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Pediatrics case presentation - Meningitis
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- 1. Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 2. Identifying data JI, 5 mo old male Pasig City Parents as caregivers Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 3. History of Present Illness JI, 5-mo old male Pasig City Parents as caregivers Chief complaint: Fever 1 day PTA fever (38.5°C) cold 2 episodes of vomiting Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 4. History of Present Illness JI, 5-mo old male Pasig City Parents as caregivers Chief complaint: Fever On the day of admission fever (39.5°C) increased irritability upward rolling of eyeballs hyperextension of neck inconsolable cry 1 day PTA fever (38.5°C) cold 2 episodes of vomiting Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 5. Review of Systems JI, 5-mo old male Pasig City Parents as caregivers No history of trauma No cyanosis No rashes CC: fever (Tmax=39.5°C) (+)inc irritability (+)hyperextension of neck (+)inconsolable cry (+)upward rolling of eyeballs Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 6. Past Medical History JI, 5-mo old male Pasig City Parents as caregivers Diagnosed with G-6-PD deficiency No history of Primary Koch’s No history of Pneumonia No history of trauma No history of past hospitalizations/surgeries CC: fever (Tmax=39.5°C) (+)inc irritability (+)hyperextension of neck (+)inconsolable cry (+)upward rolling of eyeballs No history of trauma No cyanosis Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 8. Hypertension
- 9. AllergiesCC: fever (Tmax=39.5°C) (+)inc irritability (+)hyperextension of neck (+)inconsolable cry (+)upward rolling of eyeballs No history of trauma No cyanosis Diagnosed with G-6-PD No history of Primary Koch’s No history of Pneumonia No history of trauma No history of past hospitalizations/surgeries Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 11. Hypertension
- 12. AllergiesParents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 14. Hypertension
- 15. AllergiesParents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 17. Hypertension
- 18. AllergiesParents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 19. Physical Examination JI, 5-mo old male Pasig City Parents as caregivers Came in for fever Height = 69 cm, Weight = 7.4 kg interpretation: healthy P90-95 length for age P50 weight for age P10 weight for length HC: 42 cm, AC: 39cm, CC: 43 cm interpretation: normal P25 head circumference BP: 90/60 (normotensive) HR: 138 (normal) RR: 38 (normal) Temp: 39.1°C (febrile) Pain Scale: ✔ Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 20. Physical Examination JI, 5-mo old male Pasig City Parents as caregivers Came in for fever HEENT Flat fontanels Anictericsclerae Pink conjunctivae No TPC, No CLAD Neck veins not dilated Grey, imperforated tympanic membrane No nasal discharge Anthropometrics: normal Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 21. Physical Examination JI, 5-mo old male Pasig City Parents as caregivers Came in for fever CardioPulmo Equal chest expansion Clear breath sounds No rales/crackles No wheezes Apex beat at 5th ICS MCL Regular rate, normal rhythm No murmurs Anthropometrics: normal HEENT: normal Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 22. Physical Examination JI, 5-mo old male Pasig City Parents as caregivers Came in for fever Anthropometrics: normal HEENT: normal CardioPulmo: normal Abdomen Flat, soft abdomen No tenderness No organomegaly No masses Normoactive bowel sounds Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 23. Physical Examination JI, 5-mo old male Pasig City Parents as caregivers Came in for fever Anthropometrics: normal HEENT: normal CardioPulmo: normal Abdomen: normal Extremities Full pulses No edema, no cyanosis Good turgor No rashes, no lesions Equally distributed hair No clubbing CRT <2sec Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 24. Physical Examination JI, 5-mo old male Pasig City Parents as caregivers Came in for fever Neuro Cranial nerves: intact Motor: 2+ on all extremities Sensory: 100% on all extremities DTRs 2+ (+) Babinski sign (+) nuchal rigidity Was not tested for Kernig’s and Brudzinski sign GCS = 12 (E4V2M6) Anthropometrics: normal HEENT: normal CardioPulmo: normal Abdomen: normal Extremities: normal Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 25. Salient Features 5 mo male 2 day history of fever (Tmax = 39.5C) 2 episodes of vomiting increased irritability upward rolling of eyeballs hyperextension of neck inconsolable cry Family history of BFC Incomplete dose of Hib (+) nuchal rigidity GCS 12 (E4V2M6) Clinical Impression: Meningitis Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 26. Differential Diagnosis Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 28. neonates and young infants may have minimal signs and symptoms
- 29. signs of symptoms of neonatal sepsis are indistinguishable from neonatal meningitisParents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 30. Signs and Symptoms Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 31. Signs and Symptoms Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 32. Signs and Symptoms Sensitivity of triad of fever, neck stiffness and altered mental status is low (44%) Almost all patients will have at least two of four: - headache - fever - neck stiffness - altered mental status (GCS < 14) van de Beek et al. NEJM2004;352:1849-59 Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 33. Epidemiology Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 34. Epidemiology 7th leading cause of mortality in children 1-4 and 5-9 years Case fatality rate of 3-33% of untreated cases Neurologic sequelae present in 1/3 who survive Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 35. Etiology Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 37. <1 yr old - Gram negative bacilli
- 38. Statistics might have changed due to immunizations
- 39. Group B streptococcus is an infrequent cause of meningitis and Listeriamonocytogenes has not been isolated in CSF cultures Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 40. Etiology Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 41. Pathophysiology Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 42. Pathophysiology Organism Colonization Local Invasion Bacteremia/ Viremia Meningeal Invasion Replication in the Subarachnoid Space Release of Cytokine Components Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 43. Pathophysiology Bacterial Colonization Local Invasion Bacteremia Meningeal Invasion Bacterial Replication in the Subarachnoid Space Release of Bacterial Components Subarachnoid space inflammation Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 44. Pathophysiology Bacterial Colonization Local Invasion Bacteremia Meningeal Invasion Bacterial Replication in the Subarachnoid Space Release of Bacterial Components Subarachnoid space inflammation Increase CSF outflow resistance Increase BBB permeability hydrocephalus Cytotoxic edema Interstitial edema Vasogenic edema Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health Increased intracranial pressure
- 45. Diagnostics Lumbar puncture is essential Cornerstone in the diagnosis should be performed in all cases whenever the diagnosis of meningitis is known or suspected on the basis of clinical signs Contraindications to doing a lumbar tap 1. presence of significant cardio-pulmonary compromise and shock 2. signs of increased ICP 3. suspected case of space occupying lesion 4. infection in the area that the spinal needle will traverse to obtain CSF 5. hematologic problems Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 46. Diagnostics CSF Analysis Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 48. good specificity, poor sensitivity
- 49. Rapid diagnostic test (< 15min)Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 51. yield of CSF Gram stain may be ∼20% lower for patients who have received prior antimicrobial therapyParents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health S.Pneumoniae in a CSF gram stain
- 54. most useful in diagnosing complications of meningitis
- 55. normal ultrasound does not rule out the presence of meningitis
- 56. Local study by Lee, et al: 22 out of 202 pts with bacterial meningitis has normal results Coronal-plane US shows marked increased echogenicity of the gyri and sulci associated with diffuse brain atrophy and causing increased extraaxial fluid spaces. Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 58. Diagnostics Back to the patient… Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 59. Diagnostics Back to the patient… Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 60. Treatment Empiric Therapy for Bacterial Meningitis Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 62. The three drugs are still recommended for use for H. influenzaeCarlos C, et al. (Philippine) Antimicrobial Resistance Surveillance Program, January-December, 2000 Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 63. Treatment Higher resistance to penicillin than 1999 Only 13(18%) of 72 resistance isolates were sent for confirmation of which only 4(6%) were truly penicillin resistant by MIC True extent of penicillin resistant S. pneumoniaestill unknown Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 64. Treatment Duration of Therapy of Bacterial Meningitis *Quagliarello, et al, NEJM 1997, 336(10):708-716 Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 66. in developed countries
- 68. RCTs showed higher mortality in the dexamethasone group and hardly any differences in rates of neurologic sequelae and hearing impairment among the dexamethasone group and the placebo group
- 69. routine use of dexamethasone as adjuvant therapy in bacterial meningitis was not recommended. *Qazi, et al. Arch Dis Childhood 1996; 75: 482-488 Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 70. Treatment Back to the patient… 6 days afebrile Less irritable Supple neck No cranial nerve deficit No seizure recurrence Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 72. The highest mortality rates are observed with pneumococcal meningitis.
- 73. Prognosis is poorest among infants younger than 6 mo and in those with high concentrations of bacteria/bacterial products in their CSFParents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 75. due to labyrinthitis after cochlear infection and occurs in as many as 30% of patients with pneumococcal meningitis, 10% with meningococcal, and 5–20% of those with H. influenzae type b meningitis.Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 76. Preventive Measures Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 78. Powerpoint slides of Dr. Cecile Maramba-Untalan on Pediatric Bacterial Meningitis in the Philippines
- 79. Powerpoint slides of Dr. MediadoraSaniel on CNS infections
- 80. Lectures from YL5 to YL7
- 81. Tunkel et. al, Practice Guidelines for the Management of Bacterial Meningitis
- 82. Nigrovic et. al, Clinical Prediction Rule for Identifying Children With Cerebrospinal Fluid Pleocytosis at Very Low Risk of Bacterial MeningitisParents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
- 83. Parents’ Worst Nightmare By: Cristal Ann G. Laquindanum Year Level 8, Ateneo School of Medicine and Public Health
Editor's Notes
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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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