of uh a strep pneumonia. So that's how the colonies look. They're alpha hemolytic. So they have this greenish color and the colon is themselves on day two or so that you will see that they change in shape. So they become flat in the middle and they're called draft man colonies. So as soon as you see this, you know that this is uh strep pneumonia. So uh clinical features of uh meningitis, uh you can, we can kind of divide them according to um of, of, of, you know, general uh features of sepsis. So patients uh can present with uh most of most patients present with fever and then other features of sepsis like uh tachycardia tachypnea, they'll be short of breath because of that altered mental state and can be uh can present with septic shock, uh meningeal irritation. So the features of that is knuckle rigidity, they'll have uh neck stiffness so they can't move their neck photophobia. They're just very difficult to, you know, they'll prepare sitting in the dark, the light irritates them and the headache they can present also with change in their mental status and a, a drop in the gcs. There are features that, uh you know, um signs that you can elicit uh to elicit the, the meningeal irritation, including the nic sign which the picture shows it's the one on the top. Uh So it's, it's the inability or reluctance to allow full extension of the knee when the hip is flexed to 90 degrees. And the Rudzinski sign which is a spontaneous flexion of the hips uh during attempted passive flexion of the neck, uh features of increased intracranial pressure include high BP, altered mental state, again, bradycardia. So they can present with tachycardia as we mentioned earlier as a sign of sepsis. But if they have put increased intracranial pressure, it will cause bradycardia. And again, papilloma, uh other features which are usually less common in meningitis, uh seizures, aphasia, a again, comma cranial neck pulses and uh rash, the, the rash we see in certain uh organisms as I will mention uh in the next slide. So um that as I, as I mentioned earlier, that there are clinical features associated with certain organisms. So um particular rash like this uh poor child has is, you know, and the pe pe palpable pep and septic arthritis are features of nice meningitis. Mostly it can happen in others in streptococcus uh pneumonia. But uh it's, it's less common. Listeria patients usually uh um present with seizures, um focal neurology, ataxia and cranial nerve palsy. So that these features, once you see them, you start thinking about listeria, especially if uh the patients, uh you know, the past history or the im immune status reflects that, you know, if they are uh immunocompromised, then you would start thinking about listeria. Uh in terms of viral meningitis, the commonest causes of viral meningitis are enteroviruses, mostly coxsackie viruses and echo viruses and uh usually infections. Um uh by these organisms seen in uh the summer and uh autumn months, uh herb simplex virus. HSB one, um mostly, well, HSV one and HSV two. So HSV two usually is associated with meningitis, more associated with meningitis. HSV, one is more associated with encephalitis and then uh varicella zoster virus can cause meningitis as well. But it's uh not that common and it can occur as a, a complication of, of chicken pox. There are other, many other viruses that can cause uh meningitis, including HIV, mumps, Saint Louis, Encephalitis. There's many other uh other, many other viruses as well. So how do your diagnosis? Uh I guess clinical diagnosis is probably, um, you know, with the presentation, that's, that's the main way you diagnosis. But in terms of laboratory tests, uh when you do a peripheral blood test, you'll notice that the white cell count is raised. If it's bacterial meningitis, uh then neutrophil count will be high. The peripheral neutrophil count, they can be low in certain. If, if, if it's low, if your patient has neutropenia and thrombocytopenia and deranged clotting, then that is a poor prognostic si uh sign and uh is an indication of severe disease. Blood culture is important in certain. If patient is, is uh pyrexia and septic, it's really important to take a blood culture because there are certain situation when you cannot uh do an LP. So uh it's preferably that you send a blood culture whenever a patient is septic and uh preferably of course, before starting antibiotics. Um CSF uh again, that's the main diagnosis. Uh We do a gram stain and a cell count and again, preferably should be done before antibiotic treatment, but it should not delay antibiotic treatment. So if, if you've uh that's the main, I think uh thing that you need to remember because it's, it's a time really matters. So you should not delay antibiotic treatment. If you find, you know, if the CSF, you don't think you can be doing an LP within the next, you know, um minutes or so, or, you know, half an hour then or any minute, you know, in the next few minutes, you think that this process might be delayed because you want to rule out something, then you just start antibiotics, don't delay antibiotics. Uh The open impression when uh LP is done, uh it, if it's elevated, then that's uh again, a sign of bacterial meningitis. If it is a uh if, if we're suspecting viral meningitis, then you'd need to send that uh for uh molecular testing for viral PCR. So, uh lumbar puncture is contraindicated in patients with suspected meningococcal septicaemia. Do you know why? Why can't you do an LP? Why is it not advisable to do an LP in someone who's got meningococcal septicemia or got the rash? A rash? Is it cause it's um one of the contraindications of a, of a lumbar puncture is a skin infection. Uh lump. Yes, that can be a cause but that's not the, the cause I'm after here. I can cause infection. I mean, is it um contamination cause infection something like that because that can be a cause. But I guess it's in these patients, they are very sick. So it, it's, it's not the main cause. The main cause is that sorry. Go ahead. Hello. Right. I'm, I'm thinking of the pressure because they're gonna quickly reduce the pressure. When you um um doing the point, there might be a quick reduction of the pressure. That's good cause. Yes. Yes. And then the other thing is is that because they, they've, if, if they've got these uh the Peric rash, it's an indication of um uh of the clotting. So you, you, your risk of uh there's a risk of bleeding as well um and the other, you know, the increased in ran pressure again, you can't do that because you can't uh it, it's contraindicated LP because you, there's a risk of, of coning as well. So if in, in, in, in situations where you think uh you're, you're not sure, it's, it's advisable to do a CT uh before doing an LP. And of course, uh imaging. Yeah. So imaging is one of the ways that you can diagnose uh meningitis. There will be um meningeal enhancement in the imaging. So this is a good slide. And I think it, it, it really helps, you know in in the diagnosis of uh meningitis. So you would know it will give you a clue about um what what, what the next step can be on how you can manage the patient. So um I've I've kind of simplified it. So for bacterial meningitis for the, well, the white cell count will be very high and it will be predominantly polymorph, the protein will be high and the glucose is low. And again, if you do a gram stain, you are likely to see something you'll see, likely to see an organism with viral meningitis. The white cell count is high, not as high as bacterial, but you can see it in certain situations, but it it is high, but it's mostly lymphocytic protein can be high, but it's, it's usually normal glucose is normal and the gram stain of course, is not is, is gonna be uh negative. And the in terms of glucose, you would compare the, the serum glucose to the CSF glucose. So if it's two thirds, if it's less than two thirds, that's low and, and uh otherwise, you know, it, it would be normal. So if it's for low, when we say low, it's, it's less than the two thirds of the serum. Uh for mycobacterium tuberculosis, the white cell count is usually high and it's mostly lymphocytes. So, in that, it, it, it mimics the or it, it's similar to the uh viral, viral meningitis. But the protein what differentiates it is the protein is usually very high. So if it's, if it's more than one or it's sometimes two or three, then you would think the first thing you would start to think about is tuberculosis. Uh glucose is low like uh the rest of the bacterial infections and then gram stain, of course, you'll be negative. So if you have high protein, then you would think about uh M TB. So you'll do special staining, which is Zel Nelsen stain or ORAM stain. So the management of meningitis is usually supportive. So uh the first thing you would do, you would reus resuscitate your patient, make sure that um they're got their fluids and you manage their shock if they come in in that status antibiotics. Usually the cefTRIAXone is the agent of choice because it covers the common most organisms actually. So uh all the organisms that we've mentioned, it is covered by the cefTRIAXone in adults. The dose is two g. You give a high dose two g. BD. Uh in neonate, you go for cefotaxime, uh especially if they're very young because uh cefTRIAXone is associated with uh biliary sludging. So younger than one month usually give Ceta or once they're a bit older, then you can, you know, cefTRIAXone is, is, is what you go for in uh patients who are allergic, known to have a severe allergy to penicillin. Chloramphenicol is, is the uh is the agent of choice. Um, dexamethasone is really important to be given with antibiotics in pneumococcal infections because pneumococcal infection can cause brain edema. It's associated with that. So you give dexamethasone to, to, to and, and to limit the damage. And of course, you know, most of the situa at that time, you would not know what the causative organism is. So usually it's, it's, it's advisable to give it if, if uh if bacteria men, uh meningitis is suspected. And uh again for, for specifically for the meningococcal meningitis because it is uh there is a, a risk of, of uh you know, uh passing it on all of the, the, the uh close contacts to, there will be at risk of having it. So it, it, it's uh you have to have a droplet precautions for the 1st 24 hours. So, patients are usually isolated uh for the 1st 24 hours of treatment. And uh chemo prophylaxis is offered to the close contacts. So, uh roommates or, or close family and it's in the form of a single dose of uh ciprofloxacin. And the alternative would be azithromycin in pregnant ladies and uh Children. So, uh in terms of prognosis, uh the actually, it is a severe disease, mortality is approximately, can go up to 20% uh for all causes and even worse for pneumococcal meningitis. It can go up to 30%. There are other risk factors that put patients or can um have a, you know, a be a kind of a poor prognostic sign which is uh older age. Uh patients who present with low gcs then and, and the pneumococcal meningitis, as I've mentioned earlier is quite severe. So this uh is associated with uh worse outcome and patients as as well who have underlying immunosuppression. Uh Some patients are left with uh long term neurological complications including impaired mental state, focal neurological deficits, uh hearing loss and as well as uh intellectual impairment uh for in terms of prevention. Uh Of course, the vaccination has, has been uh a game changer. Uh We've uh most countries now have uh pneumococcal P CV vaccines in in childhood, introducing the childhood vaccination and uh for meningitis, B, hip and men C. Uh In the UK. Here, teenagers are also offered uh vaccines to cover the other stereotypes of meningitis, ac wy and older age uh patients, older patients are offered the the pneumococcal vaccine. So, um another kind of clinical case. So let's see what we've learned so far. So this is a 51. All these cases I've mentioned are actually real cases that we've that, you know, I've picked up throughout uh my work. So this one is a 51 year old female who was admitted with the confusion and fever and she was found collapsed by a friend who brought her to hospital. Uh The friend did mention that she actually was complaining of ear pain and headache days before uh her presentation. So on examination, she had a temperature of uh 39.5 her gcs was low uh 12 and she had neck stiffness. So she did, she was diagnosed with meningitis but given kind of the history, there is a hint there. So what do you think the organism would be? She's someone who's fit and well. So she doesn't have any underlying uh conditions, any guesses it strep pneumonia. Yeah. All done. Yeah. Why do you say that the was the classical symptoms? Nothing uh complication or nothing? Uh It's just, it's just it, they're fitting. Well, that's why with fever it starts with fever. Which which is actually so yes. And what else, what else other than the fever and the confusion, the age everything fits. But there is a kind of also another clue. GSSG CS stool, sorry, ear pain, ear pain. Yes. Ear pain because, um, you know, it's, it's one of the causes of uh, you know, ear infection, otitis media. So, if she's had problems with her ear, it suggests that there is that she probably has an infection infected. Uh uh and she did, actually, she did have otitis uh uh immediate history of ear infections and, and she did grow it before from her ear. So, um it is a, it was a strep pneumococcus. So, yeah, well done. Um so uh encephalitis. So the presentation is usually, so it's encephalitis is is inflammation of the brain parenchyma. So the presentation is is uh somewhat, sometimes you do see them mixed up together. So meningoencephalitis. So patients would come in with features of both with encephalitis. The features are mostly of uh the brain function. So it patients come in with uh included altered mental status. They can come in with uh you know, motor sensory deficits, altered behavior, uh personality changes, uh if and and speech or movement disorders, they're more likely to come in with fits as well. Um hemiparesis paralysis, uh all can be all can be seen in, in the presentations and seizures. As I said, is more common in encephalitis than meningitis. And uh again, diagnosis uh in, in, especially in pictures where you get men, you've got uh meningoencephalitis, the CSF uh sometimes it would be positive for uh you know, uh the PCR testing would be positive, it's mostly viral. Uh and treatment, uh, there's no specific treatment. So, if, if it is an HSV, encephalitis, then, uh, Acyclovir would, would, uh, uh, is the treatment of choice. So, um, HSV and VV are the ones, the main ones that have treatment which is Acyclovir. Um, and, and the rest of the viruses, usually there's not much to do and not, not much treatment to offer antivirals except for supportive management. Uh, HSV, encephalitis does have, uh um unfortunately, high mortality if, if the treatment is delayed, uh brain abscesses. Uh So uh it's, it's uh defined as an abscess, but it's a focal collection within the brain parenchyma and can arise as a complication of vi of a variety of infections, trauma or surgery. So, uh it uh can be a uh through direct spread. So, patients who, for example, with otitis media or myoid sinus or dental infection, then they can develop a brain abscess uh as a result of that. So, if, if it's uh otitis media, you would be in an area in the temporal um lobes of the brain dental, usually you can see it in the frontal. So the site would be an indication of, of the source of that and again, in neurosurgery. So that's a common complication as well of, of neurosurgical procedures, uh hematological or hematogenous story spread uh happens in uh can occur in chronic infections. So, um endocarditis if patients are throwing emboli. So it's, it's, it's again something we we, we see and uh pulmonary or abdominal chronic infections, cyanotic congenital heart disease, which is, yeah, mostly in Children. So it can be either diet spread or hematogenous Equis organisms. Uh a bit. Um So for mostly gram positive. So uh streptococcus uh which is uh strep MRI. So, and uh the strep pneumonia strep pyrogen, which is group A strep and staph aureus. These are the most common organisms uh causing it. It can be caused also by anaerobic organisms bacter or you know, a pro bacterium use a bacterium which is also associated with collections and then gram-negative organisms which usually so with, with gram positives organism, which it happens spontaneously can happen with uh endocarditis as well. Gram negatives is usually a result of, of surgery. So it's usually as uh secondary to either surgery or trauma. Um an organism that is known to cause collections regardless. It is Klebs pneumonia. It usually causes abscesses or in, in the brain or it can cause in, in the lungs as well. So it's, it's one of the uh or liver abscesses. So it's, it's a an organism that is known to cause collections. And uh in the immunocompromised hosts are the causes of collect or, or, or reenhancing lesions or abscesses are toxoplasma, uh nocardia listeria again, as we've mentioned earlier. And uh other organisms you can get fungal, um like Aspergillus, uh especially in patients who are immunocompromised or diabetic and others like streptococcus NEMIS cois and parasites, but these are uh less commonly seen. Um Again, this is just, I'm not gonna go through all of this. But it's just to let you to, to give you an idea that actually, you know, knowing your microbiology and knowing what you grow can give you a uh a clue about where the infection is, is is coming from. So, for example, in paranasal sinuses, if someone has got sinusitis, then the usual organism you would expect in a brain abscess is the your streps, uh especially strep mide, the haemophilus um uh f the bacterium. So that's where you and end bactero is, that's where you get that these kinds of infections, automatic infections or auto sorry, auto uh sort of autogenic sources of the mouth. Usually you get the streps and the prola which is a gram. Again, anaerobic organisms, Fuso bacterium, uh ear, you get the causative organisms from the ear, which is the uh uh pseudomonas can cause that. As I said, streps earlier, pseudomonas in patients who've got oitis exna, uh elderly patients. So it can cause uh uh uh brain abscesses can be caused by that lung. You, you get your streps and your fusobacterium head trauma, as we've mentioned earlier, the gram negatives and staph as a wound infection. So again, and, and with endocarditis, you get the streps very di and the staph. So it depends you the organisms according to the site. You know, the the organism differ according to the site. Um the presentation usually is um they present uh can present with headache um and features of cerebral edema like a change in mental state and uh nerve forces, mostly the 3rd and 6th nerve forces. And uh if pap edema, if there's an increased pressure, um seizures, if uh if uh frontal lobe abscess for urology and the diagnosis is by CT or MRI and the management is usually aspiration of, of the collection. So how to diagnose it. Uh if if is is to, to, to send the cultures of that uh the pus to for, for microbiology testing, gram stain culture PCI. If you can't find, you know, if your cultures are negative and then you can do other tests if, if it's likely to be other causes like uh serology or uh or histopathology. Just if, if you, you, you're clearing other parasitic uh infections. Um As I've mentioned earlier, it's really important to identify the the, the causative organism to be able to offer the right treatment. And uh the duration for a brain abscess is usually further out rather long. So you give it for 4 to 6 weeks. And in immunocompromised patients, you might need to give it for longer than that. Um drainage is important. And uh and again, um you can, patients are monitored by uh imaging just to make sure that they have uh they are responding to treatment. Um aga again, I'm gonna go through this very quickly because I think I want to, you know, go, I've got a few questions at the end and I think that's more important. So in terms of health associated CNS infections, um this is, as I, as I said, it's, it's a result of, of um neurologic neurosurgical procedures and the organisms are different because it's actually, um you get infections by hospital organisms and you get infections uh secondary to colonization of the shunts itself. So you've got a foreign material, for example, in patients who've got the shunts, uh then once you've got plastic or foreign material, then you attract a different kind of organisms. So, infection can be either colonization of the shunts or direct contamination of, of the wound. It can be uh hematogenous as well. Um And uh the, the presentation really differs according to, to uh you know, what kind of, for example, what kind of shunt you have. So if you've got a, a ventricular peritoneal shunt and you've got an infection um on the distal end of the shunt. So the patients can present with peritonitis if uh it's, it's, it's, it's uh if the shunt is uh ventricular atrial shunt. So it's in the heart, then they can present with endocarditis if it's in the pleural ventricul peritoneal, sorry. Um uh pleural shunts, then they can present with empyema. So these are the presentation. It depends really on, on, on the site of the infection and uh the treatment. The uh again, the, the presentation is different because these patients are usually, you know, this GCS is because they, you know, they've already had neurological neurosurgical procedure. Their GCS is low already. So it's very difficult to, to um elicit, it's not as clear as the patients who present with community acquired infections because the GCS is low. So, um if it drops any further, then it's, it's not easy to detect uh the CSF S as well because of the neurosurgical procedures, it is not normal to start with. So it needs monitoring and they usually do se several TSF samples just to kind of monitor and see whether what if it's worsening or the patient develops a fever or. So it's, it really needs uh the the doctor to be alert to, to the, to the possibility of, of that. It's not as easy or as, as si as easy as uh the diagnosis of uh uh community a men. And again, the organisms, as I mentioned are different because it, it can cause by it be caused by the organisms that colonize the skin. So, coagulate negative stops that usually don't cause community acquired pneumonia, gram negatives that they acquire from the hospital setting. So, uh it's, it's a really, it's a totally different uh presentation and causative organisms to the community acquired infections. So, uh yes, we've got a few tests. Now we have a few questions. So uh let, let's go through that I think it's just to refresh and to see what we've learned today. So we've got a, uh, this case is a two week old baby who was brought in by mother is, uh in his mother, by his mother after birth. So he, um, said he had a fever and has been refusing feeds for the last two days on examination. He was found to be lethargic and his CSF had a, a high white cell count, mostly lymph, uh polymorph. And below is the gram stain of the uh his, uh they've done an LP and, and that's the grand stain of the CSF. So, what do you think the causative organism is? So you've got a list of three or four organisms? Which one is it, do you think? E coli? Yeah. So, yeah. Why? Um, was it a gram-negative organism? Yes. And it's a gram-negative. What is it? Gram-negative? Um, well done. And, and it's the commonest cause, isn't it? So, we've got group B strep and E coli. So this is a gram negative. Yeah. So it's an E coli which is, yeah, the second common cause of meningitis in, in babies. Thank you. Well done. This is a 60 year old, 68 year old man who's uh admitted again with lethargy not, has not been feeling well for a while, severe headache and he's known to be um past history. He's, he's known diabetic and has got chronic kidney disease and he presented with features of meningitis. He had neck stiffness and a fever. Um So a blood culture and CS F were, were done before starting him on antibiotics. So, yeah, kind of. Yeah. So what antibiotics was he started on? I guess you should, you should know the diagnosis and then tell me what, what you would give for 14 days. What, what can you see in the grams? Uh gram positives Road. Road. Yes. So what is a gram positives Road? We've mentioned it. Yes. Yes. Sorry. Listeria, Listeria well done list. So how do you treat Listeria? Amoxicillin, amoxicillin. Yes, amoxicillin. So usually, you know, sorry, can you repeat that please? Sorry, I couldn't hear that anyway. Yeah. So when your patients present, usually you wouldn't know that. You know, I'm, I'm giving you the end story, but then if you are suspecting it, then you add it to the cefTRIAXone. So usually all patients we start, you know, in meningitis mostly because we know that the commonest causes are strep uh pneumonia and Neisseria, you would start uh cefTRIAXone. But once you suspect it, if the history suggests that this patient is immunocompromised, he's got um you know, past history of any kind of, you know, transplants or and he um presentation sometimes it's different. So um I didn't mention it earlier but what, what the clue sometimes can be in the uh in the CSF findings. So the white cell count would be usually with Listeria. It's lymphocytic, not polymorph, not polymorph, although it's a bacteria, but you see that it's, it's mostly lymphocytic. The other features are fits with the bacterial meningitis, but it's just us, you, you see a lymphocytic picture rather than a polymorphic picture. Uh So that, that gives you a clue that it might be a listeria and you add, you would add amoxicillin to that and once you've confirmed it, then the treatment of choice is amoxicillin, high dose and, and gentamicin. Ok. Well done. Thank you. So this is another question. So there are um this is uh CS F laboratory microscopy results for a patient presenting with meningitis. So have a look, I'll give you a few seconds and then you can tell me which do you think it is like uh men meningitis, coccal meningitis? Yes, I shouldn't put in the Grand stain. I shouldn't put I where it is but well done. Yes, it's meningococcal meningitis. Yes. So what would you need to give Dexa, which, which infection would you? You need to give uh dexamethasone for? Yes. Yes. Yeah. Thank you. And when is it contraindicated to perform a lumbar puncture without a rash, rash? And I see, I see that in pressure increase in pressure edema. So B and C Yes. So, yeah, I think we've come to the end. So it's just uh I think uh just a few take home messages. So, um as I said, men, meningitis is associated with high mortality and uh if not managed well. So it's really important to uh recognize it early and offer treatment as early as possible. Um Nice meningitis and streptococcus pneumonia are the most common causes of community acquired meningitis in adults and young uh and and older Children in young Children or neonate. The, the commonest causes are group B strep and E coli uh many other organisms can cause meningitis in different settings as we've, as we've mentioned. And it's, it's really good to know your microbiology because it does, it does help. And uh as I said, that, I think that's the most important message that is, you know, the investigation should not delay antibiotic treatment, antibiotic any minute counts. So you should uh make sure that you start antibiotics as early as possible to for the patients. So I think that's it for me. So if you have any questions, I'm happy to answer. Yeah, please. I um I have a question. Um What was the normal um protein level? And c it is, can you remind me, please? The normal uh protein level? It's, it's around. Yeah, it's around uh uh kind of naught 0.4 uh milligram per liter dl. So anything more than that is high and, and so usually with bacterial infection, it's, it's, it, you, you see higher levels of 0.91 g in TB. You can see up to 234, it can go up, you know, higher than that So that's u the usual level there. Ok. Thank you. Any other questions? No. All right then. Thank you very much. Thank you so much, Doctor Ard for your time today. We're just going to end the meeting recording and then the next election starts in about 10 minutes. So if anyone has any remaining questions, feel free to put them in the chat. Thank you. Thank you very much.