Meningitis In Children

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Information about Meningitis In Children

Published on March 6, 2008

Author: blackempress

Source: slideshare.net

Meningitis In children Harim Mohsin 02-13

Definition Meningitis is the inflammation of the membranes surrounding the brain & spinal cord, including the dura, arachinoid & pia matter.

Meningitis is the inflammation of the membranes surrounding the brain & spinal cord, including the dura, arachinoid & pia matter.

Incidence Meningitis can occur at all ages but it is commonest in infancy. While 95% of the cases take place between 1 month- 5 years of age. It is more common in males than females.

Meningitis can occur at all ages but it is commonest in infancy. While 95% of the cases take place between 1 month- 5 years of age.

It is more common in males than females.

Transmission The bacteria are transmitted from person to person through droplets of respiratory or throat secretions. Close and prolonged contact (e.g. sneezing and coughing on someone, living in close quarters or dormitories (military recruits, students), sharing eating or drinking utensils, etc.) The incubation period ranges between 2 -10 days.

The bacteria are transmitted from person to person through droplets of respiratory or throat secretions.

Close and prolonged contact (e.g. sneezing and coughing on someone, living in close quarters or dormitories (military recruits, students), sharing eating or drinking utensils, etc.)

The incubation period ranges between 2 -10 days.

Routes of Infection Nasopharynx Blood stream Direct spread (skull fracture, meningo and encephalocele) Middle ear infection Infected Ventriculoperitoneal shunts. Congenital defects Sinusitis

Nasopharynx

Blood stream

Direct spread (skull fracture, meningo and encephalocele)

Middle ear infection

Infected Ventriculoperitoneal shunts.

Congenital defects

Sinusitis

Signs & Symptoms The symptoms of meningitis vary and depend on the age of the child and cause of the infection. Common symptoms are: Flu-like symptoms fever lethargy Altered consciousness irritability headache photophobia stiff neck Brudzinski sign Kernig sign skin rashes seizures

The symptoms of meningitis vary and depend on the age of the child and cause of the infection. Common symptoms are:

Flu-like symptoms

fever

lethargy

Altered consciousness

irritability

headache

photophobia

stiff neck

Brudzinski sign

Kernig sign

skin rashes

seizures

Signs & symptoms Other symptoms of meningitis in Neonates/infants can include: Apnea jaundice neck rigidity Abnormal temperature (hypo/hyperthermia) poor feeding /weak sucking a high-pitched cry bulging fontanelles Poor reflexes

Other symptoms of meningitis in Neonates/infants can include:

Apnea

jaundice

neck rigidity

Abnormal temperature (hypo/hyperthermia)

poor feeding /weak sucking

a high-pitched cry

bulging fontanelles

Poor reflexes

Types Bacterial Viral (aseptic) Fungal Parasitic Non-infectious

Bacterial

Viral (aseptic)

Fungal

Parasitic

Non-infectious

Pyogenic Meningitis ETIOLOGY ‘ Meningococcal’ meningitis- N. meningitidis. A, B, C and W135) are recognized to cause epidemics The commonest organisms according to age groups are: N.Meningitides (serotypes A,B,C, Y & W135) S.Pneumoniae (serotypes 1,3, 6,7) H.Influenzae 2 yrs – 15+yrs H.Influenzae type b , S.Pneumoniae, N.Meningitides. 2 months- 2yrs E.Coli , Group B streptococci, S.Aureus, Listeria Monotocytogenes 0-2 months

ETIOLOGY

‘ Meningococcal’ meningitis- N. meningitidis. A, B, C and W135) are recognized to cause epidemics

The commonest organisms according to age groups are:

Bacterial Meningitis Pathogenesis: Entry of organism through blood brain barrier release of cell wall & membrane products Outpouring of polymorphs & fibrin cytokines & chemokines Inflammatory mediators Inflamed meninges covered with exudate (most marked in pneumoccocal meningitis).

Pathogenesis:

Entry of organism through blood brain barrier

release of cell wall & membrane products

Outpouring of polymorphs & fibrin

cytokines & chemokines

Inflammatory mediators

Inflamed meninges covered with exudate (most marked in pneumoccocal meningitis).

Pathogenesis Meningeal irritation signs: inflammation of the spinal nerves & roots. Hydrocephalus: Adhesive thickening of the arachinoid in basal cistern or fibrosis of aqueduct or Foramina of Lushka or Magendie Cerebral atrophy: thrombosis of small cortical veins resulting in necrosis of the cerebral cortex. Seizures: depolarisation of neuronal membranes as a result of cellular electrolyte imbalance. Hypoglycorhachia: decreased transport of glucose across inflammed choroid plexus & increased usage by host.

Meningeal irritation signs: inflammation of the spinal nerves & roots.

Hydrocephalus: Adhesive thickening of the arachinoid in basal cistern or fibrosis of aqueduct or Foramina of Lushka or Magendie

Cerebral atrophy: thrombosis of small cortical veins resulting in necrosis of the cerebral cortex.

Seizures: depolarisation of neuronal membranes as a result of cellular electrolyte imbalance.

Hypoglycorhachia: decreased transport of glucose across inflammed choroid plexus & increased usage by host.

Neonates Suspect meningitis with temperature more than 100.7 ‘F(38.2’C). Risk factors: Infective illness in mother PROM Difficult delivery Premature babies Spina bifida

Suspect meningitis with temperature more than 100.7 ‘F(38.2’C).

Risk factors:

Infective illness in mother

PROM

Difficult delivery

Premature babies

Spina bifida

D/D: Tuberculous Meningitis Viral /aseptic Meningitis Brain Abscess Brain tumor Cerebral malaria

Tuberculous Meningitis

Viral /aseptic Meningitis

Brain Abscess

Brain tumor

Cerebral malaria

Viral meningitis Viral meningitis comprises most aseptic meningitis syndromes. The viral agents for aseptic meningitis include the following: Enterovirus (polio virus, Echovirus, Coxsackievirus ) Herpesvirus (Hsv-1,2, Varicella.Z,EBV ) Paramyxovirus (Mumps, Measles) Togavirus (Rubella) Rhabdovirus (Rabies) Retrovirus (HIV)

Viral meningitis comprises most aseptic meningitis syndromes. The viral agents for aseptic meningitis include the following:

Enterovirus (polio virus, Echovirus, Coxsackievirus )

Herpesvirus (Hsv-1,2, Varicella.Z,EBV )

Paramyxovirus (Mumps, Measles)

Togavirus (Rubella)

Rhabdovirus (Rabies)

Retrovirus (HIV)

Fungal Meningitis It’s rare in healthy people, but is a higher risk in those who have AIDS, other forms of immunodeficiency or immunosuppression. The most common agents are Cryptococcus neoformans, Candida, H capsulatum.

It’s rare in healthy people, but is a higher risk in those who have AIDS, other forms of immunodeficiency or immunosuppression.

The most common agents are Cryptococcus neoformans, Candida, H capsulatum.

Parasitic Meningitis Infection with free-living amoebas is an infrequent but often life-threatening human illness. It’s more common in underdeveloped countries and usually is caused by parasites found in contaminated water, food, and soil. The most common causative agents are: Free-living amoebas (ie, Acanthamoeba, Balamuthia, Naegleria) Helminthic eosinophilic meningitis

Infection with free-living amoebas is an infrequent but often life-threatening human illness.

It’s more common in underdeveloped countries and usually is caused by parasites found in contaminated water, food, and soil.

The most common causative agents are:

Free-living amoebas (ie, Acanthamoeba, Balamuthia, Naegleria)

Helminthic eosinophilic meningitis

Non-infectious meningitis Rarely, meningitis can be caused by exposure to certain medications, such as the following: Immune globulin Levamisole Metronidazole Mumps and rubella vaccines Nonsteroidal anti-inflammatory drugs (e.g., ibuprofen, diclofenac, naproxen)

Rarely, meningitis can be caused by exposure to certain medications, such as the following:

Immune globulin

Levamisole

Metronidazole

Mumps and rubella vaccines

Nonsteroidal anti-inflammatory drugs (e.g., ibuprofen, diclofenac, naproxen)

Tuberculous meningitis It’s a complication of Childhood tuberculosis & common cause of prolonged morbidity, handicap & death. Children below 5 years are specially prone.

It’s a complication of Childhood tuberculosis & common cause of prolonged morbidity, handicap & death.

Children below 5 years are specially prone.

CLINICAL FEATURES Always sec. to primary tuberculosis. First Phase : Vague symptoms. Child doesn’t play, is irritable, restless or drowsy. Anorexia & vomiting may be present Older child may complain of headache. Possibly preceding history of Measles or another illness with incompletely recovery

Always sec. to primary tuberculosis.

First Phase : Vague symptoms.

Child doesn’t play, is irritable, restless or drowsy.

Anorexia & vomiting may be present

Older child may complain of headache.

Possibly preceding history of Measles or another illness with incompletely recovery

SECOND PHASE : Child is drowsy with neck stiffness, & rigidity. Kernig & Brudzinski sign may become positive, anterior fontanels bulges Twitching of muscles, convulsions, raised temperature. strabismus, nystagmus, and papilloedema may be present. Fundoscopy: Choroidal TB may be seen

SECOND PHASE :

Child is drowsy with neck stiffness, & rigidity.

Kernig & Brudzinski sign may become positive, anterior fontanels bulges

Twitching of muscles, convulsions, raised temperature.

strabismus, nystagmus, and papilloedema may be present.

Fundoscopy: Choroidal TB may be seen

TERMINAL PHASE Child is characteristically comatose with opisthotonus, & multiple focal paresis. Cranial nerve palsies are present. High grade fever often occurs terminally.

TERMINAL PHASE

Child is characteristically comatose with opisthotonus, & multiple focal paresis.

Cranial nerve palsies are present.

High grade fever often occurs terminally.

Diagnosis Lumbar Puncture : pressure usually raised, 10-500 PMNs early but later lymphocytes predominate Protein- 100-500,raised Glucose less than 50mg/dl in most cases Culture for tubercle bacilli. Presence of tuberculous focus elsewhere in the body is strong supportive diagnosis. CXR. Tuberculin skin test .

Lumbar Puncture : pressure usually raised,

10-500 PMNs early but later lymphocytes predominate

Protein- 100-500,raised

Glucose less than 50mg/dl in most cases

Culture for tubercle bacilli.

Presence of tuberculous focus elsewhere in the body is strong supportive diagnosis.

CXR.

Tuberculin skin test .

Treatment Antituberculous Therapy: Includes simultaneous administration of 4 drugs (Isoniazid, rifampicin,streptomycin , pyrazinamide) for first 3 months, followed by 2 drugs for another 15 months usually Rifampicin & INH. Total period: 18 months.

Antituberculous Therapy: Includes simultaneous administration of 4 drugs (Isoniazid, rifampicin,streptomycin , pyrazinamide) for first 3 months, followed by 2 drugs for another 15 months usually Rifampicin & INH.

Total period: 18 months.

Treatment STEROIDS: to reduce cerebral edema and to prevent subsequent fibrosis & subsequent obstruction to CSF 2mg/kg/24 hours of prednisolone for 6-8 weeks at the start of treatment starting 3 days after initiation of anti tuberculous therapy.

STEROIDS: to reduce cerebral edema and to prevent subsequent fibrosis & subsequent obstruction to CSF

2mg/kg/24 hours of prednisolone for 6-8 weeks at the start of treatment starting 3 days after initiation of anti tuberculous therapy.

D/D Partially treated bacterial meningitis Viral meningitis Cerebral malaria Viral encephalitis

Partially treated bacterial meningitis

Viral meningitis

Cerebral malaria

Viral encephalitis

Chronic Meningitis Chronic meningitis is a constellation of signs and symptoms of meningeal irritation associated with CSF pleocytosis that persists for longer than 4 weeks.

Chronic meningitis is a constellation of signs and symptoms of meningeal irritation associated with CSF pleocytosis that persists for longer than 4 weeks.

Examination General physical- Check for Consciousness level according to GCS scoring, jaundice or irritability. Resuscitation: incase of septic shock, or DIC. Vitals: temperature , HR, B.P., R/R. Signs of Increased ICP- Bulging fontanelle, headache, nausea, vomiting, ocular palsies, altered level of consciousness, and papilledema Fundus: papilloedema CN palsies: (esp. occulomotor, facial, and auditory)

General physical- Check for Consciousness level according to GCS scoring, jaundice or irritability.

Resuscitation: incase of septic shock, or DIC.

Vitals: temperature , HR, B.P., R/R.

Signs of Increased ICP- Bulging fontanelle, headache, nausea, vomiting, ocular palsies, altered level of consciousness, and papilledema

Fundus: papilloedema

CN palsies: (esp. occulomotor, facial, and auditory)

Examination Meningismus - check for nuchal rigidity with passive neck flexion (gives 'involuntary resistance). Brudzinski sign (hip & knee flexion with neck movement) Kernig sign (extend knee with hip flexed) Hemiparesis. Rash: petechial or purpuric rash (not only in meningococcal but also pneumococcal bacteremia).

Meningismus - check for nuchal rigidity with passive neck flexion (gives 'involuntary resistance).

Brudzinski sign (hip & knee flexion with neck movement)

Kernig sign (extend knee with hip flexed)

Hemiparesis.

Rash: petechial or purpuric rash (not only in meningococcal but also pneumococcal bacteremia).

 

 

Investigations CBC Blood culture Gram staining LP- D/r, C/s (color, leukocyte count, differential, glucose, protein) Electrolytes PCR Coagulation profile liver and kidney function Chest X-ray CT/ MRI Blood gases EEG ECG

CBC

Blood culture

Gram staining

LP- D/r, C/s (color, leukocyte count, differential, glucose, protein)

Electrolytes

PCR

Coagulation profile

liver and kidney function

Chest X-ray

CT/ MRI

Blood gases

EEG

ECG

Diagnosis CSF picture is quite diagnostic of the kind of meningitis present.

CSF picture is quite diagnostic of the kind of meningitis present.

Contraindication for LP .Increase intracranial pressure. .Unstable patient. .Skin infection at site of LP. .Thrombocytopenia. .Papilloedema.

.Increase intracranial pressure.

.Unstable patient.

.Skin infection at site of LP.

.Thrombocytopenia.

.Papilloedema.

Diagnosis Latex particle agglutination: detects presence of bacterial antigen in the spinal fluid. useful for detection of H.influenzae type b, S.Pnemoniae, N.Meningitidis, E.Coli Concurrent immuno-electrophoresis (CIE)-used for rapid detection of H.influenza, S.pneumoniae & N.meningitides. Smears: taken from purpuric spots may show meningococci in Meningococcaemia DNA sequences : are helpful in identifying bacteria

Latex particle agglutination: detects presence of bacterial antigen in the spinal fluid. useful for detection of H.influenzae type b, S.Pnemoniae, N.Meningitidis, E.Coli

Concurrent immuno-electrophoresis (CIE)-used for rapid detection of H.influenza, S.pneumoniae & N.meningitides.

Smears: taken from purpuric spots may show meningococci in Meningococcaemia

DNA sequences : are helpful in identifying bacteria

Treatment Supportive therapy: Maintain fluid & electrolyte balance as required Transfuse whole blood, PRC, FFP or platelets as required. Maintain temperature control Monitor OFC

Supportive therapy:

Maintain fluid & electrolyte balance as required

Transfuse whole blood, PRC, FFP or platelets as required.

Maintain temperature control

Monitor OFC

Treatment Steroids : Dexamethasone useful for H.influenzae type b, First dose should be given 1 hr prior to starting antibiotics. Antibiotics IV . Duration:1-3 weeks depending on age & type of organisms.

Steroids :

Dexamethasone useful for H.influenzae type b, First dose should be given 1 hr prior to starting antibiotics.

Antibiotics IV .

Duration:1-3 weeks depending on age & type of organisms.

Treatment Initial till results of C/S are known Probable/Proved Meningococci Ampicillin 300mg/kg/day+ Chloramphenicol 75-100mg.kg/day Penicillins 2-5 lac units /kg/day

Initial till results of C/S are known

Probable/Proved Meningococci

Ampicillin 300mg/kg/day+

Chloramphenicol

75-100mg.kg/day

Penicillins

2-5 lac units /kg/day

Treatment Probable H.Influenzae Probable E.Coli Ampicillin + chloramphenicol or 3 rd generation cephalosporin (cefotaxime 200mg/kg/day) Ampicillin + gentamycin 200mg/kg+2.5-4 mg/kg IV 12hrly

Probable H.Influenzae

Probable E.Coli

Ampicillin + chloramphenicol or

3 rd generation cephalosporin

(cefotaxime 200mg/kg/day)

Ampicillin + gentamycin

200mg/kg+2.5-4 mg/kg IV 12hrly

Treatment Probable group B streptococci Penicillin 50,000i.u/kgI.V/4 hourly.

Probable group B streptococci

Penicillin 50,000i.u/kgI.V/4 hourly.

Other Drugs available Anti-microbials Ceftriaxone Cefotaxime Penicillin G Vancomycin Ampicillin Gentamicin Anti-Virals Acyclovir Ganciclovir (>3mths) Anti-fungals Amphotericin B Fluconazole

Anti-microbials

Ceftriaxone

Cefotaxime

Penicillin G

Vancomycin

Ampicillin

Gentamicin

Anti-Virals

Acyclovir

Ganciclovir (>3mths)

Anti-fungals

Amphotericin B

Fluconazole

Prevention The vaccines against Hib, measles, mumps, polio, meningococcus, and pneumococcus can protect against meningitis Hib vaccine: all infants should receive at 2,4,6 months of age & booster 1 year later. After 1 year 1 dose is given till the age of 5 years. Pneumococcal vaccine: 0.5 ml is given IM (<2 yrs)

The vaccines against Hib, measles, mumps, polio, meningococcus, and pneumococcus can protect against meningitis

Hib vaccine: all infants should receive at 2,4,6 months of age & booster 1 year later.

After 1 year 1 dose is given till the age of 5 years.

Pneumococcal vaccine: 0.5 ml is given IM (<2 yrs)

Prevention High-risk children should also be immunized routinely. Vaccination before travelling to an endemic area Chemoprophylaxis for susceptible individuals or close contacts: H influenzae type b : Rifampin(20 mg/kg/d) for 4 days N meningitidis: Rifampin (600 mg PO q12h) for 2 days upto 10weeks Ceftriaxone (250 mg IM) single dose or Ciprofloxacin(500-750 mg) single dose.

High-risk children should also be immunized routinely.

Vaccination before travelling to an endemic area

Chemoprophylaxis for susceptible individuals or close contacts:

H influenzae type b : Rifampin(20 mg/kg/d) for 4 days

N meningitidis: Rifampin (600 mg PO q12h) for 2 days upto 10weeks

Ceftriaxone (250 mg IM) single dose or Ciprofloxacin(500-750 mg) single dose.

Complications Bacterial meningitis may result in Cranial nerve palsies Subdural empyema Brain abscess Hearing loss Obstructive hydrocephalus Brain parenchymal damage: Learning disability, CP, seizures, Mental retardation. Septic shock/ DIC Ataxia Stroke SIADH (Na+ <130 mE/l), puffiness of face, dec UO.

Bacterial meningitis may result in

Cranial nerve palsies

Subdural empyema

Brain abscess

Hearing loss

Obstructive hydrocephalus

Brain parenchymal damage: Learning disability, CP, seizures, Mental retardation.

Septic shock/ DIC

Ataxia

Stroke

SIADH (Na+ <130 mE/l), puffiness of face, dec UO.

Treatment of Complications: Convulsions: Diazepam I.V, Can be repeated q4 hours as required. Cerebral edema: *I.V Mannitol 1g/kg in 20-30 mins 6-8 hourly given for first few days. IV Dexamethasone can then be used 6 hourly .

Convulsions: Diazepam I.V, Can be repeated q4 hours as required.

Cerebral edema: *I.V Mannitol 1g/kg in 20-30 mins 6-8 hourly given for first few days.

IV Dexamethasone can then be used 6 hourly .

Subdural effusion: Aspirate subdural effusion if large. Shock: Treat with IV Fluids, maintanence of BP. SIADH: Increase body weight, decreased serum osmolality, hyponatremia. Prevented by fluid restriction to 800-1000ml/m2/24 hours. Hyperpyrexia: Tepid sponging, correction of dehydration.

Subdural effusion:

Aspirate subdural effusion if large.

Shock: Treat with IV Fluids, maintanence of BP.

SIADH: Increase body weight, decreased serum osmolality, hyponatremia.

Prevented by fluid restriction to 800-1000ml/m2/24 hours.

Hyperpyrexia: Tepid sponging, correction of dehydration.

Prognosis It depends on the age of the patient, the duration of the illness, complications, micro-organism & immune status. Patients with viral meningitis usually have a good prognosis for recovery. The prognosis is worse for patients at the extremes of age (ie, <2 y, >60 y) and those with significant comorbidities and underlying immunodeficiency. Patients presenting with an impaired level of consciousness are at increased risk for developing neurologic sequelae or dying.

It depends on the age of the patient, the duration of the illness, complications, micro-organism & immune status.

Patients with viral meningitis usually have a good prognosis for recovery.

The prognosis is worse for patients at the extremes of age (ie, <2 y, >60 y) and those with significant comorbidities and underlying immunodeficiency.

Patients presenting with an impaired level of consciousness are at increased risk for developing neurologic sequelae or dying.

Prognosis A seizure during an episode of meningitis also is a risk factor for mortality or neurologic sequelae. Acute bacterial meningitis is a medical emergency and delays in instituting effective antimicrobial therapy result in increased morbidity and mortality. The prognosis of meningitis caused by opportunistic pathogens depends on the underlying immune function of the host as may require lifelong suppressive therapy.

A seizure during an episode of meningitis also is a risk factor for mortality or neurologic sequelae.

Acute bacterial meningitis is a medical emergency and delays in instituting effective antimicrobial therapy result in increased morbidity and mortality.

The prognosis of meningitis caused by opportunistic pathogens depends on the underlying immune function of the host as may require lifelong suppressive therapy.

References Nelson textbook Basis of pediatrics WHO recommendations E-medicine

Nelson textbook

Basis of pediatrics

WHO recommendations

E-medicine

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