Meningitis In Children

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Meningitis In Children

  1. 1. Meningitis In children Harim Mohsin 02-13
  2. 2. Definition <ul><li>Meningitis is the inflammation of the membranes surrounding the brain & spinal cord, including the dura, arachinoid & pia matter. </li></ul>
  3. 3. Incidence <ul><li>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. </li></ul><ul><li>It is more common in males than females. </li></ul>
  4. 4. Transmission <ul><li>The bacteria are transmitted from person to person through droplets of respiratory or throat secretions. </li></ul><ul><li>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.) </li></ul><ul><li>The incubation period ranges between 2 -10 days. </li></ul>
  5. 5. Routes of Infection <ul><li>Nasopharynx </li></ul><ul><li>Blood stream </li></ul><ul><li>Direct spread (skull fracture, meningo and encephalocele) </li></ul><ul><li>Middle ear infection </li></ul><ul><li>Infected Ventriculoperitoneal shunts. </li></ul><ul><li>Congenital defects </li></ul><ul><li>Sinusitis </li></ul>
  6. 6. Signs & Symptoms <ul><li>The symptoms of meningitis vary and depend on the age of the child and cause of the infection. Common symptoms are: </li></ul><ul><li>Flu-like symptoms </li></ul><ul><li>fever </li></ul><ul><li>lethargy </li></ul><ul><li>Altered consciousness </li></ul><ul><li>irritability </li></ul><ul><li>headache </li></ul><ul><li>photophobia </li></ul><ul><li>stiff neck </li></ul><ul><li>Brudzinski sign </li></ul><ul><li>Kernig sign </li></ul><ul><li>skin rashes </li></ul><ul><li>seizures </li></ul>
  7. 7. Signs & symptoms <ul><li>Other symptoms of meningitis in Neonates/infants can include: </li></ul><ul><li>Apnea </li></ul><ul><li>jaundice </li></ul><ul><li>neck rigidity </li></ul><ul><li>Abnormal temperature (hypo/hyperthermia) </li></ul><ul><li>poor feeding /weak sucking </li></ul><ul><li>a high-pitched cry </li></ul><ul><li>bulging fontanelles </li></ul><ul><li>Poor reflexes </li></ul>
  8. 8. Types <ul><li>Bacterial </li></ul><ul><li>Viral (aseptic) </li></ul><ul><li>Fungal </li></ul><ul><li>Parasitic </li></ul><ul><li>Non-infectious </li></ul>
  9. 9. Pyogenic Meningitis <ul><li>ETIOLOGY </li></ul><ul><li>‘ Meningococcal’ meningitis- N. meningitidis. A, B, C and W135) are recognized to cause epidemics </li></ul><ul><li>The commonest organisms according to age groups are: </li></ul>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
  10. 10. Bacterial Meningitis <ul><li>Pathogenesis: </li></ul><ul><li>Entry of organism through blood brain barrier </li></ul><ul><li>release of cell wall & membrane products </li></ul><ul><li>Outpouring of polymorphs & fibrin </li></ul><ul><li>cytokines & chemokines </li></ul><ul><li>Inflammatory mediators </li></ul><ul><li>Inflamed meninges covered with exudate (most marked in pneumoccocal meningitis). </li></ul>
  11. 11. Pathogenesis <ul><li>Meningeal irritation signs: inflammation of the spinal nerves & roots. </li></ul><ul><li>Hydrocephalus: Adhesive thickening of the arachinoid in basal cistern or fibrosis of aqueduct or Foramina of Lushka or Magendie </li></ul><ul><li>Cerebral atrophy: thrombosis of small cortical veins resulting in necrosis of the cerebral cortex. </li></ul><ul><li>Seizures: depolarisation of neuronal membranes as a result of cellular electrolyte imbalance. </li></ul><ul><li>Hypoglycorhachia: decreased transport of glucose across inflammed choroid plexus & increased usage by host. </li></ul>
  12. 12. Neonates <ul><li>Suspect meningitis with temperature more than 100.7 ‘F(38.2’C). </li></ul><ul><li>Risk factors: </li></ul><ul><li>Infective illness in mother </li></ul><ul><li>PROM </li></ul><ul><li>Difficult delivery </li></ul><ul><li>Premature babies </li></ul><ul><li>Spina bifida </li></ul>
  13. 13. D/D: <ul><li>Tuberculous Meningitis </li></ul><ul><li>Viral /aseptic Meningitis </li></ul><ul><li>Brain Abscess </li></ul><ul><li>Brain tumor </li></ul><ul><li>Cerebral malaria </li></ul>
  14. 14. Viral meningitis <ul><li>Viral meningitis comprises most aseptic meningitis syndromes. The viral agents for aseptic meningitis include the following: </li></ul><ul><li>Enterovirus (polio virus, Echovirus, Coxsackievirus ) </li></ul><ul><li>Herpesvirus (Hsv-1,2, Varicella.Z,EBV ) </li></ul><ul><li>Paramyxovirus (Mumps, Measles) </li></ul><ul><li>Togavirus (Rubella) </li></ul><ul><li>Rhabdovirus (Rabies) </li></ul><ul><li>Retrovirus (HIV) </li></ul>
  15. 15. Fungal Meningitis <ul><li>It’s rare in healthy people, but is a higher risk in those who have AIDS, other forms of immunodeficiency or immunosuppression. </li></ul><ul><li>The most common agents are Cryptococcus neoformans, Candida, H capsulatum. </li></ul>
  16. 16. Parasitic Meningitis <ul><li>Infection with free-living amoebas is an infrequent but often life-threatening human illness. </li></ul><ul><li>It’s more common in underdeveloped countries and usually is caused by parasites found in contaminated water, food, and soil. </li></ul><ul><li>The most common causative agents are: </li></ul><ul><li>Free-living amoebas (ie, Acanthamoeba, Balamuthia, Naegleria) </li></ul><ul><li>Helminthic eosinophilic meningitis </li></ul>
  17. 17. Non-infectious meningitis <ul><li>Rarely, meningitis can be caused by exposure to certain medications, such as the following: </li></ul><ul><li>Immune globulin </li></ul><ul><li>Levamisole </li></ul><ul><li>Metronidazole </li></ul><ul><li>Mumps and rubella vaccines </li></ul><ul><li>Nonsteroidal anti-inflammatory drugs (e.g., ibuprofen, diclofenac, naproxen) </li></ul>
  18. 18. Tuberculous meningitis <ul><li>It’s a complication of Childhood tuberculosis & common cause of prolonged morbidity, handicap & death. </li></ul><ul><li>Children below 5 years are specially prone. </li></ul>
  19. 19. CLINICAL FEATURES <ul><li>Always sec. to primary tuberculosis. </li></ul><ul><li>First Phase : Vague symptoms. </li></ul><ul><li>Child doesn’t play, is irritable, restless or drowsy. </li></ul><ul><li>Anorexia & vomiting may be present </li></ul><ul><li>Older child may complain of headache. </li></ul><ul><li>Possibly preceding history of Measles or another illness with incompletely recovery </li></ul>
  20. 20. <ul><li>SECOND PHASE : </li></ul><ul><li>Child is drowsy with neck stiffness, & rigidity. </li></ul><ul><li>Kernig & Brudzinski sign may become positive, anterior fontanels bulges </li></ul><ul><li>Twitching of muscles, convulsions, raised temperature. </li></ul><ul><li>strabismus, nystagmus, and papilloedema may be present. </li></ul><ul><li>Fundoscopy: Choroidal TB may be seen </li></ul>
  21. 21. <ul><li>TERMINAL PHASE </li></ul><ul><li>Child is characteristically comatose with opisthotonus, & multiple focal paresis. </li></ul><ul><li>Cranial nerve palsies are present. </li></ul><ul><li>High grade fever often occurs terminally. </li></ul>
  22. 22. Diagnosis <ul><li>Lumbar Puncture : pressure usually raised, </li></ul><ul><li>10-500 PMNs early but later lymphocytes predominate </li></ul><ul><li>Protein- 100-500,raised </li></ul><ul><li>Glucose less than 50mg/dl in most cases </li></ul><ul><li>Culture for tubercle bacilli. </li></ul><ul><li>Presence of tuberculous focus elsewhere in the body is strong supportive diagnosis. </li></ul><ul><li>CXR. </li></ul><ul><li>Tuberculin skin test . </li></ul>
  23. 23. Treatment <ul><li>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. </li></ul><ul><li>Total period: 18 months. </li></ul>
  24. 24. Treatment <ul><li>STEROIDS: to reduce cerebral edema and to prevent subsequent fibrosis & subsequent obstruction to CSF </li></ul><ul><li>2mg/kg/24 hours of prednisolone for 6-8 weeks at the start of treatment starting 3 days after initiation of anti tuberculous therapy. </li></ul>
  25. 25. D/D <ul><li>Partially treated bacterial meningitis </li></ul><ul><li>Viral meningitis </li></ul><ul><li>Cerebral malaria </li></ul><ul><li>Viral encephalitis </li></ul>
  26. 26. Chronic Meningitis <ul><li>Chronic meningitis is a constellation of signs and symptoms of meningeal irritation associated with CSF pleocytosis that persists for longer than 4 weeks. </li></ul>
  27. 27. Examination <ul><li>General physical- Check for Consciousness level according to GCS scoring, jaundice or irritability. </li></ul><ul><li>Resuscitation: incase of septic shock, or DIC. </li></ul><ul><li>Vitals: temperature , HR, B.P., R/R. </li></ul><ul><li>Signs of Increased ICP- Bulging fontanelle, headache, nausea, vomiting, ocular palsies, altered level of consciousness, and papilledema </li></ul><ul><li>Fundus: papilloedema </li></ul><ul><li>CN palsies: (esp. occulomotor, facial, and auditory) </li></ul>
  28. 28. Examination <ul><li>Meningismus - check for nuchal rigidity with passive neck flexion (gives 'involuntary resistance). </li></ul><ul><li>Brudzinski sign (hip & knee flexion with neck movement) </li></ul><ul><li>Kernig sign (extend knee with hip flexed) </li></ul><ul><li>Hemiparesis. </li></ul><ul><li>Rash: petechial or purpuric rash (not only in meningococcal but also pneumococcal bacteremia). </li></ul>
  29. 31. Investigations <ul><li>CBC </li></ul><ul><li>Blood culture </li></ul><ul><li>Gram staining </li></ul><ul><li>LP- D/r, C/s (color, leukocyte count, differential, glucose, protein) </li></ul><ul><li>Electrolytes </li></ul><ul><li>PCR </li></ul><ul><li>Coagulation profile </li></ul><ul><li>liver and kidney function </li></ul><ul><li>Chest X-ray </li></ul><ul><li>CT/ MRI </li></ul><ul><li>Blood gases </li></ul><ul><li>EEG </li></ul><ul><li>ECG </li></ul>
  30. 32. Diagnosis <ul><li>CSF picture is quite diagnostic of the kind of meningitis present. </li></ul>
  31. 33. Contraindication for LP <ul><li>.Increase intracranial pressure. </li></ul><ul><li>.Unstable patient. </li></ul><ul><li>.Skin infection at site of LP. </li></ul><ul><li>.Thrombocytopenia. </li></ul><ul><li>.Papilloedema. </li></ul>
  32. 34. Diagnosis <ul><li>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 </li></ul><ul><li>Concurrent immuno-electrophoresis (CIE)-used for rapid detection of H.influenza, S.pneumoniae & N.meningitides. </li></ul><ul><li>Smears: taken from purpuric spots may show meningococci in Meningococcaemia </li></ul><ul><li>DNA sequences : are helpful in identifying bacteria </li></ul>
  33. 35. Treatment <ul><li>Supportive therapy: </li></ul><ul><li>Maintain fluid & electrolyte balance as required </li></ul><ul><li>Transfuse whole blood, PRC, FFP or platelets as required. </li></ul><ul><li>Maintain temperature control </li></ul><ul><li>Monitor OFC </li></ul>
  34. 36. Treatment <ul><li>Steroids : </li></ul><ul><li>Dexamethasone useful for H.influenzae type b, First dose should be given 1 hr prior to starting antibiotics. </li></ul><ul><li>Antibiotics IV . </li></ul><ul><li>Duration:1-3 weeks depending on age & type of organisms. </li></ul>
  35. 37. Treatment <ul><li>Initial till results of C/S are known </li></ul><ul><li>Probable/Proved Meningococci </li></ul><ul><li>Ampicillin 300mg/kg/day+ </li></ul><ul><li>Chloramphenicol </li></ul><ul><li>75-100mg.kg/day </li></ul><ul><li>Penicillins </li></ul><ul><li>2-5 lac units /kg/day </li></ul>
  36. 38. Treatment <ul><li>Probable H.Influenzae </li></ul><ul><li>Probable E.Coli </li></ul><ul><li>Ampicillin + chloramphenicol or </li></ul><ul><li>3 rd generation cephalosporin </li></ul><ul><li>(cefotaxime 200mg/kg/day) </li></ul><ul><li>Ampicillin + gentamycin </li></ul><ul><li>200mg/kg+2.5-4 mg/kg IV 12hrly </li></ul>
  37. 39. Treatment <ul><li>Probable group B streptococci </li></ul><ul><li>Penicillin 50,000i.u/kgI.V/4 hourly. </li></ul>
  38. 40. Other Drugs available <ul><li>Anti-microbials </li></ul><ul><li>Ceftriaxone </li></ul><ul><li>Cefotaxime </li></ul><ul><li>Penicillin G </li></ul><ul><li>Vancomycin </li></ul><ul><li>Ampicillin </li></ul><ul><li>Gentamicin </li></ul><ul><li>Anti-Virals </li></ul><ul><li>Acyclovir </li></ul><ul><li>Ganciclovir (>3mths) </li></ul><ul><li>Anti-fungals </li></ul><ul><li>Amphotericin B </li></ul><ul><li>Fluconazole </li></ul>
  39. 41. Prevention <ul><li>The vaccines against Hib, measles, mumps, polio, meningococcus, and pneumococcus can protect against meningitis </li></ul><ul><li>Hib vaccine: all infants should receive at 2,4,6 months of age & booster 1 year later. </li></ul><ul><li>After 1 year 1 dose is given till the age of 5 years. </li></ul><ul><li>Pneumococcal vaccine: 0.5 ml is given IM (<2 yrs) </li></ul>
  40. 42. Prevention <ul><li>High-risk children should also be immunized routinely. </li></ul><ul><li>Vaccination before travelling to an endemic area </li></ul><ul><li>Chemoprophylaxis for susceptible individuals or close contacts: </li></ul><ul><li>H influenzae type b : Rifampin(20 mg/kg/d) for 4 days </li></ul><ul><li>N meningitidis: Rifampin (600 mg PO q12h) for 2 days upto 10weeks </li></ul><ul><li>Ceftriaxone (250 mg IM) single dose or Ciprofloxacin(500-750 mg) single dose. </li></ul>
  41. 43. Complications <ul><li>Bacterial meningitis may result in </li></ul><ul><li>Cranial nerve palsies </li></ul><ul><li>Subdural empyema </li></ul><ul><li>Brain abscess </li></ul><ul><li>Hearing loss </li></ul><ul><li>Obstructive hydrocephalus </li></ul><ul><li>Brain parenchymal damage: Learning disability, CP, seizures, Mental retardation. </li></ul><ul><li>Septic shock/ DIC </li></ul><ul><li>Ataxia </li></ul><ul><li>Stroke </li></ul><ul><li>SIADH (Na+ <130 mE/l), puffiness of face, dec UO. </li></ul>
  42. 44. Treatment of Complications: <ul><li>Convulsions: Diazepam I.V, Can be repeated q4 hours as required. </li></ul><ul><li>Cerebral edema: *I.V Mannitol 1g/kg in 20-30 mins 6-8 hourly given for first few days. </li></ul><ul><li>IV Dexamethasone can then be used 6 hourly . </li></ul>
  43. 45. <ul><li>Subdural effusion: </li></ul><ul><li>Aspirate subdural effusion if large. </li></ul><ul><li>Shock: Treat with IV Fluids, maintanence of BP. </li></ul><ul><li>SIADH: Increase body weight, decreased serum osmolality, hyponatremia. </li></ul><ul><li>Prevented by fluid restriction to 800-1000ml/m2/24 hours. </li></ul><ul><li>Hyperpyrexia: Tepid sponging, correction of dehydration. </li></ul>
  44. 46. Prognosis <ul><li>It depends on the age of the patient, the duration of the illness, complications, micro-organism & immune status. </li></ul><ul><li>Patients with viral meningitis usually have a good prognosis for recovery. </li></ul><ul><li>The prognosis is worse for patients at the extremes of age (ie, <2 y, >60 y) and those with significant comorbidities and underlying immunodeficiency. </li></ul><ul><li>Patients presenting with an impaired level of consciousness are at increased risk for developing neurologic sequelae or dying. </li></ul>
  45. 47. Prognosis <ul><li>A seizure during an episode of meningitis also is a risk factor for mortality or neurologic sequelae. </li></ul><ul><li>Acute bacterial meningitis is a medical emergency and delays in instituting effective antimicrobial therapy result in increased morbidity and mortality. </li></ul><ul><li>The prognosis of meningitis caused by opportunistic pathogens depends on the underlying immune function of the host as may require lifelong suppressive therapy. </li></ul>
  46. 48. References <ul><li>Nelson textbook </li></ul><ul><li>Basis of pediatrics </li></ul><ul><li>WHO recommendations </li></ul><ul><li>E-medicine </li></ul>

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