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I've got it. That's fine. So I'm going to drop that down. So, um, I won't be able to see the chat, but I'm very much relying on a wonderful co host to maybe look at that. I'm happy to answer questions as we go along, and there will be opportunity at the end as well. Uh, so who am I? I'm Doctor Tim Young. I've been a neurologist for over 20 years in England and I'm an honorary consultant neurologist at the National Hospital for Neurology and Neurosurgery. Which is that I suppose you'd call it orangey building in the background of the picture. And I also work as an associate professor of teaching at the Institute of Neurology in Queen's Square, which is also represented in this picture. I'm going to be talking to you today about meningitis and encephalitis from a medical student perspective, and I hope it will be of some use. I will throughout this talk give a degree of information. Some of it will be actual hard facts, but I'd rather you kind of got the bigger picture. I understand my lecture will be available for you to look at later, so don't worry about every last little dot It's more, hopefully the bigger picture that I can convey here. So let's start off. And I'm just saying that my presentation is accurate as of today. But please don't post images in general just on, you know, sort of media or whatever. But you're very welcome to use this for your own learning, of course. And always check the drug doses. Okay, I will repeat that several times, but it's something a really important point. So we're going to start with a really obvious point about what is meningitis and why is it important? And possibly many of us might be tempted to start by saying, Well, meningitis is, you know, someone coming in to casualty with a bad headache, and they've got photophobia and fever. But of course we have to start by saying, What is it really? To answer this, we have to look not at the clinical or the para clinical, but actually at the pathology. So, of course, meningitis is inflammation of the meninges surrounding the brain and the spinal cord. There's a very frightening fact that the untreated bacterial meningitis has a phenomenally high mortality. Please do note. I said bacterial meningitis. Because there are other causes of meningitis, I've got a picture that which, very sadly, shows the image of someone who actually succumbed to meningitis. That images image A. You can see the meninges have got this sort of horrible white discoloration almost like pus compared to a normal looking brain brain, which is an image be please, no, It's always good practice to cite your references, so these aren't my personal images, but we are allowed to use these. But now we can work back and we can look at the clinical side. The clinical side will comprise of the history and the examination. So the history there's some key points you want to know if you're thinking about meningitis with inflammation, and I will mention briefly later things like Kernig's sign, which you may well have heard about. There may well be a reduced Glasgow coma score. G. C. S so worth documenting. And of course, there could be focal signs. It could be that they've already developed some kind of weakness or possibly even seizures. So history, examination and then investigations standard bloods. You typically might put a line in them and then take the blood from their swabs. Maybe relevant imaging, of course. Maybe relevant. And then a lumber puncture. Usually this would be something you would be thinking of strongly if you were suspicious of either meningitis or encapsulitis. So we've spoken about meningitis. Let's do the same thing now with Encapsulitis. So again we're going to start with the pathology. Encapsulitis is an inflammation of the brain and the spinal cord. Untreated HSV. That's herpes simplex virus in careful itis has a very high mortality, too at 70%. But please note we saw earlier that untreated bacterial meningitis has a very high mortality. Whatever the bacteria is untreated, viral encephalitis will not always have as higher mortality as this because there are different viruses that can cause that but nevertheless begin. It's a very serious condition. And here you will see a picture of HSV encapsulitis again in, sadly, in someone who died of it again. I've referenced the picture. So now let's go back to what you actually see as the doctor or medical student. Seeing this patient, you start again with the history, and please note that there is already a bit of overlap with meningitis. They may also get a headache and fever and malaise. But because encapsulitis involves the brain more than the covering of the brain, you tend to get symptoms associated with that so they might be getting hallucinations or psychiatric symptoms or a reduction in the Glasgow coma score. As we can see here, they may also have a rash. Of course, it's possible you might pick something up related to HSV infection. There may be altered behavior, you know. They might be acting really odd or weirdly, and then you may get focal signs and seizures just the same as you can with meningitis and the para clinical investigations are really pretty much the same as we've just seen. So blood's swabs, if need be and the imaging lumber puncture. I haven't put these in the different order here deliberately. It's just because you don't always need imaging before doing a lumber puncture, and I will go on to talk more about that. So there's a little point I want to make about the choice of words. Now neurologists tend to throw words around, and sometimes it's important to think what we're really meaning in careful itis, we've already said, means inflammation of the brain. But of course, you can't always see that. So you have to go on other criteria from the history, the exam and the investigations. Let's start with the very general term NKF allopathy, which you may well have heard about in other contexts. All in careful opathy means it can be defined as altered consciousness, persisting for longer than 24 hours with lethargy, irritability or maybe even a change in personality or behavior. That's a little bit vague, you might say. If you want to make a diagnosis of clinical encapsulitis, then typically you might think about enkephalin opathy. So all I've just mentioned, plus at least two extra features such as fever, seizures or raised white cell counts in the CSF cerebral spinal fluid we call raised white cells. Cleo Citosis. There may be e e g evidence as well, or even evidence from the MRI. But of course, if you've got to wait 24 hours to diagnose encapsulitis, someone could have died in that time. So that's the trouble in general with these wonderful gold standard diagnosis in real practice, have a high clinical suspicion that what you could be seeing could be meningitis or encephalitis, and these can evolve very rapidly. So you don't need to wait 24 hours to make this preliminary diagnosis. If you feel the case fits the bill now, we're going to think now about causes of meningitis and careful itis. I'm going to show you a table here, which I kind of made up. I say made up, It's obviously all correct, but I've put it in a table, a pill form. But before I do it, I'd like you to reactivate your prior learning. You probably as part of your studies, have come across the idea of surgical sibs their ways of trying to get you to remember causes of an illness. So when I was a medical student with do silly things like saying what could be the cause of a of a swollen toe or something like that? And you can apply this and you can do the same thing with meningitis or in careful itis, and I'm going to show it now. It's quite a busy slide, but you will have access to this later, I believe. Okay, so here we go. Now you can see under surgical sieve. You probably aware of this pneumonic so vitamin C D E f. Okay, there are other ones out there. I'm not saying you have to use this, but this is a good way of trying to remember what could be going on. It's particularly useful if you come across any medical condition, and you're thinking I haven't got a clue what could be causing this because you just go through them in sequence. Obviously, in the case of meningitis and encapsulitis, as we're mainly thinking of the second one, they're ineffective, and I will go on to look into that in more detail. But I'll say a brief word or two about the other possible causes. The first one up is an important one. U C V vascular Now subarachnoid hemorrhage. If ever you've actually seen someone who's coming with a subarachnoid hemorrhage, it can be very dramatic. Often talk telling you if they're still conscious about the worst ever headaches they've had, and it will often be agonizing for them to move their neck. That's because blood is an intense irritator of the juror of the meninges, and so that can cause meningitis even though it's not infected. And in a similar vein, you could get in careful itis with vasculitis. I won't go through every single one of these because some of these are very small, small points because they're quite rare. Conditions, I would like importantly, to mention about autoimmune conditions for encapsulitis, which are important, and I will mention later. I'd also like to mention about neoplastic causes, particularly for meningitis. So when you get any kind of secondary metastases, particularly if they spread to the C. N s, that can cause a form of meningitis, particularly if you notice that they've lost their reflexes. But that's a small print and not one we're going to deal with, But it's common. It's not uncommon, particularly sadly, in end of life care of people who've got cancers. There's a second aspect about cancers, which is they don't always need to work directly to cause effects you'll see under N neoplastic. If you follow that row along, you'll see paraneoplastic under encapsulitis. I will mention more about that. But paraneoplastic conditions, or syndromes, are caused typically by auto antibodies, which the body generates to try and fight off the cancer, but they end up having a detrimental effect elsewhere in the body. And there are some classic autoimmune encephalitis conditions which are caused by this so not directly through neoplasm but as a paraneoplastic effect. There are some endocrine effect endocrine causes, and then finally, again, this is a bigger issue. It's not even just neurology here. I'm talking about medicine just for a moment. So I'm zooming away just from meningitis or encephalitis. Functional or non organic conditions are incredibly common in medicine, particularly in neurology. By this, I mean conditions, which the patient is often absolutely convinced that they really have their feeling they are experiencing symptoms, but ultimately they may not have an organic cause, so it's really common. The difficulty is, however, it can be very dangerous to jump to that conclusion. So although functional conditions are very common, you really have to park that idea unless you're absolutely sure about that, because it is possible that actually there could be something else going on. But because it is actually common, you need to bear it in mind. I personally think it would be unlikely to fool you in the case of meningitis or encephalitis anyway, so let's think about causes of meningitis in particular, thinking about infective causes. I use deductive reasoning before, so you start from a general point, for example, someone comes in with headaches and fever, and then you work out what they could have. That's deductive reasoning. And now we go the other way around to inductive reasoning. We consider specific little points and then expand out. Specific little points, I mean, are different causes of infection. So if we think about this table now, we're only looking at ineffective causes or lower down autoimmune causes of meningitis or encephalitis. This isn't exhaustive, but this is quite important list now. Actually, the most common cause of infected meningitis is viral meningitis. It's amazingly common, and in fact, probably a lot of these are caused by relatively common viruses such as enteroviruses and even mumps or measles, especially where childhood vaccination that hasn't got those covered. Very typically, someone might come into hospital end up having imaging a lumber puncture, maybe even treated initially for bacterial meningitis, and then actually it all fades away easily, and the lumber puncture isn't very remarkable. Maybe just some slightly raised white cells. However, when we come to viral infective causes of encapsulitis, so first main row on your far right then The Communist and most potentially serious cause of encephalitis is herpes simplex virus that can either be one or two. There are a few varieties here and you can look into the small print. But HSV and careful itis is not something you want to miss. It can leave devastating sick. Really. And I've seen this. I've seen it kill people and you don't need to decide on the second. But you need to really think if someone's got a kind of meningitis picture, but they're a bit confused. Always think. Could this be HSV encephalitis? We then go on to the next row, which is bacterial causes. This is mainly for meningitis, but there is an important exception when we come to Encapsulitis. As you can see now, I put this in bold deliberately because of course, this is kind of the meat of the issue, isn't it? We're thinking about bacterial meningitis and you don't want to miss this because any bacterial meningitis is very serious. Unless it's treated the communist here in adults, you need to think about streptococcus Neisseria meningitidis or haemophilus influenzae. I we will look at those and potential treatments. There is an important little aside here, and it was concerns encapsulitis that can also be caused by bacteria. There's a very peculiar pattern that you sometimes see with listeria encapsulitis. I have seen this before in the past, and it needs a slight tweet to the treatment. It actually causes a rahmbo encapsulitis, and this is because it actually affects the brain stem area of the brain and can cause some very odd effects. But you typically look for people who are at risk of that, and I will mention a bit more of this later. But particularly older people, possibly ladies with pregnancies or maybe immunocompromised moving down the list. I've only put in bold the ones you really should know about. So although you can see further down the list, you can get parasitic or amoebic malaria. Uh, sorry. A parasitic or amoebic causes of meningitis. The two more I do want to mention a TB and cryptococcus around the world. TB, in particular, is a very common, very serious court's cause of meningitis and encapsulitis. It's a horrible beast, and I've seen it many times boast in this country, and when I worked in Singapore It's a horrible beast because it kind of affects lots of different areas that affects the meninges, but it also forms an encephalitis, and it also forms a sticky vasculitis, so these kind of people can often get stroke light effects as well. Um, so that's an important one to bear in mind. Cryptococcus can occur in in people without any illness, but there's also a classic illness and people who are immunocompromised, um, and and that's an important one to remember. One of the bizarre characteristics of this is it will very commonly lead to a very high raised CSF pressure. When you do the lumber, puncture a few little points about autoimmune conditions at the bottom there. Firstly, autoimmune could be a systemic process. So you know your autoimmune conditions like Deshays, even in theory, things like rheumatoid, I suppose, which could rarely cause a meningitis. However, there's also the important area of paraneoplastic. Remember, I said, that's where a primary neoplastic process sets off a body response to produce antibodies to get rid of or try and get rid of the neoplasm. But sometimes those antibodies have a detrimental effect on the body. The so called paraneoplastic effects. The absolute classic one which, which I would suggest even at medical school level, is worth looking into. And knowing about is the the N. M. D. A receptor in careful itis worth looking at later. It may not be the number one on the list, but it's not that rare, maybe actually, a lot more common and underdiagnosed. The classic case for this would be perhaps a younger woman, typically with an ovarian tumor, and they may behave very oddly indeed. Sometimes they even develop what appear to be mainly psychiatric symptoms. So just it's worth putting. That was a little nugget of knowledge away, or you might be interested to read a bit more about it. Let's think a bit more now about the two biggies there. So I said, the bacterial meningitis and HSB herpes simplex virus Meningitis. Oh, sorry, Encapsulitis. So meningococcal meningitis is probably the big, scary one everyone thinks of. You know that's the one with the non blanching rash. It is probably the most deadly form of one of the most deadly forms of bacterial meningitis, but thankfully it's not that common, and as you're probably aware, there are various vaccination programs which help make it much less common. Most cases actually occur in much younger Children or even in adolescents. Streptococcus, streptococcus, pneumonia. As you can see, their causes the majority of bacterial meningitis in the Western world. In fact, you can see possibly up to 70%. And again there's a good vaccination program with this in mind in mufflers influenzae I that's less common, and one reason it's less common is because of a very effective vaccination program in younger Children. When we come on to HSV encapsulitis, then the incidents you could say, Well, you know, it's sort of a bit comparable when you think about it would say meningococcal meningitis. It seems rare, you might say, Well, look only two people in 100,000 per year. But of course, that's two people in the general public, not to people presenting to casualty with fever and headaches. So in that type of scenario, in the acute scenario, it's not that rare, and you must consider it. So let's talk about management now. Now, forgive me. I'm going to be a little bit of a fuss pot now. I'm not going to say straightaway. Go in, do a neurological exam and start the antibiotics. I'm going to do something. I'd suggest you keep in the back of your minds as medical students and when you become doctors, you know when you do your basic life support training, you might well remember the first steps approach with safety and then airway breathing C spine and so on. It's worth doing that very quickly in your head as you approach any patient. Don't say that to an examiner, or they might think, What are you talking about? But actually, it makes sense in these days of Covid approach with safety, they or you may have covid. There may be a spill on the floor, or they may be very violent. There could be lots of reasons for that, and they could be actually deteriorating very rapidly if they've got meningitis or encephalitis to the point that they need intubation. So this is not a little side point here. You should always have in your mind when you approach a patient, particularly an Il one. What about a B C D approach with safety? In most cases, of course, you just flashed through that because it's not needed. If the patient's talking happily to you. That's all right. Nevertheless, there may be an in between phase where perhaps the patient's talking, but they look in a bad way, and maybe they're deteriorating. There's a useful little phrase to remind you of what to ask in these situations, and although it's particularly geared to trauma, it can be very useful in any situation. That's ample. The acronym Ample As you can see there, that means allergies, which are so easy to forget to ask about medication especially. Are they on warfarin or anticoagulants or immunocompromised or recent antibiotics? In the case of meningitis or encephalitis, those can really mess up the water because if someone thought they had a Sinus infection, where actually at the beginning of meningitis they might have taken a few antibiotics, which kind of confuse the picture when you do a CSF analysis? So that's a M, And then we come to P of ample, which is past medical history, especially of past history of headaches. Could this actually be a migraine? Actually, quite commonly it can be. But of course, if in doubt, you don't want to miss meningitis or encephalitis, so you have to be very very sure before jumping to that malignancy, as we've said already could be relevant. Pregnancy, Unusual traveler exposure. Well, I suppose you tend to think of something, perhaps slightly ridiculous. Like have they been to, you know, the far flung tropics. But you don't need to to be at risk of other weirder forms of encephalitis. And indeed, meningitis, A classic example here, I know which affects people within Ukraine as well as the whole of Europe and the UK are tick born meningitis. So if you think about Lyme disease and associated conditions in my experience, although although they're not that common, you do need to say, Have you been in a forest with deer? For some reason, the cases I've seen before it was only when I said that. And then they said, Oh, yes, But if I said, Have you been bitten by a tick, they'd say no. And then when I said, Have you been in the forest with deer? They said, Oh, yeah, that was the time I got bitten by a tick. Anyway, Sorry. That's a little bit off the beaten track there, but it could be relevant because that to rarely can cause similar symptoms. We come on to the examination here. Now I know there's a lot of the examination you do, and when I was a medical student, I'd take forever about everything. I think all the doctors were rolling their eyelids at me because of roll their eyes at me because they'll be thinking, Why is this medical student taking so long? And this is a great example of somewhere where you shouldn't take too long. I think I could sometimes take 40 minutes to do a full exam, and you won't have 40 minutes. So although you want to do a cardiovascular, respiratory, an abdominal exam, you can be focused. Although it's important when you document that that you pointed out because if someone after you thinks you've done a full exam, they think everything is fine, whereas they might actually have something else going on that you didn't pick up. The key here is, I've said, is to look for a rash and do a neurology exam. Kernig's sign you're probably familiar with So Kernig's sign is a bit outdated now, but it's when you actually get the patient. They're actually lying flat on on the on the bed and the knee is bent up and you gradually extend the knee. And technically, it's supposed to be positive if there is strong resistance in the thigh muscles, when you bend the knee up to 100 and 35 degrees now, in reality, both that and the similar Brodzinsky sign are actually not very sensitive. What that means is, probably you might get in 100 cases of meningitis. Only five would have a positive Kernig's or Pierzynski's sign. However, they're worth testing because if they're present, it's actually quite likely that they've got meningitis, not 100%. So I think, because there's such quick tests, they're worth doing. But if they're normal, it doesn't mean they don't have meningitis. Talk about treatment. So at any stage, if you think look, this guy, the old lady has got meningitis clinically, then don't you know, spend another 10 minutes examining everything. Then start the process going to start thinking about treatment, which will come onto the neurological exam, which I actually taught on last time. So that should actually be on your records. If you wanted to look at how to go through. The neurological exam can seem very long winded. But in fact you can actually train yourself to do a detailed neurological exam in about three minutes, and that's everything. And you don't need to do everything if you're in a real rush. But you should focus, particularly at least making sure that you work out what their G. C s is and record that because it could deteriorate. Note any unusual behavior, see if they've got focal signs. So have they got cranial nerve deficits? Especially, have they got a problem with the sixth cranial nerve, which often you can develop with raised intracranial pressure? Of course. Use not Thelma scope to see if they've got papilledema, which again could suggest raised intracranial pressure. And then, of course, you've got to at least approximately test the arms and legs because, you know, they could have focal signs already. Now we're talking about treatment and forgive me for saying for about the third or fourth time and sorry, I think there's one more time at the end of this slide. Check local up to date guidance and check the allergies or any contra indications to medications. Now it might seem like I'm being really risk adverse But I can tell you from firsthand experience that when you're in a stressful, pressured environment, that's when mistakes can easily happen, particularly with dozing of medication. You know, you might quickly say it down. Or, you might say, perhaps to an inexperienced colleague. Oh, just give you know, 5 g when you meant milligrams. And so it's really important to just slow down for a moment and just check. Just check. You're doing the right thing. And even if you don't have time, you can check a trust. You can ask a trusted colleague just a cross. Check your work to make sure you're giving the right dose the right patient who hasn't got a significant Contra indication, such as an allergy. Okay, so if you're in the community, so maybe if you become a GP or on a GP rotation as part of your medical student, practice is typically an idea that if you think this could be meningococcal meningitis and I've told you before about the non blanching rash, you know you put the glass over it and you can't make it go away. Then you might well think about I am intra muscular or intravenous Benzal penicillin. A illustrative dose might be 1.2 g and then giving it 2.4 g every four hours. Assuming no allergies. Assuming no contra indication, there are alternatives because penicillin allergies are quite common and things like cefotaxime could be considered. In that scenario, the hospital setting is slightly different, So in the hospital setting, you may well consider adjunctive treatment with dexamethasone. So this is particularly for people who may have pneumococcal meningitis. This is said to protect in some ways, particularly in terms of hearing. However, if you're going to do this, it has to be quite early on. I think the latest you can do it is around about 12 hours after using antibiotics. Also, there's some caveats with that. Of course, you don't really want to give high dose steroids if someone's severely insect ick or if they're immunocompromised or after surgery. I've given some illustrated doses there, but again, as I've said, please check before you actually give it. Now, what about empirical treatment of the meningitis itself? And now we're imagining you in the hospital you have, or you haven't decided on dexamethasone, no in adult in adults or indeed, in Children above three months up to adults up to 50 years of age. A typical approach, if you think this is bacterial meningitis, would be to think about a drug such as key for Tax seen assuming they don't have an allergy, and you're typically looking for about a 10 day course. So you usually kind of commit yourself to a fairly long course intravenously. Of course, at first, if there are other factors, maybe if they've been taking recent antibiotics or there are other problems, you might consider adding in other agents, like vancomycin at the bottom there if they're over 50 years of age. And I mentioned this before, you might want to consider another medication, such as amoxicillin or ampicillin, if not allergic. This is thinking about listeria. Can you remember? I said about the rahmbo encapsulitis that can be caused by listeria? I've seen this mist, actually, and it can be a terrible condition, and actually, the time I saw it missed was when I was quite junior at the time and the senior doctor had actually done everything right. They said. Well, the patient is under 50 years of age, and unfortunately they didn't get the antibiotics, so I think it's worth remembering this. And then, you know, it doesn't have to be a hard rule of 50 years. And if you're under that, don't get ampicillin. If there are other risk factors like immunocompromised or maybe pregnancy, do consider that possibility. Now, what about HSV in careful itis? So if you're thinking about encapsulitis at all, you have to think about HSB encephalitis as probably the commonest serious cause of this intravenous acyclovir is the classic treatment, typically eight hours if no contraindications as per local guidance, and you typically continue this for a long time, 10 to 14 days. Now you can adjust it slightly, depending on the results of the lumber puncture when it comes back. But we're really thinking about the acute situation and not missing these conditions, which can be terrible. They can leave terrible securely or kill people. Renal function needs to be watched with their ciclovia quite regularly, maybe even every day or so, just to make sure that's not deteriorating and sorry, you'll probably be sick to the back teeth, me saying that you can ignore that, but the bottom it's just me basically saying, Look in the formulary first. Okay, there's no more. No more information than that on it when we come to investigations and we're nearing the end of the talk already a few little points. Sorry, this is just my boring years of experience. Ensure all the labels are correct and matching, so all patient should have. Ideally, I'd on them. You make sure it's the right patient. You make special care to do so in emergencies when urgencies can leave to missing or mistaken information commonly, Okay, probably. Or you've already sadly, been in stressful or emergent situations. I've been in them in the past many times, and that's just exactly the time when we feel busy and stressed. And we say to someone, Can you take that up to the lab? And perhaps we're not paying attention. Have we labeled it per properly? Are they going to come back to say they've made it? They've taken it to the lab, so it's worth taking care on this, particularly when we come to cerebral spinal fluid that should be treated as gold dust. Okay, it's easy to go, Ms Ley, and you don't ever want to repeat a lumber puncture because of that there's some other simple things which are easy to forget. Remember, you need to actually tell perhaps the nursing staff or more junior colleagues looking after the patient people. People can deteriorate quickly with meningitis or encephalitis, so you need to have someone regularly assessing them. Ideally, you tell them what to assess and how often to assess and when to call for help again. Sadly boring experience over the time. But I have seen situations in the past where junior staff have dutifully recorded all these things on a patient, and the patient's just gone downhill overnight, and they just keep recording day to be fair. Don't necessarily always know when to call for help, so spend a bit of time putting parameters in when you actually call for help. These days, of course, with things like the new system, it's a lot easier to actually do that. Bloods and venous access have mentioned already. You might want to consider HIV testing, but you take that on a case to case basis. I beg your pardon? Everyone. I didn't realize I was muted. They're just I was only recapping as I've said, the heart rate, BP, etcetera and tell people when to call for help. You do the Bloods at the same time you're getting venous access. Remember to get clotting and check the platelet counts, because those might turn out to be a contra indication to lumber. Puncture blood cultures are important. Then we come onto the lumber puncture, and this is a typical test to strongly consider in nearly all cases of meningitis or encephalitis if you suspect it, there are some contraindications if their focal neurological signs new onset seizures or severely altered mental status. So that's a Glasgow coma score of less than 10 or severely immunocompromised. Now the reason for this is because often if you get a CT head, it can delay treatment a lot. Now, I personally am a bit more cautious about this sort of stuff, and I personally wouldn't necessarily say they have to be as bad as a Glasgow coma. Score less than 10 to get imaging first. And I would certainly say if you do need imaging, it's very important that you don't delay treatment, and if you think there's going to be a delay, but you do need imaging, then if they need treatment to start with antibiotics, then don't delay that. So, although ideally, get the lumber puncture first. That shouldn't significantly delay treatment with antibiotics. Or were they ciclovia? If you think those are needed, a few other contraindications lumber puncture I mentioned there could be a problem with their bleeding. That could be serious, of course, if they've got, you know, bleeding diathesis and you putting a needle to get CSF in could be a local infection over the back spinal cord. Impression. Compression. Unlikely. And if you do a basic exam and it's normal, then you I think it's fair to largely exclude that before the lumber puncture. This is just good practice, by the way, get explain the procedure and get proper consent or ascent from the relatives and perform according to guidelines with documentation. So in the old days, I must admit, when I used to do lumber punctures, people would just be so we'll get on with it. You know, just do the lumbar puncture, but actually can be really scary for patient's, and so do try and do. Try and explain to them you can do this without delaying the procedure, because there's a lot of setting up. And what a lot of people don't realize is that setting up is key to making it more likely to be a successful first time number puncture. Getting the patient positions, lifting them right up on the bed so that they're right level with your face will greatly improve the chance of you getting CSF first time, Um, and so moving on from there just to remember to take great care of the CSF sample. As I said, treat it like gold dust because you don't want to get a repeat lumbar puncture to try and get this because it was lost or smashed. There's a very helpful video here, and I know you'll have access to this talk later, and that actually shows you how to perform a lumber. Puncture is a really good resource there. When you do the lumber puncture. Of course it should be. It should be. You should actually use a sterile technique. You should check the opening pressure and record it now. It might be worth if every have seen a lumber puncture being done. You get these measuring tubes manometers now a little trick. I know it seems wasteful. Have a spare manometer put out on the sterile field. If that pressure starts washing up, you might need a second manometer. Otherwise it just goes over the top. So I've seen it up to a 60 before. I mean, even up to 20 you started to think that's maybe getting a little bit high over 25 is typically high, but I have seen it up to 60. A few other things to say. Of course, you want to do a cell count on the CSF, a protein count which may be raised an infection. You might want to do a gram stain lactate, cytology. If you're thinking about neoplasm TB testing cryptococcal testing possibly PCR for bacterial and viral causes, so we've pretty much done it. Okay, I did say I'd finish early. So these are my key learning points. Meningitis and encephalitis have many possible causes, not just infective. But of course, your mainly thinking about bacterial meningitis and HSV encapsulitis in the acute setting. Always have your ears and eyes open to this possibility. They can sometimes be quite easy to tell apart if someone's got, you know, headache and fever. But they're really confused and all the rest and it's more likely to being careful itis if they've got headache and fever and a stiff neck. But they're entirely alert and orientated, with no focal signs may be more likely to be meningitis. But in the real world, if there's any suggestion of crossover, we often actually start treating both. If there's any query about that and here here I've talked again about the possibility of LP before CT. The key thing here is not to delay treatment, though I'm actually quite cautious myself. So even though guidelines do seem to say, you can just crack on and do an LP in most cases if there's not a Contra indication, um, you know it is sometimes reassuring to see a CT, but definitely if someone is sitting there with no past history talking to you normally and there's no focal signs and no papilledema, then then I think it's totally reasonable to consider a lumber puncture, if not contra indications. Vaccine coverage is, I've mentioned is helping to reduce the impact of meningitis, but still there is still further coverage to be needed, so that, I think, is it. So I'm ready for any questions. Um, and I hear. I very much turned to my co host to help me with this, Um, from the chat. Um, there is a question. Now, could you explain the type of rash that will be seen in meningitis, please? Yes, it's a good question. Now, unfortunately, have got a picture with it here, but basically, firstly, to say what type of meningitis? Because there's lots of different types. The key one you're really thinking about here is it almost looks like a dark purple, almost like many bleeds under the skin is where thinking about really dark purple patches under the skin. But unlike some rashes, if you press on it, it will stay in that color so it won't blanche away. You know, some little rashes if you've ever seen them, particularly Children. If you put pressure on them, the whole skin goes white. But with the meningococcal rash classically, it's non blanching, and the rate of way to test that simple way is with a glass, a clear glass. Sorry, a clear glass container that you can obviously ideally you know, not infected. You can press over the skin because then you can look through the glass and say Is that blanching or not? Now, of course, if it's a single spot and they say they've had it for ages, that's different. But they would almost certainly say, Look, I've just come out just like in the last few hours in this rash. It's quite distinctive when you see it. I'm so sorry. I haven't got that to show as well. But that's those are the classic features of it. The non blanching rash, which is strongly suggestive of a meningococcal illness. Thank you very much. Um, there's another question. Could you explain the use of a manometer and using another slash second manometer with a while? LP? Yeah. Okay. So what happens? This isn't a manometer, obviously, but hopefully you can see my ruler. Um and so I've got a rule in front of me. Now what happens is you get a you get a manometer, which is like a thin plastic tube. It's sterile, so your helper would tip it out onto the sterile tray that you've got in front of you now they're a little bit fiddly. And when you see one, if you haven't seen one before, you see what I mean. It's a little tube, and it usually comes in two parts. You put a second part on top, which will measure up to up to up to 40 centimeters, typically, so you can you can really measure up to a high pressure, and the fiddly bit is you then have to put a little tap down at the bottom. That tap allows you to take fluid off or stop taking fluid off. You might say, Why would you want to do that if you're changing containers, so you might need to take a number of containers. You know, if you're doing all these different tests, it's not just into one container. Then you can stop the flow. While you're changing between these now, it's important. Before you take any fluid off to measure. Where it goes up to, it will keep rising to a set point, and then you'll see it goes slowly up and down with respiration. That will be the opening pressure. You might, if it's raised, want to take off a reasonable amount of fluid and then measure a low closing pressure as well. But the key thing here is the basic principle. You measure the measure, the opening pressure and then you can use that little valve to drain all that fluid into the little container that you're measuring. Most of these are simply sterile little pots, with one exception. It's probably good practice to use a glucose blood tube. You know, the grey ones, because those actually stop the Axion of cells. Let me explain that it's the same reason when you take blood glucose. You don't want cells from the blood to keep eating up that glucose while it's waiting to be processed in the lab. Instead, you want to kind of paralyze any cells that are there. So whatever glucose you measure, even if it's an hour or two later, then um then that would be the true one. I can see there's one more. One more question and I'm aware of time here. Meningitis due to assume, Um, can I Can I just ask Lola to clarify? Does she mean subarachnoid hemorrhage or does she mean vasculitis? The question was, what is the treatment of meningitis due to vascular? Is it surgery? Um, so I'm not sure if Lola meant a subarachnoid hemorrhage or if she meant vasculitis. Um, And just while I'm waiting for that I'll jump in and try and cover both. So meningitis, when it's due to subarachnoid hemorrhage, doesn't need treatment beyond. Yeah, thank you. Thanks. Local. So subarachnoid hemorrhage does cause terrible meningitis, but that's just a sign of the subarachnoid you treat the subarachnoid rather than the meningitis it causes apart from, of course, giving painkillers. Um, I must confess it's, you know, it's usually it's a typically very difficult situation. If someone has presented with a subarachnoid, it does tend to have quite a bad prognosis. But you know, a reasonable number of people will kind of escape from having had a subarachnoid, but it's quite a difficult one to escape totally Scott free from. So, unfortunately, they presented with a significant subarachnoid hemorrhage. Then you'd be guided by the scan as to how big the bleed is, whether it's something that could be coiled or clipped because, you know, the subarachnoid bleeds in the brain are usually caused by a swelling and aneurysm in the brain popping or rupturing, so you can sometimes stop that with by putting little coils in or even open surgery with clipping it. But then there's an added difficulty with subarachnoid hemorrhage all this blood can cause vasospasm. So it's a difficulty about deciding whether surgery or radio radiological techniques like catheters are done immediately or not. A final point about subarachnoid bleeding. You typically use a medication such as nimodipine to help reduce the risk of that constriction of blood vessels, which can be very bad. So sorry about that. I probably overran a little bit. So we do have a few more minutes and there is one more question. Yes. Quickly. Um, could you explain how to define the real psychiatric disorder from psychiatric symptom of, uh, sorry. NCF NMDA receptor antibodies. Yes. Uh, sorry. I'm assuming that's what was said. Yes, it's a good question. And now this is quite small print, and I've only seen it a few times. Um so basically, you might recall what I said that there is this weird form of encephalitis which is called a paraneoplastic, or autoimmune encephalitis. Not all autoimmune encephalitis is a caused by a neoplasm, so they're not all paraneoplastic. But this classical one is the anti NMDA receptor antibody one. Now, it doesn't always present the same way, but it can present in this very bizarre way, particularly in young women because it seems to be associated, especially with ovarian tumour. And they can present, really, as if it's just a first acute psychiatric events, often with very passive or even stiff joints. It's almost like they've become very waxy to try and move them, and it's like everything is just sort of stiffened up. It's a very, very peculiar thing, and it's understandable, Um, that that that that might be mistaken for a psychiatric condition. Always worth bearing that in mind. I'm just I'm just reading. There was sorry. There was one more question. I wonder perhaps if I could turn to my my my great helper there because I can't quite read that. Oh, yes. Sorry. I've got it now. Uh, should I read it? I've got it. No, it's got it. So, as I thank you for the comment, I've heard that the range measurements of neck elevation and depression techniques while neck stiffness does forefinger distance techniques still being used to differentiate between hemorrhage and meningitis. Um, I personally as said I thank you for that. I wouldn't say that clinical, Um uh, clinical evaluation is really very reliable. So in terms of neck stiffness. I've seen it being severe in subarachnoid, but sometimes it's not severe at all. I've seen it severe with meningitis, but sometimes not at all. I think if someone come comes in with clear neck stiffness and not just meningitis, and it's a bit painful when I move my leg. But you know it's rigid, then that's a real marker of likely pathology, whatever that is. And if, as they often are, with the subarachnoid hemorrhage, they're quite drowsy as well. You would automatically try and do. Imaging first CT in the acute state would almost certainly show the bleed if it's a significant subarachnoid hemorrhage. So I think the bottom line is, although these tests can be quite useful, these clinical bedside tests they're not really to be relied on there just part of the jigsaw puzzle, so they're useful. But I wouldn't spend too much time on them to be honest. So hopefully that's of some help. So thank you all very much. So I really appreciate your time. I can't see any other questions. I really appreciate you all joining me today and sorry if I waffled on a bit, I tend to be it. Thank you. I said I thank you, everyone. I tend to be a bit excitable about all this because it really interests me and did as a medical student many years ago. But I really I appreciate your time today. Please do. Filling those those forms. Hope is of some use to you. And I wish you all the very best with your studies. Particularly this terrible situation you're having to deal with. Thank you so much, everyone. And I wish you all the very best. Thank you. Thank you very much, Doctor Young. Thank you. And I'm happy. I know. I should have probably stopped. Stopped sharing that. Let's stop sharing, so yeah.