Post neonatal menengitis

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  • Post neonatal menengitis

    1. 1. <ul><li>POST NEONATAL MENENGITIS BY DR. AYESHA AHMED ALI </li></ul>
    2. 2. <ul><li>MENENGITIS:- </li></ul><ul><ul><li>It is an inflammation of the menengies, the membrane that </li></ul></ul><ul><ul><li>line the brain and the Spinal Cord. </li></ul></ul><ul><li>Types of Menengitis :- </li></ul><ul><li>Common:- </li></ul><ul><li>1. Bacterial (Pyogenic) </li></ul><ul><li>2. Viral Menegitis </li></ul><ul><li>3. Aseptic Menegitis </li></ul><ul><li>Un Common:- </li></ul><ul><li>1. T.B Menegitis </li></ul><ul><li>2. Fungal Menegitis </li></ul><ul><li>3. Syphillis (Acute) Leptospirosis </li></ul><ul><li>4. Amebic </li></ul>
    3. 3. <ul><li>Etiology:- </li></ul><ul><li>1. Bacterial Menengitis :- </li></ul><ul><li>(i) S.Pneumoniae:- (Otitismedia, sinusits, Pneumoniae, CSF Otorhea). </li></ul><ul><li>(ii) N.Menengitidis :- It may be Sporadic or Epidemic . </li></ul><ul><li>Peak age younger than five year. </li></ul><ul><li>(iii) H.Influniza Type B :- 50% in Ist year of life. </li></ul><ul><li>2. Viral Meningoencephlitis :- </li></ul><ul><li>(i) Entro Virus </li></ul><ul><li>(ii) Arbo Virus </li></ul><ul><li>(iii) Herpes Simplex-1 </li></ul><ul><li>(iv) Vericella Zooster Virus </li></ul><ul><li>(vi) EBV </li></ul><ul><li>(vii) Mumps </li></ul><ul><li>(viii) Adeno Virus, influnza, Para influnza Virus, Rubella or Rabies </li></ul>
    4. 4. <ul><li>3. Aseptic Menengitis :- </li></ul><ul><li>Virus </li></ul><ul><ul><ul><li>Common:- </li></ul></ul></ul><ul><ul><ul><li>Antro Virus </li></ul></ul></ul><ul><ul><ul><li>Arbo Virus </li></ul></ul></ul><ul><ul><ul><li>HSV- 2 </li></ul></ul></ul><ul><ul><ul><li>Human Harpes Virus 6 </li></ul></ul></ul><ul><ul><ul><li>Un Common:- </li></ul></ul></ul><ul><ul><ul><li>HIV-1 </li></ul></ul></ul><ul><ul><ul><li>Epstenbarr Virus </li></ul></ul></ul><ul><ul><ul><li>Mumps </li></ul></ul></ul><ul><ul><ul><li>Rare:- </li></ul></ul></ul><ul><ul><ul><li>Adenovirus </li></ul></ul></ul><ul><ul><ul><li>Vericella Zooster Virus </li></ul></ul></ul><ul><ul><ul><li>CMV </li></ul></ul></ul><ul><ul><ul><li>Measles </li></ul></ul></ul><ul><ul><ul><li>Rubella </li></ul></ul></ul><ul><ul><ul><li>Influnza A & v </li></ul></ul></ul>
    5. 5. <ul><li>Bacteria </li></ul><ul><li>Common:- </li></ul><ul><li>Pyogenic ( Partially Treated ) </li></ul><ul><li>Mycobactrium T.B </li></ul><ul><li>Mycoplasma Pneuomonia </li></ul><ul><li>Leptospria Species </li></ul><ul><li>Un Common :- </li></ul><ul><li>Treponema Pallidum </li></ul><ul><li>Borrelia Speices </li></ul><ul><li>Rickettesia Rickettisii </li></ul>
    6. 6. <ul><li>Rare:- </li></ul><ul><li>Coxilla Burnetti </li></ul><ul><li>Brucella Abortus </li></ul><ul><li>Streptobacillus Moniliformis </li></ul><ul><li>Mums and Polio </li></ul><ul><li>Systemic:- </li></ul><ul><li>Bacterial endocarditis </li></ul><ul><li>Kawasaki Disease </li></ul><ul><li>SLE </li></ul><ul><li>Sjoggron Syndrom </li></ul><ul><li>Rehumatoid Arthritis </li></ul><ul><li>Sarcoidosis </li></ul>
    7. 7. <ul><li>Melignency:- </li></ul><ul><li>Leukemia </li></ul><ul><li>Lymphoma </li></ul><ul><li>Metastatic Ca: </li></ul><ul><li>CNS Tumor </li></ul><ul><li>Drugs:- </li></ul><ul><li>Intrathecal Injunction </li></ul><ul><li>Contrast Media </li></ul><ul><li>NSAID </li></ul><ul><li>Carbamezepine </li></ul><ul><li>Azathioprine </li></ul><ul><li>IV Immunoglobulin </li></ul><ul><li>Antibiotics ( Isoniazid, Ciprofloxacin ) </li></ul>
    8. 8. <ul><li>Miscellenius :- </li></ul><ul><li>Heavy Meatal (Lead, Arsenic </li></ul><ul><li>F. B ( Shunt, Reservior ) </li></ul><ul><li>Post Migrain </li></ul><ul><li>Post Neoro Surgery </li></ul>Esinophillic Fungus Parasites ( Esinophillic ) Parasites ( Non Esinophillic ) Post Infectious Vaccine, Rabies, Measels, Polio
    9. 9. <ul><li>Epidimiology :- </li></ul><ul><li>B.Menengitis </li></ul><ul><li>Major risk factor for B.M is lack of immunity to specific Pathogen specially in young age. </li></ul><ul><li>Risk factor include recent pathogenic Bacteria close contact (House hold, day care centre, College, Military Barracks) crowding, poverty, black race and male gender. </li></ul><ul><li>Mode of transmission is person to person contact through respiratory Sec: or droplet. </li></ul><ul><li>Risk of Menengitis in infant and young children meningococcus 85 time HIB 12 time in relation to that of Pneumococcus. </li></ul><ul><li>Defect in compliment system (C5-C8) associated with recurrent meningococcus infection. </li></ul><ul><li>Splenic disfuction (Sickle cell Anemia) </li></ul><ul><li>Asplenia (due to troma or cong: defects) </li></ul><ul><li>T-lymphocyte defect </li></ul><ul><li>Risk of B.M with Chochlear implant or treatment of hearing loss </li></ul><ul><li>Lumbosacral Dermal sinus and meningomiclocele with staphylococcal and gram negative Bacteria </li></ul>
    10. 10. <ul><li>Viral Encephalitis </li></ul><ul><li>The epidiomologic pattern of viral meningo encephalitis is primarily determine by the presence of entro virus the most common etiology </li></ul><ul><li>Infection with entro virus is spread directly person to person with incubation period 4-6 days. </li></ul><ul><li>Epidiomologic consideration in Aseptic menenigitis include season, Geography, climatic condition, animal exposure and specific pathogen </li></ul><ul><li>Esinophillic Menengitis :- </li></ul><ul><li>A.cantonensis is found in South East Asia, Japan, Taiwan, Egypt and Cuba </li></ul><ul><li>Infection is acquired by eating raw or under cooked fresh water snail, Prawn or Crabs containing infectious larvae. </li></ul><ul><li>Gnathostoma Infection found in Japan, China, India, Bangladesh and South East Asia. </li></ul><ul><li>This infection is acquired by eating under Cooked or raw Fish, Frog, Birds or Snake meat. </li></ul>
    11. 11. <ul><li>Sign & Symptom :- </li></ul><ul><li>Acute Menengitis represent two patterns </li></ul><ul><li>1. The dramatic but less common presentation are rapidly progressive menifestation </li></ul><ul><li>Shock </li></ul><ul><li>Purpura </li></ul><ul><li>DIC </li></ul><ul><li>Reduced level of consciousness </li></ul><ul><li>resulting Comma and death with in 24 hours </li></ul><ul><li>2. Menengitis is preceded by saveral days of fever </li></ul><ul><li>Acampained by upper RTI & GIT symptom, followed by non specific sign of CNS infection. </li></ul><ul><li>Non Specific Sign:- </li></ul><ul><li>Fever </li></ul><ul><li>Anorexia </li></ul><ul><li>Headache </li></ul><ul><li>Mylgia </li></ul><ul><li>Athralgia </li></ul><ul><li>Tachycardia </li></ul><ul><li>Hypotension </li></ul><ul><li>Nausea </li></ul><ul><li>Vomiting </li></ul><ul><li>Photophobia </li></ul><ul><li>Petechie </li></ul><ul><li>Purpura </li></ul><ul><li>Erythmatous Macular rash </li></ul>
    12. 12. <ul><li>Specific Sign :- </li></ul><ul><li>Sign & Symptom of menengial irritation :- </li></ul><ul><li>Neck Stiffness 40% </li></ul><ul><li>Kerning Sign ( Flexion of the Hip 90 degree with subsequent pain with extension of the leg ) </li></ul><ul><li>Brudzinski sign ( Involuntarily Flexion of the knees and Hips after passive flexion of the Neck while supine ) </li></ul><ul><li>Sign of ICP:- </li></ul><ul><li>Headache Bulging Fontanel or Widening of Suture (Diastases) </li></ul><ul><li>Cranial Nerve Involvement with B.M it can be permanent </li></ul><ul><li>Paralysis of extra occular or facial Nerve </li></ul><ul><li>Eight ( Auditary ) Nerve often affected </li></ul><ul><li>Deafness </li></ul><ul><li>Blindness is rare </li></ul><ul><li>Papilleedema un common </li></ul><ul><li>Decree of CNS derangement observed of B.M range from irritability to coma </li></ul><ul><li>50% of Children with B.M have subdural effusion occur </li></ul><ul><li>20-30 % of Children have Seizure (Focal or Generalize) </li></ul><ul><li>20% of Children with B.M have focal Neurological Sign </li></ul><ul><li>15% of Children with B.M are Comatos or Semi Comatos </li></ul><ul><li>Peticae and Purpura if present considered danger of developing septic shock </li></ul><ul><li>Decereberate or decorticate posture </li></ul>
    13. 13. <ul><li>S/S OF VIRAL MENINGOENCEPHLITIS :- </li></ul><ul><li>Progress of dieasease are determind by relative degree of menengial and parenchymal involvement and specefic etiology . </li></ul><ul><li>The onset of illness are generaly acute . </li></ul><ul><li>Headach(generalized,frontal,reterobulbar pain) </li></ul><ul><li>Hyperasthesia </li></ul><ul><li>Lethargy </li></ul><ul><li>Irritability </li></ul><ul><li>Fever </li></ul><ul><li>Nausea </li></ul><ul><li>Vomitting </li></ul><ul><li>Photophobia </li></ul><ul><li>Pain in leg </li></ul><ul><li>Pain in neck </li></ul><ul><li>Mental dullness </li></ul><ul><li>Convulsion </li></ul><ul><li>Flacid paralysis </li></ul><ul><li>Loss of blader and bowel control </li></ul>
    14. 14. <ul><li>S/S OF ASEPTIC MENENGITIS </li></ul><ul><li>S/S Of of aseptic menengitis are same but less severe </li></ul><ul><li>Esionophillic Menengitis </li></ul><ul><li>Illness start 1-3 wk after exposure </li></ul><ul><li>Fever </li></ul><ul><li>Periphral esinophillia </li></ul><ul><li>Vomitting </li></ul><ul><li>Abdominal pain </li></ul><ul><li>Creeping skin infection </li></ul><ul><li>Pleurisy </li></ul><ul><li>Headach </li></ul><ul><li>C.N palsies </li></ul><ul><li>Parasthesia </li></ul><ul><li>T.B Menengitis:- </li></ul>
    15. 15. <ul><li>Diagnosis </li></ul><ul><li>Base line </li></ul><ul><li>CBC </li></ul><ul><li>RBS </li></ul><ul><li>S.Electrolite(esp;NA) </li></ul><ul><li>Urea/Creatinine </li></ul><ul><li>S.Ca </li></ul><ul><li>P.T </li></ul><ul><li>APTT </li></ul><ul><li>Fibrinogen </li></ul><ul><li>Specific </li></ul><ul><ul><li>L.P </li></ul></ul><ul><ul><li>Gram stain </li></ul></ul><ul><li>Bacterial culture </li></ul><ul><li>Cell count </li></ul><ul><li>CSF conc: of protein and glucose </li></ul><ul><li>Specific stain for isolation of organism </li></ul><ul><li>Blood culture </li></ul><ul><li>Serology </li></ul><ul><li>Brain biopsy </li></ul>
    16. 16. <ul><li>Blood culture </li></ul><ul><li>Serology </li></ul><ul><li>Brain biopsy </li></ul><ul><li>Imaging:- </li></ul><ul><li>C.T scane </li></ul><ul><li>MRI </li></ul><ul><li>Imaging help in complicated cases </li></ul><ul><li>If herniation of brain is present </li></ul><ul><li>If significant increase in ICP </li></ul><ul><li>Children with history of Immunosupression,Hydrocephalus;V.P Shunt, head trauma; etc </li></ul><ul><li>May be help full for decision on management during course of therapy </li></ul><ul><li>Imaging not be routinely done as result of prologed or sec;fever </li></ul><ul><li>PCR(Sesitive method of diagnosis in menengitis caused by Enterovirus; Herpesvirus ; or other virus) </li></ul>
    17. 17. <ul><li>CSF FINDING IN CNS DISORDER </li></ul><ul><li>Condition Pressure (MM H2 O) Leukocytes (MM3) Protein (MG/DL) Glucose (MG/DL) </li></ul><ul><li>Normal 50-80 <5,>75% LYM 20-45 >50 (75%)S.G </li></ul><ul><li>Aqute B.M Elevated (100-300) 100-1000 or more 100-500 <40 OR <50% </li></ul><ul><li>PMNS Serum Glucose </li></ul><ul><li>Viral M.N Normal or slightly Rarely >1000 pmns 50-200 Normal or dec: </li></ul><ul><li>Elevated b/t mononuclear </li></ul><ul><li>T.B, M.N Elevated 10-500 PMNS early 100-3000 <50 </li></ul><ul><li>b/t Lymphocytes may be high </li></ul><ul><li>Fungal M.N Elevated 5-500 PMNS early 25-500 <50 </li></ul><ul><li>b/t mononuclear late </li></ul><ul><li>Sphilis Elevated 50-500 lymphosytes 50-200 Normal </li></ul><ul><li>Amebic M.N Elevated 1000-10000 PMNS 50-500 Normal or Dec </li></ul>
    18. 18. <ul><li>Plan of Treatment </li></ul><ul><li>Bacterial Menengitis </li></ul><ul><li>Acute menengitis is always medical emergency and should dictete immediate management. All children with altered state of consciousness should observe closely </li></ul><ul><li>Assessment of child who is vitaly stable frequently first 72 hour consist of </li></ul><ul><li>Early sign of CNS </li></ul><ul><li>(level of consciousness, pupilary reflex, motor strength, cranial nerve sign, development of seizure etc) </li></ul><ul><li>CVS </li></ul><ul><li>Metabolic complication </li></ul><ul><li>Changes in vital sign (pulse, B.P, R.rate) </li></ul><ul><li>Development of SIADH </li></ul><ul><li>Assessment of child with rapidly progressive diseases of less than 24 hour patient is in profound coma or whose detoriate level of consciousness should evaluated for complication </li></ul><ul><li>cerebral abcess </li></ul><ul><li>Multiple organ failure </li></ul><ul><li>Shock </li></ul><ul><li>ICP </li></ul><ul><li>ARDS </li></ul><ul><li>Obstructive hydrocephalus </li></ul>
    19. 19. <ul><li>Therapy that are crucial for all patient with B.M </li></ul><ul><li>Initial management </li></ul><ul><li>Maintain IV line </li></ul><ul><li>pass NG tube </li></ul><ul><li>NPO </li></ul><ul><li>Specific treatment </li></ul><ul><li>1.Fluid management </li></ul><ul><li>2.Anti microbial therapy </li></ul><ul><li>3.Anti inflammatory therapy </li></ul><ul><li>4.Anti convulsant therapy </li></ul><ul><li>Fluid Management </li></ul><ul><li>If pt is half to two normovolumic normal BP IV fluid should be restricted to one third of maintenenceor 800,1000ml/m2/24hr </li></ul><ul><li>- To minimize brain edema and prevent SIADH with has been reported in 29 to 88% of B.m </li></ul><ul><li>2. Fluid restriction is not appropriate in the presence of systemic hypotension b/c reduce BP may result in reduced cerebral perfusion pressure and CNS ischemia. Therefore shock must be treated aggressively to prevent Brain and other Organ dis-function (ATN, Acute respiratory distress syndrome. </li></ul>
    20. 20. <ul><li>3. Fluid Administration may be returned to normal 1500 – 1700 ml/ m2/24 hours, When S.NA level are normal. </li></ul><ul><li>4. Patient with septic shock may required fluid resuscitation and with Vaso constrictive agent such as Dopamine and Epinephrine. </li></ul><ul><li>5. Patient with shock and Markedly Elevated ICP, coma and refractory Seizure require central Arterials monitoring and Venous acess and Pediatric ICU care. </li></ul><ul><li>6. S.NA concentration should be closely monitor every 4-6 hours during ist 24 hours of Therapy – </li></ul><ul><li>- If S.NA level decrees to <125 mEq/L this should repeat as soon as possible </li></ul><ul><li>-If S.NA level is still <125 mEq/L fluid should be restricted to keep Vein open until S.Electrolyte concentration have been corrected. </li></ul><ul><li>- For B.M providing routine maintenance fluid at approximately 80% of maintenance rate after fluid repletion and advancing to full maintenance rate as S.NA increased >135 mEq/L seem to be appropriate. </li></ul><ul><li>7. The period of fluid restriction may only need to be <1 day. </li></ul><ul><li>Anti Microbial Therapy:- </li></ul><ul><li>Initial Therapy </li></ul><ul><li>Initial (empirical) choice of therapy based on age B/C of causative agent is present at the time of diagnoses. </li></ul><ul><li>Adjustment of therapy can be made as Vaccination history and result of CSF culture are confirmed. </li></ul>

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