2. Definition
โข Inflammation of meninges (membrane surrounding the brain and
spinal cord)
โข Pachymeningitis : inflammation of dura
โข Leptomeningitis : inflammation of arachnoid
โข Common in children less than 4 years old
โข Peak 3-8 months old
โข Incidence of encephalitis related to vaccination in childhood
3. Etiology
โข Neonates
โข GBS,E.Coli,Staph. Aureus,Listeria Monocytogenes,Group A Streptococcus
โข Infants
โข GBS,E.Coli,Listeria Monocytogenes
โข Children
โข Neisseria Meningitides,Strep. Pneumonia,Haemophilus Influenza,Myco. TB,
Staph. Aureus
โข School age children
โข Neisseria Menigitides,Strep. Pneumonia
4. Pathogenesis
1. Nasopharynx > haematogenous > cross BBB > subarachnoid space
2. Direct through the skull from infected loci (parasinus/middle ear/
PNS/nose > meninges)
3. Direct spread following skull fractur
4. Direct inoculation into CSF
โข Meningomyelocele
โข Neurosurgical procedure
5. Clinical Features
โข Neonatal : vague and non specific
โข Fever
โข Refuse to feed + vomit
โข Irritable + drowsiness
โข Irregular respirations
โข Neck stiffness > rare and late findings
โข Tense + bulging fontanelle > late course of illness
6. Clinical Features
โข Infant
โข Fever + vomiting
โข Marked irritability + convulsion + somnolence
โข Tense + bulging fontanelle > late course of illness
8. Physical Examination
โข General
โข GCS
โข Level of consciousness
โข Vital signs
โข Febrile
โข Shock
โข Hypertension
โข Bradycardia/apnea
โข Head
โข Bulging and tense fontanelles
โข Eye
โข papilledema
โข Skin
โข Purpuric rash (meningococcal rash)
โข Brudzinki's : Knee automatically brought up toward body when neck is bent forward or
pain in the legs when bent
โข Kernig's : Inability to straighten a child's knee after hip flexion 90 degree
โข Focal neurological sign
10. Investigations
โข Full blood count
โข BUSE
โข Blood C&S
โข Urine C&S
โข RBS
โข LP
โข Imaging
โข CT brain
โข MRI
โข Throat swab
โข Rapid antigen test in body fluid
โข CSR and Mantoux test
11. Lumbar puncture
Appearance Cell Type CSF:serum
glucose ratio
Protein (mg/dL)
Normal Clear 0-5 Mononuclear
cell
High >0.5 10-50
Bacterial Turbid 10-10000 PMN Low <0.4 High
Viral Clear or slightly
turbid
10-2000 Lymphocytes Normal Normal or high
TB and fungi Clear or slightly
turbid
10-1000 Lymphocytes Low High
Encephalitis Clear 10-2000 Lymphocytes Normal Normal or high
12. Management
โข Supportive
1. Vital sign monitoring 4 hourly
2. Input and output chart
3. KNBM in unconscious
4. Fluid therapy : maintenance fluid
โข If SiADH occur : reduce to 2/3 maintenance for initial 24h,may need more fluid if
dehydrated
5. Daily head circumference
6. Daily CNS assessment
7. Observe 24h after stopping therapy > no complications,discharged
13. Management
โข General
1. Increase ICP : rapid administration of IV mannitol
2. Seizures : anticonvulsant drugs (IV diazepam in acute phase)
โข Anti-microbial therapy
โข 0-1 months : C.Penicillin + Cefotaxime for 3 weeks
โข 1-3 months : C.Penicillin + Cefotaxime for 3 weeks
โข >3 months : C.Penicillin + Cefotaxime or Ceftriaxone
โข HiB : 10 days
โข S.Pneumonia : 2 weeks
โข N.Meningitides : 1 weeks
14. Management
โข Steroid therapy
โข Dexamethasone 0.15mg/kg 6hourly for 4 days or 4mg/kg 12hourly for 2 days
โข Improve meningeal inflammation and reduce hearing impairment
โข Tubercular meningitis
โข Triple therapy : isoniazid + rifampicin + ethambutol ยฑ pyrazinamide (excellent
penetration into CSF)
15. Follow-up
โข Development of child
โข Head circumference
โข Occurrence of fit or behaviour abnormalities
โข Assessment of vision,hearing and speech
17. Prognosis
โข Worse in younger patients
โข Duration of illness prior to effective antibiotics
โข More complications in HiB and Strep. Pneumoniae
โข Worse when presence of focal sign
18. Prevention
โข Immunization : N.Meningitis,Strep. Pneumonia,Hib
โข Chemoprophylaxis : intrapartum ampiccilin for GBS,rifampicin for HiB
contact,azithromycin/ciprofloxacin for meningococcal carriage in
adult
Editor's Notes
If fever persists:
Thrombophlebitis and intramuscular abscess
Intercurrent infection : pneumonia,UTI or nosocomial infection
Resistant organism
Subdural effusion,empyema or brain abscee
Antibiotic fever