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Meningitis
- 1.
- 2. Definition • Inflammation ofmeninges (membrane surrounding the brain and spinal cord) • Pachymeningitis : inflammation of dura • Leptomeningitis : inflammation of arachnoid • Common in children less than 4 years old • Peak 3-8 months old • Incidence of encephalitis related to vaccination in childhood
- 3. Etiology • Neonates • GBS,E.Coli,Staph.Aureus,Listeria Monocytogenes,Group A Streptococcus • Infants • GBS,E.Coli,Listeria Monocytogenes • Children • Neisseria Meningitides,Strep. Pneumonia,Haemophilus Influenza,Myco. TB, Staph. Aureus • School age children • 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 • Meningomyelocele • Neurosurgical procedure
- 5. Clinical Features • Neonatal: vague and non specific • Fever • Refuse to feed + vomit • Irritable + drowsiness • Irregular respirations • Neck stiffness > rare and late findings • Tense + bulging fontanelle > late course of illness
- 6. Clinical Features • Infant •Fever + vomiting • Marked irritability + convulsion + somnolence • Tense + bulging fontanelle > late course of illness
- 7. Clinical Features • Children •Fever + chills • Headache + photophobia + vomiting • Stiff neck + lethargy • Convulsion + delirium + drowsiness + irritability
- 8. Physical Examination • General •GCS • Level of consciousness • Vital signs • Febrile • Shock • Hypertension • Bradycardia/apnea • Head • Bulging and tense fontanelles • Eye • papilledema • Skin • Purpuric rash (meningococcal rash) • Brudzinki's : Knee automatically brought up toward body when neck is bent forward or pain in the legs when bent • Kernig's : Inability to straighten a child's knee after hip flexion 90 degree • Focal neurological sign
- 9. Differential diagnosis • Intracranialinfection • Brain abscess • Cerebral malaria • Metabolic disorder • Acid-base disorder • Inherited metabolic disease (urea cycle disorder and lactic acidosis) • Seizure disorder • Status epilepticus • Hemiconvulsion-hemiplegia syndrome • Increase ICP • Tumor • Hematoma • Acute hydrocephalus • Lead poisoning • Subarachnoid haemorrhage
- 10. Investigations • Full bloodcount • BUSE • Blood C&S • Urine C&S • RBS • LP • Imaging • CT brain • MRI • Throat swab • Rapid antigen test in body fluid • CSR and Mantoux test
- 11. Lumbar puncture Appearance CellType 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 • Supportive 1. Vitalsign monitoring 4 hourly 2. Input and output chart 3. KNBM in unconscious 4. Fluid therapy : maintenance fluid • 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 • General 1. IncreaseICP : rapid administration of IV mannitol 2. Seizures : anticonvulsant drugs (IV diazepam in acute phase) • Anti-microbial therapy • 0-1 months : C.Penicillin + Cefotaxime for 3 weeks • 1-3 months : C.Penicillin + Cefotaxime for 3 weeks • >3 months : C.Penicillin + Cefotaxime or Ceftriaxone • HiB : 10 days • S.Pneumonia : 2 weeks • N.Meningitides : 1 weeks
- 14. Management • Steroid therapy •Dexamethasone 0.15mg/kg 6hourly for 4 days or 4mg/kg 12hourly for 2 days • Improve meningeal inflammation and reduce hearing impairment • Tubercular meningitis • Triple therapy : isoniazid + rifampicin + ethambutol ± pyrazinamide (excellent penetration into CSF)
- 15. Follow-up • Development ofchild • Head circumference • Occurrence of fit or behaviour abnormalities • Assessment of vision,hearing and speech
- 16. Complications • Meningococcemia –shock + DIVC • Neurologic - hemi/quadriparesis,facial palsy or visual defects • Seizures • Subdural collection of fluid • Arthritis(Hib) • Buccal cellulitis • Pericarditis • Pneumonia
- 17. Prognosis • Worse inyounger patients • Duration of illness prior to effective antibiotics • More complications in HiB and Strep. Pneumoniae • Worse when presence of focal sign
- 18. Prevention • Immunization :N.Meningitis,Strep. Pneumonia,Hib • Chemoprophylaxis : intrapartum ampiccilin for GBS,rifampicin for HiB contact,azithromycin/ciprofloxacin for meningococcal carriage in adult
Editor's Notes
- #13 If fever persists: Thrombophlebitis and intramuscular abscess Intercurrent infection : pneumonia,UTI or nosocomial infection Resistant organism Subdural effusion,empyema or brain abscee Antibiotic fever