Meningitis_Pedia_case presentation

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Pediatrics case presentation - Meningitis

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  • A delay in treatment leads to higher morbidity and mortality, thus early recognition of the disease is necessary. Signs and symptoms of bacterial meningitis is variable and depends on the age of the patient and the duration of illness before treatment. Neonates and young infants may only have subtle manifestations. These are difficult to distinguish from a coexisting septicemia.
  • Signs and symptoms include non-specific signs, and signs of meningeal inflammation. Signs and symptoms of increased intracranial pressure and focal neurologic signs may already be late indicators of disease. Depending on the age of the patient, these manifestations may differ. No one clinical sign is pathognomonic of meningitis. Bacterial meningitis should be suspected in a child with any 2 or more non-specific signs or symptoms or any of the specific neurologic signs and symptoms.
  • Signs and symptoms include non-specific signs, and signs of meningeal inflammation. Signs and symptoms of increased intracranial pressure and focal neurologic signs may already be late indicators of disease. Depending on the age of the patient, these manifestations may differ. No one clinical sign is pathognomonic of meningitis. Bacterial meningitis should be suspected in a child with any 2 or more non-specific signs or symptoms or any of the specific neurologic signs and symptoms.
  • Signs and symptoms include non-specific signs, and signs of meningeal inflammation. Signs and symptoms of increased intracranial pressure and focal neurologic signs may already be late indicators of disease. Depending on the age of the patient, these manifestations may differ. No one clinical sign is pathognomonic of meningitis. Bacterial meningitis should be suspected in a child with any 2 or more non-specific signs or symptoms or any of the specific neurologic signs and symptoms.
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  • Since meningitis is a leading cause of mortality in the Philippines, specially for those less than 5 years old, knowledge of the top CSF isolates in each age group is essential. Unfortunately, studies on etiology specific meningitis is lacking. A study done by Arciaga (1992) showed that H. influenzae and S. pneumoniae were the most common causes in meningitis beyond the neonatal age group. In those less than one year old, gram negative bacilli most common. The incidence of H. influenzae B and S. pneumoniae has probably not changed in the last ten years because immunizations for these two diseases are not routinely given due to their high cost. In contrast to other Western countries, Group B streptococcus is a rare cause of meningitis and Listeriamonocytogenes has not been isolated in the CSF even in neonates. In a developing country like the Philippines with limited resources, the most cost effective drug must be chosen.
  • Since meningitis is a leading cause of mortality in the Philippines, specially for those less than 5 years old, knowledge of the top CSF isolates in each age group is essential. Unfortunately, studies on etiology specific meningitis is lacking. A study done by Arciaga (1992) showed that H. influenzae and S. pneumoniae were the most common causes in meningitis beyond the neonatal age group. In those less than one year old, gram negative bacilli most common. The incidence of H. influenzae B and S. pneumoniae has probably not changed in the last ten years because immunizations for these two diseases are not routinely given due to their high cost. In contrast to other Western countries, Group B streptococcus is a rare cause of meningitis and Listeriamonocytogenes has not been isolated in the CSF even in neonates. In a developing country like the Philippines with limited resources, the most cost effective drug must be chosen.
  • Since meningitis is a leading cause of mortality in the Philippines, specially for those less than 5 years old, knowledge of the top CSF isolates in each age group is essential. Unfortunately, studies on etiology specific meningitis is lacking. A study done by Arciaga (1992) showed that H. influenzae and S. pneumoniae were the most common causes in meningitis beyond the neonatal age group. In those less than one year old, gram negative bacilli most common. The incidence of H. influenzae B and S. pneumoniae has probably not changed in the last ten years because immunizations for these two diseases are not routinely given due to their high cost. In contrast to other Western countries, Group B streptococcus is a rare cause of meningitis and Listeriamonocytogenes has not been isolated in the CSF even in neonates. In a developing country like the Philippines with limited resources, the most cost effective drug must be chosen.
  • To develop bacterial meningitis, the invading organism must gain access to the subarachnoid space. This is usually via hematogenous spread from the upper respiratory tract where the initial colonization has occurred. Less frequently, there is direct spread from a contiguous focus (eg, sinusitis, mastoiditis, otitis media) or through an injury, such as a skull fracture.
  • To develop bacterial meningitis, the invading organism must gain access to the subarachnoid space. This is usually via hematogenous spread from the upper respiratory tract where the initial colonization has occurred. Less frequently, there is direct spread from a contiguous focus (eg, sinusitis, mastoiditis, otitis media) or through an injury, such as a skull fracture.
  • To develop bacterial meningitis, the invading organism must gain access to the subarachnoid space. This is usually via hematogenous spread from the upper respiratory tract where the initial colonization has occurred. Less frequently, there is direct spread from a contiguous focus (eg, sinusitis, mastoiditis, otitis media) or through an injury, such as a skull fracture.
  • To develop bacterial meningitis, the invading organism must gain access to the subarachnoid space. This is usually via hematogenous spread from the upper respiratory tract where the initial colonization has occurred. Less frequently, there is direct spread from a contiguous focus (eg, sinusitis, mastoiditis, otitis media) or through an injury, such as a skull fracture.
  • In any case suspected of meningitis based on the clinical signs, a lumbar puncture is essential. Sometimes parents are afraid of the procedure and fear it is harmful to the child. It should be emphasized to them that treatment is highly dependent on CSF results. A lumbar puncture may be postponed or withheld in the following situations: presence of significant cardiac or respiratory distress and shock, sign of increased intracranial pressure, infection in the area that the spinal needle will traverse to obtain CSF, and hematologic problems such as thrombocytopenia and coagulation defects.
  • In any case suspected of meningitis based on the clinical signs, a lumbar puncture is essential. Sometimes parents are afraid of the procedure and fear it is harmful to the child. It should be emphasized to them that treatment is highly dependent on CSF results. A lumbar puncture may be postponed or withheld in the following situations: presence of significant cardiac or respiratory distress and shock, sign of increased intracranial pressure, infection in the area that the spinal needle will traverse to obtain CSF, and hematologic problems such as thrombocytopenia and coagulation defects.
  • Rapid diagnostic tests such as coagglutination and latex agglutination which directly detect soluble bacterial antigens, may be useful. These may provide true positive results when culture and gram stain results are negative and for patients who have already received antimicrobial therapy. Antigen detection methods should never be substituted for culture and gram stain. If only a small amount of CSF is received, gram stain and culture should always have priority over antigen detection tests.
  • Rapid diagnostic tests such as coagglutination and latex agglutination which directly detect soluble bacterial antigens, may be useful. These may provide true positive results when culture and gram stain results are negative and for patients who have already received antimicrobial therapy. Antigen detection methods should never be substituted for culture and gram stain. If only a small amount of CSF is received, gram stain and culture should always have priority over antigen detection tests.
  • Blood cultures should be obtained in every patient suspected of having bacterial meningitis. A positive blood culture in the presence of signs and symptoms of meningitis would suggest the possible etiologic agent of the meningitis. In patients with otitis media and concomitant meningitis, needle aspiration of middle ear fluid may permit early identification of the likely organism. Cultures from the throat, nasopharynx and urine have not been rewarding and do not correlate with organisms recovered from the CSF or blood.
  • In cases where lumbar puncture is contraindicated and the anterior fontanel is open, a cranial ultrasound may be useful in detecting the presence of complications of bacterial meningitis such as hydrocephalus, effusion, empyema, malacic changes, ventriculitis or mass lesions. In a local study by Lee, out of 224 cases of bacterial meningitis, 202 had abnormal findings, while 22 patients had normal results. Thus a normal ultrasound does not rule out the presence of meningitis.*Lee, LV et al, Phil J. Neurology 1994; 2:30-38
  • Meningitis may be diagnosed using CT scan and Magnetic resonance imaging by detecting an increased degree of enhancement and thickening of the meninges beyond the normal range. However, these changes may be subtle and difficult to perceive because of the density of the overlying skull. Nonspecific abnormalities include widening of spaces containing CSF or mild basilar enhancement. In a prospective study by Cabral, et al, out of 41 children with proven bacterial meningitis, only 14 had abnormal CT scan findings. MRI is a far more sensitive imaging technique than CT scan in demonstrating abnormalities of the brain parenchyma and showing changes that affect the meninges. However, meningeal enhancement demonstrated on MRI are nonspecific and is also seen with involvement by a tumor, intracranial hemorrhage, trauma or radiation therapy. Also the use of the MRI is limited by its high cost. Thus these imaging techniques should be considered for patients with signs of increased intracranial pressure prior to obtaining a lumbar puncture, and for patients with persistent neurologic dysfunction (prolonged obtundation, irritability, seizures, focal neurological abnormalities, enlarging head circumference), persistent elevation of CSF protein, persistent preponderance of PMNs in the CSF, or recurrence of disease. *Cabral DA, et al. J Pediatrics 1987; 11:423-32
  • The following tables are the current recommendations by the Task Force of Meningitis based on available local data for empiric therapy of bacterial meningitis prior to availability of CSF results. Alternative therapies may be used if there is an allergy to the first line drugs or resistance is suspected.
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