The lethargic infant

1. THE LETHARGIC
INFANT
Mohammed Bakheet Alghamdi
20151411691

2. The Case:
A six-month-old male presents to the emergency department with a history of lethargy. He was seen 3 days ago
with fever and upper respiratory infection symptoms, diagnosed with otitis media and treated with oral
amoxicillin. This morning he had become irritable and was less active than usual. He has vomited three times
and his urine output is noticeably decreased. He has no diarrhea.
Exam: Temp. 40.0 OC, P 90, RR 30 (irregular), BP 120/90, weight 8 kg. He is lethargic and arousable only to
painful stimuli. His anterior fontanel is full and tense, and he has questionable neck rigidity. His pupils are
reactive, but his eyes do not focus well on his parents. His heart, lungs and abdomen are normal. His color and
perfusion are good. He has no petechiae. He moves all his extremities weakly and his tendon reflexes are
hyperactive.
A CBC, blood culture and chemistry panel are drawn. An IV is started. Since an increased ICP (intracranial
pressure) is suspected, a lumbar puncture (LP) is initially delayed and he is immediately given 500 mg of
ceftriaxone IV. A stat CT scan of the brain is normal, so an LP is done and the CSF (cerebrospinal fluid) is visibly
hazy. An infectious disease consultant is called to inquire about IV dexamethasone and vancomycin. Both are
recommended and given. The CSF results return 1 hour later showing 450 WBCs, 95% segs, 5% monos, total
protein 75, glucose 25 mg/dl. Gram stain of the CSF shows many WBCs with few gram-positive cocci. He is
admitted to the pediatric ICU.

3. Background:
Lethargy causes you to feel sleepy or fatigued and sluggish. This
sluggishness may be physical or mental. People with these symptoms
are described as lethargic.
Based on a history of Lethargic infant followed by listlessness and a
decreased level of consciousness, the differential diagnosis included
sepsis, meningitis or encephalitis, head trauma (including shaken baby
syndrome [SBS]), intussusception, seizure disorder, toxic ingestion,
cardiac arrhythmia or inborn errors of metabolism.
A change in behavior may be one of the first signs of illness in a
newborn. It's normal for a baby's activity, appetite, and cries to vary
from day to day, even hour to hour. But a distinct change in any of
these areas may signal illness.
Generally, if your baby is alert and active when awake, is feeding well,
and can be comforted when crying, occasional differences in these
areas are normal.

4. MENINGES

5. Anatomy:

6. Cont,

7. Cont,
There are three connective tissue membranes invest the brain and the spinal cord.
These are from outward to inward are:
1- Dura mater.
2- Arachnoid mater.
3- Pia mater.
Between the pia and arachnoid mater lies the
subarachnoid space which contains the main vessels and CSF.

8. Pathophysiology
: Bacterial infection of
meninges follows
bacteraemia.
 Damage is due to host
response to infection, not
from organism itself.
 Inflammatory mediators.
 Activated leucocytes.
 Endothelial damage.
 Cerebral edema.
 Raised intracranial pressure.
 Decreased cerebral blood
flow.

9. The Causes:
Is an inflammation of the membranes that cover the brain and spinal cord.
Sometimes called: spinal meningitis.
And to be according one of the following causes of meningitis:
 Viral
 Bacterial
 Fungal : Cryptococcus neoformans

10. Cont,
Bacterial:
bacterial meningitis can be quite severe and may result in brain damage, hearing loss, or
learning disabilities.
Before the 1990s, Haemophilus influenzae type b (Hib) was the leading cause of bacterial
meningitis.
Hib vaccine is now given to all children as part of their routine immunizations.
Today, Streptococcus pneumoniae and Neisseria meningitidis are the leading causes of
bacterial meningitis.
Neisseria meningitides:
These bacteria commonly cause an upper respiratory infection but can cause meningococcal
meningitis when they enter the bloodstream.
Transmission:
The majority of meningitis infections are acquired by blood-borne spread. Direct spread occurs
when an already resident infectious agent spreads from infected tissue next to or very near the
meninges.

11. MANAGEMENT OF MENINGITIS

12. Signs and Symptoms:
Symptoms usually start 7 to 14 days after exposure to the virus.
Many people infected with the virus have few or no symptoms and others have short-term
symptoms, Babies who develop meningitis may show different signs and symptoms of an
infection than adults.
These symptoms can include:
 headache,
 tiredness,
 fever,
 stiff neck and back and
 muscle pain.

13. Cont,
Viral meningitis: is common in infants. It develops as a result of colds, cold sores, flu,
and diarrhea. The viruses that cause these common conditions also cause viral
meningitis.
Bacterial meningitis: which is common but life-threatening, most likely spreads from a
serious infection in a nearby area of the body. For example, the bacteria from a severe
ear infection or sinus infection can enter the bloodstream and find their way to the
brain or spinal cord and cause a bigger infection.

14. Complications:
 Hearing loss
 Memory difficulty
 Learning disabilities
 Brain damage
 Gait problems
 Seizures
 Shock
 Death

15. Investigation:
 Blood test or culture.
 PCR.
 The virus can be found in the throat for about one week after infection and in the
stool for six weeks or longer.

16. Prevention and vaccine:
 oral vaccine.
 IV vaccine.

17. Treatment:
 antibiotics given directly into a vein: penicillin G ;cephalosporin.
 fluids given directly into a vein to prevent dehydration.
 oxygen through a face mask if there are any breathing difficulties.
 steroid medication to help reduce any swelling around the brain.

18. Differential Diagnoses:
 Brain Abscess.
 Brain Neoplasms.
 Delirium Tremens (DTs).
 Emergent Management of Subarachnoid Hemorrhage.
 Encephalitis.
 Febrile Seizures.
 Herpes Simplex Encephalitis.
 Herpes Simplex Virus (HSV) in Emergency Medicine.
 Pediatrics, Meningitis and Encephalitis.

19. References:
 Hasbun R. Update and advances in community acquired bacterial meningitis. Curr Opin
Infect Dis. 2019 Jun.
 Gallegos C, Tobolowsky F, Nigo M, Hasbun R. Delayed Cerebral Injury in Adults With
Bacterial Meningitis: A Novel Complication of Adjunctive Steroids?. Crit Care Med. 2018
Aug.
 Tunkel AR, Hasbun R, Bhimraj A, Byers K, Kaplan SL, Michael Scheld W, et al. 2017
Infectious Diseases Society of America's Clinical Practice Guidelines for Healthcare-
Associated Ventriculitis and Meningitis. Clin Infect Dis. 2017 Feb.
 El Sahly H, Udayamurthy M, Parkerson G, Hasbun R. Survival of an AIDS patient after
infection with Acanthamoeba sp. of the central nervous system. Infection. 2017 Oct.
 Douglas D. Meningitis Vaccine Safe in Young Infants. Medscape [serial online].
Available at http://www.medscape.com/viewarticle/819521. Accessed: January 27,
2014.
 La Crosse encephalitis. Centers for Disease Control and Prevention. Available
at http://www.cdc.gov/lac/. Accessed: March 29, 2013.
 Koedel U, Klein M, Pfister HW. New understandings on the pathophysiology of bacterial
meningitis. Curr Opin Infect Dis. 2010 Jun. 23(3):217-23.
 https://www.stanfordchildrens.org/en/topic/default?id=behavior-changes-90-P02663
 https://emedicine.medscape.com/article/232915-differential

20. Thank you