What is the treatment for meningitis with 8th cranial nerve involvement?

Treatment of Meningitis with 8th Cranial Nerve Involvement

For meningitis with 8th cranial nerve involvement, intravenous ceftriaxone (100 mg/kg/day, not exceeding 4 grams daily) is the recommended treatment, with therapy continuing for at least 14 days or until the patient is clinically stable and improving. 1, 2

Diagnostic Approach

• Perform lumbar puncture to confirm diagnosis, unless contraindicated by signs of increased intracranial pressure 3
• Brain imaging (CT or MRI) before lumbar puncture is indicated in patients with:
  • Focal neurological deficits
  • New-onset seizures
  • Severely altered mental status (Glasgow Coma Scale <10)
  • Severely immunocompromised state 3
• CSF analysis remains the principal contributor to final diagnosis, with CSF leukocyte count being the best diagnostic parameter 3
• If lumbar puncture is delayed, obtain blood cultures and start empiric antibiotics immediately 1

Antibiotic Treatment

• For pediatric patients with meningitis:

  • Ceftriaxone 100 mg/kg/day (not exceeding 4 grams daily), administered once daily or in divided doses every 12 hours 2
  • Duration of therapy is typically 7-14 days 2

• For adult patients with meningitis:

  • Ceftriaxone or cefotaxime plus vancomycin or rifampicin 1
  • For adults >50 years or immunocompromised, add ampicillin/amoxicillin/penicillin G to cover Listeria 1

Management of Cranial Nerve VIII Involvement

• Any cranial nerve involvement should be managed as at least moderate severity 3
• Cranial nerve palsies in Lyme disease are often associated with lymphocytic CSF pleocytosis, with or without symptoms of meningitis 3
• Permanent bilateral vestibular and auditory loss can result despite adequate antibiotic treatment, as seen in cases of meningococcal meningitis 4
• Consider audiometry to document baseline hearing function and monitor for improvement 1

Adjunctive Therapy

• Dexamethasone should be administered before or with the first dose of antibiotics in bacterial meningitis 1
• For adults, recommended dose is 10 mg IV every 6 hours for 4 days 1
• For children, recommended dose is 0.15 mg/kg every 6 hours for 4 days 1
• Dexamethasone should be discontinued if Listeria monocytogenes is confirmed as the causative organism 1

Monitoring and Supportive Care

• Consider intracranial pressure monitoring in severe cases with signs of increased ICP 5
• Intensive care referral is indicated for patients with:
  • Glasgow Coma Scale ≤12
  • Cardiovascular instability
  • Respiratory compromise
  • Frequent seizures
  • Altered mental state 1
• Maintain euvolemia with crystalloids as initial fluid of choice and target mean arterial pressure ≥65 mmHg 1

Follow-up and Prognosis

• Hearing loss occurs in 5-35% of patients with bacterial meningitis 1
• Assess hearing function before discharge and arrange follow-up audiometry 1
• Other potential sequelae include cognitive deficits, seizures, motor deficits, and visual disturbances 1
• Neurological deficits occur in up to 50% of adults with bacterial meningitis 1

Common Pitfalls

• Delaying antibiotic treatment while awaiting imaging or lumbar puncture results 1
• Failing to recognize atypical presentations, especially in elderly patients 1
• Overlooking the need for ampicillin in older adults to cover Listeria 1
• Neglecting to assess for hearing loss and other sequelae before discharge 1
• Relying solely on the classic triad of fever, headache, and neck stiffness for diagnosis, which may not be present in all cases 1