Meningitis

paediatrics

By e. j. matoga

MCHS
 Meningitis
 Infection causing inflammation of
the membranes covering the
brain and spinal cord
 Medical emergency with
significant mortality
 Most frequent in children age 2
months to 2 years of age
 Higher incidence during dry
season peak July
 It is a very important
peadiatric problem for 2
reasons;
 Has a high mortality and
morbidity rate .
 The diagnosis is often
missed or

made too late.

Types of meningitis

 Meningitis can be considered based on

the following:
 Causative organism –
 bacterial,
 viral,
 fungal
 Age at onset – neonatal or meningitis
after neonatal period
 Characteristic type – pyogenic or
aseptic meningitis
Bacterial Pathogens- Neonatal
pyogenic meningitis
 Bacterial pathogens likely acquired at or shortly
after birth and seed meninges via hematogenous
spread
 Gram negative bacilli
Coliforms [E.coli]
Klebseilla
Salmonellae.
 Group B streptococci
 Staphylococcus aureas.
 Streptococcus pneumonia.
 H. Infuenzae
 Listeria monocytogenes - with impaired immunity
(at any age)
 Pyogenic meningitis
after neonatal period
 Main causes are
 Strep. Pneumonia [commonest ]
(ass. With most complications)
 Heamophilus infuenzae.
 Neiseria meningitidis. [ out breaks
may occur]
 Salmonellae – in babies < 1 year
 Lymphocytic meningitis/aseptic
 Meningitis with mainly lymphocytes in the
CSF ;
 All non-bacterial causes of meningitis
 Typically pt less ill appearing than bacterial
meningitis
 Most common cause is viral
 HSV
 Consider especially in infants presenting with
seizure
 Usually HSV type II
 Lymphocytic
meningitis/aseptic
 Viral – mumps  Fungal
enteroviruses.  Cryptococcus
 Tuberculosis .  Histoplasmosis
 Leptospires. Parasitic
Toxoplamosis
 Aseptic Meningitis
 Other infections
 Other Viral  Treponema
 HIV pallidum
 CMV  Mycoplasma
 EBV pneumoniae
 VZV  Rickettsia,
 Measles  Also in brain
 Rubella abscess or
tumours.
 Pathogenesis
 Meningitis is usually blood borne .
 May come from direct infection from-
 Chronic otitis media [often gives
brain abscess]
 Compound fractures – spread of
infection from the skin , sinuses or
meddle ear.
 In babies with myelomeningocoel.
 Pathogens- Special Situations
 There are certain situations which
predispose children to particular
pathogens
 VP shunts/penetrating head trauma-
Staph epi
 Neural tube defects- Staph aureus,
enteric organisms
 T-cell defects (HIV)- cryptococcus, listeria
 Sinus fracture- Strep pneumo
 Asplenia (HgB SS)- Neisseria, H. flu, S.
pneumo
Clinical Presentation
 Bacterial meningitis usually presents
in two patterns
 Acute (<1 day)- common with S.
pneumoniae and N. meningitides
 Subacute (2-3 days)- with
preceding URI like symptoms,
more common with H. flu and
other pathogens
Clinical features Con’t…
 These vary according to age.
Neonates
 In neonates signs are vague like
those of many other conditions.
 Not sucking – also in general sepsis
tetanus.
 Irritable or drowsy – also in
hypoxia hypoglycemia .
 convulsions
 Clinical features Con’t…
 Floppy or spastic
 Vomiting - also in intestinal
obstruction
 Hypothermia or febrile – also in
environmental temperature changes,
septicaemia, birth hypoxia.
 Jaundice – haemolytic disease of the
new born congenital infection
/syphilis, sepsis.
 Full fontanelle [late sign] –also in
increased intracranial pressure
Clinical features Con’t…
Order infants and children
 Fever -also in malaria typhoid measles
and many infections.
 Convulsions – also in febrile convulsions
cerebral malaria, hypoglycemia and
epilepsy.
 Headache – also in other fevers malaria
hepatitis.
 Neck stiffness [late sign] - also in
tonsillar, retropharyngeal abscess,
tetanus, typhoid, pneumonia.
Clinical features
Con’t…
 Behaviour disorders - also
from drugs [including alcohol]
typhoid, hypoglycaemia.
 Vomiting -+ diarrhea - also in
G/E malaria and hepatitis.
 Clinical features Con’t…
 Physical exam findings may be subtle or
nonexistent, especially in newborns
 Bulging fontanel
 Opisthotonos- stiff neck causing arched
position
 Focal neurologic signs
 Petechia/purpura- DIC with N.
menigitidis
 Positive Kernig’s and Brudniski’s
Purpura
CLINICAL FEATURES CT
 Nuchal rigidity
Passive or active flexion of the neck will usually
result in an inability to touch the chin to the
chest
 Tests to illustrate nuchal rigidity
The Brudzinski sign refers to spontaneous
flexion of the hips during attempted passive
flexion of the neck
The Kernig sign refers to the inability or
reluctance to allow full extension of the knee
when the hip is flexed 90 degrees
Kernig’s Sign
 Patient placed supine with hips
flexed 90 degrees. Examiner
attempts to extend the leg at the
knee
 Positive test elicited when there is
resistance to knee extension, or pain
in the lower back or thigh with knee
extension
Brudzinski’s Sign
 Patient placed in supine position and
neck is passively flexed towards the
chest
 Positive test is elicited when flexion
of neck causes flexion at knees
and/or hips of the patient
Diagnosis
 Do a lumber puncture.
Preferably with lab. Examination
of the CSF
 Do LP in all children who present
with
 Convulsions
 Irritability and reduced BCS.
 Or when the diagnosis is
uncertain in critically ill children.
Avoid LP
 In deeply unconscious children
because of the danger of brain oedema
and conning after LP.
 In the presence of raised intracranial
pressure.
 Severe respiratory / cardiac failure .
 Evidence of bleeding disorder .
 Infection of overlying skin .
 DO NOT delay treatment because of a
postponed LP
Meningitis-Diagnosis
 Lumbar Puncture
 Locate L3-L4 disk space using
superior iliac crests as landmarks
 Midline between spinous processes
 Aim for umbilicus
 Contraindicated in evidence of
increased ICP, hemophilia or
thrombocytopenia, infection in area
of LP, or cardiorespiratory
compromise
Lumbar Puncture-CSF Studies
 Test 1: gram stain and culture,
 Test 2: glucose, protein
 Test 3: cell count and differential
count
 Test 4: hold
 Fungal – Indian ink
 mycobacterium – ZN stain
 CSF Diagnosis
WBC Glucose Protein
Normal <5 (lymphs 2/3 serum 15-40 (½
70%, PMN’s glucose > serum
3%) 50 mg/dl level)
Bacterial >100, PMN’s Low Elevated
Meningitis predominate compared (>100)
to serum
(<20)
Aseptic Elevated Normal to Normal or
Meningitis (PMN’s early, low slightly
lymphs late) elevated

TB Elevated Low (<50) Elevated

Meningitis (PMN’s early, (>100)
lymphs late
CSF Diagnosis
Cell Count
 Increasing RBC’s in setting
of non-traumatic tap think
of intracranial bleed or HSV
Meningitis-Diagnosis
 CBC
 Normal WBC does not rule out
meningitis
 Low WBC in sepsis
 Blood cultures- up to 15% of
CSF positive meningitis in
newborns will have negative
cultures
 Meningitis-Differential
Diagnosis
 Cerebral malaria
 Brain abscess
 Encephalitis
 Epidural abscess
 Subarachnoid hemorrhage
 Tumor
Management Empiric Antibiotic Choices
 Quick initiation of antibiotics is a must
 Supportive care only for aseptic
meningitis
 HSV is the only exception
 The choice of antibiotics will depend on
the following ;
• Causative organism by age group or gram
stain , preferably after culture and
sensitivity results.
• Toxicity - especially in neonates.
• Penetration in the CSF
 Meningitis treatment
pre-referral
 At health center –
 Follow IMCI guidelines on
management of severe febrile
disease
 Give quinine for severe malaria
 Give first dose of benzyl pen.
 Treat to prevent hypoglycaemia
 PCM for fever
 Refer urgently
 In hospital

 Neonates

• Give X-pen 50,000 iu/kg/dose Q6Hrs

plus
• Gentamycin 6mg/kg od for 14-21 days
• Or ceftriaxone 100/kg od for 10-14
days
Meningitis treatment
Order infants and children
 X-pen 50,000 u/kg/dose Q4Hrs or
100,000 u/kg/doseQ6Hrs im/iv
and chloramphenicol 25mg/
kg/doseQ6Hrs im/iv
 Give chloramphenicol orally when
the child has improved for 10
days.
 Alternative- ceftriaxone 100mg/
kg od iv/im 7 -10 days.
Antibiotic Choices Con’t…
 Consider alternate antibiotics if child
is at risk for particular pathogen
 Alter antibiotic choices once CSF
gram stain results are available if
appropriate
 Consider repeat LP 24-36 hours after
initiating treatment to assure
sterilization of CSF if resistant
organism or poor response to
treatment
 Supportive treatment
 Fluids and nutrition
 Correct shock and dehydration then give
maintenance fluids iv or by NGT unless
the child is able to take orally.

 Convulsions
 Give anticonvulsants.
 Analgesics
 Give paracetamol or aspirin for fever and
pain
 Supportive treatment ct

 Nursing care
 Airway – position/ suction
 Turning to prevent pressure sores in
the comatose
 Physiotherapy if spastic to prevent
contractures, postural drainage to
prevent hypostatic pneumonia.
 Oral hygiene to prevent parotitis
Complications
 Subdural effusion especially
(H.influenzae)
 Hydrocephalus.
 Mental defects.
 Paralysises – cranial, monoplegias,
and hemiplegia.
 Deafness.
 Cortical blindness.
 Epilepsy.
Meningitis
prognosis
 Even with appropriate antibiotics, mortality rate
for bacterial meningitis is significant
 8% H. influ, 15% Neisseria, 25% Pneumococcal
 Up to 35% of survivors have sequelae including
deafness, seizures, blindness, paresis, ataxia,
hydrocephalus
 Poor prognosis is associated with young age,
long duration of illness prior to antibiotics, late-
onset seizures, coma at presentation, shock,
low CSF WBC with visible bacteria on gram
stain, immunocompromised state
Meningitis- Prevention
 Chemoprophylaxis for close
contacts of index case if
Neisseria; no policy in Malawi
 Vaccination – pentavalent -
H. influenzae
Normal Child
Cryptococcol
meningitis

 This is a fungal infection .

 Caused by creptococcus
neoformans.
 Incidence of C.neoforman increased
from 1981.
pathogenesis
 Organisms enter through inhalation.
 Thought to involve reactivation of
initial infection.
 Seen in order children with
advanced HIV infection
 CD4 counts usually less than 100
 Aids defining condition.
Clinical features
 Causes sub acute meningitis with;
 headache/neckache and little
stiffness
 intermittent fever
 Malaise.
 Nausea.
 altered mental status.
 seizures.
 raised intracranial pressure
leading to blindness and death.
Diagnosis

 LP – CSF for Indian ink stain

other characteristics are
 high opening pressure
 Increased WBCs
 CSF clear
 slightly increased high protein and mildly
low glucose
 sometimes normal CSF
 Creptococcol antigen assay
 Fungal cultures.
Management
 Creptococcol meningitis is fatal
without treatment.
 Give fluconazole orally
 Or amphotericin B IV 0.5mg/kg od
for 14 days followed by fluconazole
for 8 weeks
 After the treatment give life long
maintenance treatment with
fluconazole to prevent relapse.
 Refer to ART clinic
Treatment
 If evidence of raised intracranial
pressure:
 Repeated lumbar punctures
 acetazolamide
 Intraventricular shunting
Other associated OI
 Oral candida
 Tuberculosis
 Herpes Zoster
 Wasting syndrome
Prevention

 Primary and secondary

prophylaxis
 Early diagnosis
 HAART