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Fever with Fits 22.1.2016 (to print), update.pptx
1. Prof: Thi Tar
MBBS (Mdy), MMedSc (Paed)
MRCPCH, FRCP (Edin)
Dip Med Ed, Dr Med Sc (Paed)
550 bedded Children Hospital, Mandalay
Keng Tong 22-Jan-2016
10. • LP is not usually done in well appearing child after febrile
seizure
• LP is indicated in
• Any signs suspicious of meningitis
• <12 months old child after 1st febrile seizure
• 12 and 18 months old child (d/t subtle clinical features
of meningitis)
• >18 months old child if clinical features of meningitis
presence
10
11.
12. Definition
• Seizures occurred between the age of 6 and 60
months
• with a temperature of 38'C or higher,
• that are not the result of CNS infection or any
metabolic imbalance,
• Dx is given only after exclusion of other treatable
and life threatening causes
13. Types of febrile convulsion
Simple febrile convulsion Complex febrile convulsion
2-5 % of neurologically healthy
infants & children may experience
at least one
Probably secondary to coexisting
pathology
Duration <15 minutes >15 minutes
Type Generalized, usu. TC Focal
Recurrence Not recur within 24 hr period Recur within 24 hr period
Mortality Not have increased risk of
mortality
2-fold long term increase in
mortality over subsequent 2 years
14.
15. Management of febrile convulsion
• First aid measures
• Control fever
oTepid sponging
oParacetamol 15mg/kg 6hrly
• Advise parents
oBenign nature
oFirst aid measures
16.
17. Recurrence of febrile seizures
• approximately 30% of those experiencing first episode
• 50% after 2 or more episodes and
• 50% of infants <1 year old at febrile seizure onset
• Prevention of recurrence
oGenerally not recommended because
• The risks and potential side effects of
antiepileptic medications outweigh the benefits.
• No medication has been shown to prevent the
future onset of epilepsy.
17
21. Bacterial meningitis
• One of most serious infections occurring in infants
and older children
• 5-10% mortality
• Incidence – high in febrile infants
• Over 10% of survivors are left with long term
neurological impairment
Paediatric emergency
22. Aetiological agents
• In neonates,
Gram negative
E.coli
Pseudomonas
Proteus
Gram positive
Group B streptococcus
Staphylococcus aureus
Listeria monocytogenes
24. Route of infection
• Mainly from blood
• Direct from nearby focus (mastoiditis, otitis media,
sinusitis)
• Direct from head trauma and skull fracture
25. Clinical Presentation
• Depends on the age of the patient and the offending
organism
• Generally more abrupt onset than viral
• Infants have a variable presentation
• Fever, poor feeding, lethargy, irritability, high-pitched
cry, full fontanelle
• Older children may have
• acute onset of fever, headache, vomiting, photophobia,
and altered mental status
• +/- Kernig or Brudzinski sign
26. Clinical Presentation
*Seizures may be the presenting
feature in nearly 1 in 6 children
*Papilledema is uncommon at
presentation
*Focal signs can be found in 14%
of cases
Sudural epyema, cortical
infarction, cerebritis
*Rashes are not uncommon
Petechial or purpuric rash
highly suggests
meningococcemia
30. Evidence of increased ICP
Severe cardiopulmonary compromise
Infection of skin overlying site of LP
If LP is delayed, empirical antibiotic therapy should
be initiated
32. Blood for CP- neutrophil leucocytosis
Blood cultures performed in all pts with suspected
meningitis (positive in 80-90%)
Chest X-ray
USG head and CT head
Urea and electrolytes
Clotting profile
34. Empirical antibiotic therapy- initiated as soon as
possible
Neonates - Ampicillin+Cefotaxime+Genta
Babies 1-3mths - Ampicillin + cefotaxime or ceftriaxone
> 3mths - 3rd G cephalosporin
Neonate 2-3 wks
Older child 2 wks
N.meningitidis 7 days
35. Dexamethasone (0.15mg/kg/dose 6hrly) for 1st 4 days
Should be given before first dose of antibiotics
Aim – suppression of overactive inflammation
- shorter duration of fever, lower CSF protein,
reduction of hearing loss (due to H.influenzae type b)
36. Meningitis present with dehydration and hypovolemia
• Fluid replacement should be done
SIADH
• Fluid restriction (2/3 of maintenance)may be required
37. Fever control
Fits control
Nutritional support
Care of unconscious patient
Treatment of complications
Rehabilitation and follow up
•Cerebral oedema – IV mannitol
•Apnoea – mechanical ventilation
38. Rifampicin
- 10mg/kg bd for 2d
Ciprofloxacin
- 1 to 5 years - 125 mg as single dose
- 5 to 12 years -250mg as a single dose
- >12 years -500mg as a single dose
42. Clinical Staging
Stage Signs and Symptoms
Stage 1 (Early)
Days to weeks
Fever, HA, malaise
Lethargy, behavior changes
No neuro deficits
No alteration of
consciousness
Stage 2 (intermediate)
Weeks to months
Meningeal irritation
Minor neuro deficits (CN)
Stage 3 (late)
Months to years
Abnormal movements
Convulsions
Stupor or coma
Severe neuro deficits
43. CSF analysis
ZN stain – AFB (+ only in 25% of CSF smear)
Sputum for AFB (>8yrs of age)
Gastric aspiration (<8yrs of age)
CXR (50% of pts)
Tuberculin skin test
Tuberculous
meningitis
Turbid/viscous
(cobweb)
Lymphocytes
10-500/mm3
Protein Glucose
44. • CSF kept in tube for 12hrs coagulum forms in the
form of cobweb due to fibrin in higher protein content
50. Clinical features
• Nonspecific symptoms
high fever, headache, vomiting, irritability
• seizures, confusion
• maculopapular rash, arthralgia
• muscle weakness
• problems with speech or hearing
• loss of consciousness
51. Investigations
CSF examination
• Viral encephalitis- lymphocytic pleocytosis
- slight elevation in protein content
- normal glucose level
EEG (electroencephalogram) – to check abnormal
brain waves
Serology for arboviruses, Epstein-Barr virus, HIV
PCR
Brain imaging (MRI, CT)
52. Treatment
• Maintain airway, breathing, circulation
• Vital signs monitoring
• Seizures - IV diazepam and phenytoin
• Raised ICP
IV infusion of 20% mannitol 7-10ml/kg within 20
minutes
53. Specific treatment
• HSV - acyclovir
• CMV - ganciclovir
• HIV - antiretroviral agents
• Mycoplasma pneumoniae - doxycycline,
erythromycin, azithromycin, or clarithromycin
54. Prevention
• It is not always possible to prevent encephalitis
• The most effective way to reduce the risk of getting
encephalitis
- protection against mosquitoes and ticks bite
- MMR vaccine, JE vaccine
- pre-exposure or post exposure vaccination for
rabies
56. • Brain abscesses are focal infections of the cerebrum
and cerebellum
• Many microbes can cause suppurative infection of
the CNS including bacteria, fungi and parasites
• Most common in children between 4 to 8 yr and
neonates
59. Clinical features
• Manifestations of intracranial suppuration
irritability, drowsiness, stupor and meningeal
irritation
• Features suggesting toxemia
low grade fever, chills
• Focal neurological signs
focal convulsions, cranial nerve palsies, aphasia,
ataxia, visual field defects
• Features of raised ICP
60. Investigations
• Blood tests
Blood for CP - WBC … normal or elevated
ESR and CRP - raised
Blood culture - positive in 10% of cases
• Detection of primary source of infection
ear swab in otitis media
CXR - pneumonia/ lung abscess
• Lumbar puncture - not necessary to diagnose brain
abscess and has high risk of herniation
61. • Brain imaging with contrast CT or MRI
CT – single or multiple low density areas, ring
enhancing with contrast and surrounding cerebral
oedema
MRI – most reliable, parenchymal low density
lesion
62. Right temporal cerebral abscess (arrows), with
surrounding oedema and midline shift to the left
(A) Unenhanced CT image. (B) Contrast-enhanced CT
image
63. Treatment
• Antibiotics and surgery are mainstay of treatment
• Can be treated with antibiotics without surgery
-if the abscess is <2cm in diameter
-illness is of short duration <2 weeks
-no signs of increased ICP
64. Choice of antibiotics
• Empirical treatment
vancomycin, 3rd generation cephalosporin and
metronidazole
• CSOM, sinusitis, mastoiditis
vancomycin, 3rd generation cephalosporin and
metronidazole
• Head injury, neurosurgery
vancomycin and 3rd generation cephalosporin
65. • If CHD is precipitating factor
ampicillin – sulbactam alone or
3rd generation cephalosporin and metronidazole
• Infection of ventriculoperitoneal shunt
vancomycin and 3rd generation cephalosporin
• Immunocompromised patients
broad spectrum antibiotics and amphotericin B
therapy
*Duration – 4 to 6 weeks
*Follow up
66. •Indications for surgery
-abscess is >2.5 cm in diameter
-gas is present in the abscess
-lesion is multiloculated
• The patient should be evaluated by a neurosurgeon
for drainage and samples should be sent to
microbiology laboratory for culture
67. Prognosis
• Mortality rate is decreased to 15-20% with the use
of CT or MRI and prompt treatment
• Factors associated with high mortality rate at the
time of admission include age <1 yr, multiple
abscesses and coma
• Morbidity (long-term sequelae) – 50% of survivors
69. Clinical features
• Cerebral malaria
sudden or gradual onset
generalized or partial convulsions
confusion, coma
tone and reflexes are variable
up-going planter response
loss of corneal reflex
70. • Common clinical features
intermittent fever characterized by the presence of
chills
anaemia, tinge to mild jaundice
Hepatosplenomegaly
• History of travel to or have lived in malaria endemic
area
72. Investigations
• To confirm the diagnosis
blood for MP (thin film, thick film)
Rapid antigen test for detection of P.falciparum
• To detect complications
FBC - severe anaemia, thrombocytopenia
blood glucose
clotting profile - if DIC is suspected
renal function assessment
liver function tests - hepatic dysfunction
CXR - acute pulmonary oedema
USG abdomen - hepatosplenomegaly
CSF examination - to exclude meningitis if suspected
73. Treatment
Immediate management
• Assessment of airway, breathing and circulation
• Diagnosis and treatment of hypoglycemia and
electrolyte imbalance
• Management of unconscious patients
adequate nutrition via nasogastric tube
skin care - 2 hourly position change
bladder care - urinary catheterization
bowel care
74. Antimalarial therapy
• Inj Artesunate 2.4 mg/kg I/V immediately followed by
1.2 mg/kg for 6 days OR
• Inj Artemether 3.2 mg/kg I/M immediately followed by
1.6 mg/kg for 6 days OR
• IV slow infusion quinine dihydrochloride 20 mg/kg as
loading dose over 4 hr followed by 10 mg/kg 8 hrly for
6 days
• PLUS doxycycline or tetracycline or clindamycin for 7
days
75. Supportive therapies
• Maintain fluid and electrolytes balance
• Anticonvulsant therapy with diazepam or
phenobarbitone
• Antipyretics for fever - paracetamol 15mg/kg/dose 4-6
hourly
• Tepid sponging
• For hypoglycemia - IV 10% dextrose
• Blood transfusion for severe anaemia
76. Prevention
• Use of screened windows, mosquito net, burning
repellent coils
• Impregnation of bed nets with permethrin
• Use of repellent creams or spray
• Protective clothing
78. Neurocysticercosis
- Most common parasitic CNS
infection.
Important cause of epilepsy in the
tropics.
- Most cases present with seizures.
1/3 present with raised ICP.
- Endemic in Latin America, Mexico,
India, sub-Saharan Africa, and China.
Including developed countries.
>1000 new cases are diagnosed in
the US each year.
82. Treatment
- Praziquantel and albendazole are both effective
- But albendazole is better tolerated and penetrates
CSF better.
15 mg/kg/day x 28 days
- Use steroids to reduce cerebral edema or if there
is encephalitis
- Repeat CT in 3-6 months to assess lesions
83. - There are some times NOT to use cysticidal
therapy:
Markedly raised ICP – inflammatory response
will be bad, give only steroids
Ophthalmic NCC
Calcified lesions – parasite is already dead
Treatment
86. CNS Fungal Infections
• Don’t forget about the fungi that can cause disease
in a healthy host:
• Cryptococcus, Histoplasma, Blastomyces,
Coccidioides
• Fungal infections are on the rise worldwide due to
increasing prevalence of HIV
87. Fungal Meningitis
• Most common causes are Cryptococcus
neoformans, C. immitis, Candida, and Aspergillus
• Fungal meningitis in general has a more insidious
onset than bacterial
• Symptoms may develop over days
• Always consider it with subacute/chronic
presentation
• C.neoformans may develop more quickly in patients
on high-dose steroids or with HIV
88. Diagnosis
* Have a low index of suspicion in
immune compromised patients with
fever and CNS signs
* CSF usually has high protein, low
glucose, and 20-500 WBC’s
Cell count may be LOW (<20) with
AIDS or high dose steroids
* India ink prep can identify >50% of
C.neoformans cases (up to 80% in
AIDS)
89. Treatment
Fungus Initial
Regimen
Second
Regimen
Other
Considerations
Candida Amphotericin B
+ flucytosine x
2 wks
Fluconazole x
8-10 weeks
Remove shunt
if appicable.
Cryptococcus Ampho B +
flucytosine x 2
wks
Fluconazole x
8-10 weeks
Repeat LP after
2wks of ampho.
Stop steroids.
Coccidio Ampho x 4wks Fluconazole or
ampho 4eva
Serial
monitoring of
CSF
Aspergillus High dose
ampho +
excision
PO
ampho x 1 yr
Excision is key.
90. Prognosis
• Depends on underlying disease process
• Why are they immune suppressed?
• Candida meningitis has a mortality of 10-20%
• Only 50% of patients with coccidioidal meningitis
survive initial treatment
• Survivors have a high risk of relapse
91. Take Home Message
• Fever with fits is the common clinical presentation
in children under five
• Febrile convulsion is the most common cause
But
• Always need to exclude CNS Infections
Editor's Notes
These stages have been proposed as a guideline, it is not always a smooth continuum for every patients. Infants and children may progress rapidly.
Seriously, Rogers went through the Taenia solium life cycle. Humans have to ingest eggs, which hatch into larvae and penetrate the intestinal mucosa, migrating throughout the body, penetrating the CNS, skeletal muscle, SubQ tissues, and eyes, where mature cysts form.
Fever is unusual!
Pathologic confirmation by biopsy or autopsy is the gold standard. However, hopefully all you will have is neuroimaging. ELISAs are not very good. CSF is non-specific.
Characteristic CT has small, low density, ring enhancing lesions with surrounding edema.
Most CNS fungal infections are associated with a disorder of immunity.
Neutropenia, malignancy, malnutrition, immunosuppressive drugs, broad spectrum abx, HIV.
Amphotericin B is the most used and most successful drug for fungal infections of the CNS, even though CNS levels are very low. Flucytosine penetrates the CNS well and is often used synergistically with amphotericin. Fluconazole penetrates the CNS well, but takes longer for CSF sterilization.
