1. Extern
conference
4 OCT 2007

2. History
 A 4-month-old boy
 Chief complaint: high-grade fever 1 day
 Present illness:
 3 d PTA he had low grade fever with no other
symptoms.
 1 d PTA he had high grade fever with chill
without URI symptoms, N/V, or diarrhea.
 He exhibited lethargy and food refusal. The
bulging of his anterior fontanelle was observed.
He had no seizure.

3. History
 Present illness:
 He took only acetaminophen every 4 hours but
his symptoms did not relieved.
 On the day of admission, he sought for a doctor
and was diagnosed as brain edema. He was
suggested to go to a hospital.
 He had no history of trauma. Nobody in his
family had symptoms like him.

4. History
 Pertinent underlying disease: none
 Significant medical history: none (healthy)
 Significant neonatal history: none
 Developmental history: normal
 Smile, hold head up, crawl, localize sounds, glare
 Dietary history: absolute breast feeding

5. History
 Immunization: BCG, 1OPV, 1DPT, 2HBV
 Current medication: none
 Significant family history:
 Father - HBV carrier
 Mother - Euthyroid goiter

6. Physical examination
 T 38.5oC, RR 50/min, HR 180/min,
BP91/62mmHg
 BW 8.1 kg , Ht 50 cm
 GA: look sick, drowsiness, not pale, no
jaundice, no edema, dry lips, slightly sunken
eye ball, anterior fontanelle-bulging, 2x3 cm
 HEENT: pharynx-not injected, normal TM
both ears

7. Physical examination
 RS: normal breath sound, no adventitious
sound
 CVS: normal S1&S2, no murmur
 Abd: soft, not tender, liver and spleen-not
palpable
 Genitalia: WNL

8. Physical examination
 CNS:
 pupil 3 mm BRTL, no facial palsy
 motor power grade IV+ all
 DTR 3+ all
 Stiff neck : positive
 Brudzinski’s sign : positive
 Kernig sign : positive

10. Brudzinski sign

11. Problem list
 Fever for 3 days
 Drowsiness for 1 day
 Bulging ant.fontanelle and presence of
meningeal signs
 Mild dehydration

12. Differential diagnosis
 Meningitis
 Sepsis

13. Approach to Acute Febrile
Illness

14. Definition of fever
 temperature -Rectal >38ºc
-Oral >37.6
-Axillary >37.3
 Acute fever - fever with source
- fever without source

15. History taking
 Fever : character, pattern, duration
 Associate organ/systemic symptom
- RS : cough, rhinorrhea, dyspnea
- GI : nausea, vomiting, diarrhea,
- GU : abnormal urine
- NS : alteration of consciousness, seizure,
severe headache

16. History taking
 Behavior activity e.g. drowsy, food/milk
intolerance
 Sick contact
 Previous treatment, past medication
 Underlying disease, recent immunization

17. Physical Examination
 Vital signs :
 GA : irritability, sign of dehydration, pale,
jaundice
 HEENT : TM, nasal discharge, tonsils &
pharynx
 Skin rash , sign of soft tissue infection
 CVS : new onset of murmur, embolic
phenomenon

18. Physical Examination
 RS : breath sound, adventitious sound,
percussion
 Abdomen : BS, hepatosplenomegaly
 NS : level of consciousness, fontanelle, motor
system, meningeal irritation sign
 Bone and joint system

19. Investigation
 CBC ,UA
 Indication for LP in children with fever
- alteration of consciousness
- age<18 months with first episode of febrile
seizure or complex febrile seizure
- age<3 months with sepsis
- suspected meningitis

20. Meningitis with sepsis

21. Clinical presentation
 Depend on the patient’s age
- newborn: nonspecific
- infancy: fever, vomiting, irritability,
convulsion, tense& bulging fontanelle
- children: fever, chills, vomiting, severe
headache
 Meningococcemia : purpura fulminans

22. purpura fulminans

23. Clinical presentation
 Meningeal irritation sign
- significantly less frequent in neonates
- Brudzinski sign, stiff neck, Kernig sign

24. Kernig’s sign
Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is
flexed to 90 degrees.

25. Brudzinski’s sign
Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed .

26. AGE COMMON ORGANISM EMPIRICAL
ANTIBIOTIC
Newborn infants GBS Ampicillin + Gentamicin
E.coli and other gram Or Cefotaxime
negative enteric bacteria
enterococci
Infants & children < 5 yo H.influenzae type b Cefotaxime
S.pneumoniae
Salmonella
N.meningitidis
Children older than 5 yo S.pneumoniae Cefotaxime
N.meningitidis

27. Treatment
 Dexamethasone in Hib meningitis with in min
after first dose of ATB can reduce risk for
hearing and neurologic complication
- 0.15 mg/kg q 6hr for 4 days or
0.4 mg/kg q 12 hr for 2 days

28. gram negative diplococci within a neutrophil, typical for Neisseria
meningitidis

29. GBS

30. S.pneumoniae

31. H.Infuenzae type B

32. E.coli

33. Salmonella sp.

34. Diagnosis
 definite diagnosis: CSF examination and C/S
 CSF gram stain
 Rapid antigen testing:
GBS, E.coli K1, S.pneumoniae, Hib,
N.meningitidis
 Hemoculture

35. Investigation :admission D1
 Blood for H/C , CBC , BUN , Cr ,
Electrolyte , BS
 LP and CSF analysis, CSF culture, gram stain
 UA ,MUC

36. Lab : Admission day1
 CBC : Hct 35.4, WBC 21160, N72.7, L 15.3,M11.9,
Plt 371,000, MCV79.2
 BUN7, Cr0.3 , Na133, K 4.3, Cl 97, HCO3
16,AG20, BS 137
 U/A : pH 6.0 ,sp.gr1.015, WBC0-4, Glu3+, Protein -,
Ketone -
 CSF : Glu 56, TP 100, RBC 10,000, WBC 1,960
(correct WBC : 1,946)
 CSF G/S : no bacteria was seen, few PMN

37. Lab : Admission Day2
 Bacterial Ag profile: Hib, N. Meningitidis A,
B/Ecoli, C, Y/W, Strep. Agalactiae, Strep.
Pneumo : All Negative

38. CSF profile
Condition Normal CSF Normal CSF Bacterial meningitis
(newborn)
Color Clear Clear Cloudy
Pressure (mm.H2O) 50-80 Usually elevated
WBC (mm3) <5, 75% 0-30, > 1000
lymphocyte 2-3% PMN PMNs > 50%
Protein (mg/dl) 20-30 19-149 Usually 100-500
Glucose (mg/dl) >50, 75% BS 32-121 Depressed
Comments Organism may be
seen by gram stain/
culture

39. CSF profile
Condition Viral TB
meningitis meningitis
Pressure (mm.H2O) Normal or slightly Usually elevated
WBC (mm3) elevated
100-500 10-500, PMN early but
PMN<40% lymphocyte predominated
Protein (mg/dl) 50-100 100-3,000
Glucose (mg/dl) >30 <50
Comments AFB almost negative
M.TB may be detected by
PCR/C/S
Nelson Textbook of Pediatrics 16th ed.

40. Diagnosis
Bacterial
meningitis

41. Treatment1
 1.Empirical antibiotics
 Cefotaxime (300mg/kg/day) 300mg iv q 6hr
 Gentamicin (5mg/kg/day) 15mg iv q 8hr
 2.supportive treatments
 Paracetamol(120mg/5ml)4ml oral prn for fever
q4-6 hr
 IV fluid

42. Treatment2
 3.monitoring
 Record v/s q 4hr
 Record neuro sign q4hr
 HC,BW OD
 Record I/O

43. Lab : Admission Day2
 H/C : gram –ve rod
 MUC : no growth
 Bacterial Ag profile: Hib, N. MeningitidisA,
B/Ecoli, C, Y/W, Strep. Agalactiae, Strep.
Pneumo : All Negative

44. Treatment3
 Ciprofloxacin <40 MKD>
sig 110 mg iv q 8 hr

45. Treatment
Causal organism Duration(days)
GBS,L.monocytogenase 14-21
H.influenzae,S.pneumoniae 10-14
N.meningitidis 7-10
Salmonella 28
Gram negative bacilli 21
-Add ciprofloxacin in Salmonella meningitis to prevent
relapse
-Change ATB to PGS in mennigococcal meningitis if
sensitive

46. Lab : Admission Day3
 CSF culture : Salmonella groupD
 H/C :Salmonella groupD
 Drug sensitivity : Cefotaxime, Ciprofloxacin

47. Repeated LP
 For diagnosis : in questionable case repeated
LP in 24 hrs
 For evaluate response of treatment(48-
72hrs after treatment)
- cases with poor response
- resistant organism
- neonatal meningitis
-those received steroid

48. Complication
 Seizure
 Subdural effusion 20-30%,subdural empyema
1%
 SIADH
 Hearing loss (require hearing evaluation at the
end of treatment)
 Hydrocephalus
 brain abscess

49. Progress note

50. Progress note

51. Plan
 Continue ATB 28 days

52. Special thanks
 A. Kulkanya Chokephaibulkit,
 A. Jeeranda Santiprapob
 A. Panjama