Thread by @scott_mintzer

thestar.com/calgary/2019/0…

I don’t have medical facts, but it points up the confusion many people (even in healthcare) have about different kinds of CNS infections.

So, a brief #tweetorial on meningitis and the like. /1

There are two main types of nervous system infections: meningitis and encephalitis.

ENCEPHALITIS is infection of the brain substance. It presents with marked alteration of mental status, along with fever & elevated white blood cell count. Other symptoms are variable. /2

MENINGITIS is infection of the lining around the brain (& spinal cord). Cardinal symptoms are severe headache, nausea/vomitting, light sensitivity, and, above all neck stiffness.

It looks different than encephalitis. Alteration of mental state may or may not be present. /3

Confusion arises because there are actually 3 different types of infections that are commonly seen:

1. Bacterial meningitis

2. Viral meningitis

3. Viral encephalitis

And one of these is VERY different from the other two. So let’s go through them. /4

BACTERIAL MENINGITIS, a bacterial infection of the brain lining, is a medical emergency.

Patients will have the aforementioned meningitic signs, PLUS serious alteration of mental state. It usually comes on quickly, and mortality is high. /5

Bacterial meningitis can cause many complications, including deafness, hydrocephalus (increased spinal fluid pressure), venous sinus thrombosis (blood clots in the head!), and acute seizures or (chronic) epilepsy.

It’s treatable w/antibiotics, but you gotta get on it FAST. /6

VIRAL ENCEPHALITIS, a viral infection of the brain substance itself, is also an emergency. Patients will present with the symptoms mentioned above. Mortality is pretty high, and neurologic injury in survivors also common (as with bacterial meningitis). /7

Many different viruses cause encephalitis.

The good news: the most common one, herpes simplex, is treatable, using the same drugs used for genital herpes.

The bad news: almost all of the other ones are not. We have to wait & see if the patient can fight off the infection. /8

Now for the part that causes the confusion.

VIRAL MENINGITIS, a viral infection of the lining of the brain (& spinal cord), IS A BENIGN CONDITION.

Patients present w/the aforementioned meningeal signs. They feel like utter crap. But they’re completely neurologically intact. /9

Viral meningitis resolves on its own in several days to a week. It does NOT cause terrible complications like the other two do. EVER. No seizures. No neurologic injury. No hydrocephalus. Nothing.

In fact, a patient w/this doesn’t even need to be in the hospital. /10

Typically they will get an urgent spinal tap. But that’s just to make sure it isn’t bacterial meningitis (or another more rare kind that’s dangerous). Once we’re sure it’s a virus, the patient can go home and sleep the whole thing off. /11

(BTW, an identical syndrome occurs as a kind of “allergic” reaction to certain drugs. Exact same symptoms, course, prognosis. We call this “aseptic meningitis”, and it’s just like a viral meningitis, without a virus. You stop the offending drug & patient gets better.) /12

I mention this b/c the judge in this case apparently determined that “it was not proven that this was viral meningitis, and that this was life-threatening”.

There is no such thing as life-threatening viral meningitis. It’s a benign condition. /13

So, this child did not die from viral meningitis.

Now, did he HAVE viral meningitis in the first place?

Of course I can’t say for sure, but I doubt it.

He is described as having “unusual neurologic symptoms” & “abnormal movements”. That doesn’t happen w/viral meningitis. /14

But it says his “body was stiff” — that sure sounds like meningitis.

The lethargy could’ve been due to a systemic/respiratory illness, so that doesn’t help us determine if it was a viral or bacterial infection. /15

It is generally not difficult to distinguish between the two, as spinal fluid results will usually make this pretty clear.

medistudents.com/en/learning/os… /16

It’s not clear what caused the diagnostic ambiguity in this case. Were the CSF results weird?

But one thing‘s for sure: if there’s an argument in court about what the kid had, the parents surely could not have known. /17

And if your kid is lethargic & has “unusual neurologic symptoms”, YOU TAKE HIM TO THE HOSPITAL.

This is not debatable.

Failure to do so is neglectful in the extreme. /18

I generally don’t pass judgment on legal cases. We don’t know all the facts.

But exonerating the parents because prosecution “didn’t prove it was bacterial meningitis” smacks of one of two things:

/19

1. Gross incompetence on the part of the prosecution; or

2. Gross medical ignorance on the part of the judge.

Either one is a tragedy.

/20x