Meningitis in children and its Management. Definition Incidence Transmission Route of infection Sign & symptoms Types Pathogenesis Risk factors Clinical features Diagnosis Examination Investigation Prevention Compliication Prognosis Reference

1. . MENINGITIS IN CHILDREN

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3. • MENINGITIS IS THE INFLAMMATION OF THE MEMBRANES
SURROUNDING THE BRAIN & SPINAL CORD, INCLUDING THE DURA,
ARACHINOID & PIA MATTER.

4. • MENINGITIS CAN OCCUR AT ALL AGES BUT IT IS COMMONEST IN
INFANCY.
• WHILE 95% OF THE CASES TAKE PLACE BETWEEN 1 MONTH- 5
YEARS OF AGE.
• IT IS MORE COMMON IN MALES THAN FEMALES.

5. THE BACTERIA ARE TRANSMITTED FROM PERSON TO PERSON
THROUGH DROPLETS OF RESPIRATORY OR THROAT
CLOSE AND PROLONGED CONTACT (E.G. SNEEZING AND
COUGHING ON SOMEONE, LIVING IN CLOSE QUARTERS OR
DORMITORIES (MILITARY RECRUITS, STUDENTS), SHARING EATING
OR DRINKING UTENSILS, ETC.)
THE INCUBATION PERIOD RANGES BETWEEN 2 -10 DAYS.

6. NASOPHARYNX
BLOOD STREAM
DIRECT SPREAD (SKULL FRACTURE, MENINGO AND ENCEPHALOCELE)
MIDDLE EAR INFECTION
INFECTED VENTRICULOPERITONEAL SHUNTS.
CONGENITAL DEFECTS
SINUSITIS

7. • THE SYMPTOMS OF MENINGITIS VARY AND DEPEND ON THE AGE OF THE
CHILD AND CAUSE OF THE INFECTION.
• COMMON SYMPTOMS ARE:
• FLU-LIKE SYMPTOMS
• FEVER,LETHARGY
• ALTERED CONSCIOUSNESS
• IRRITABILITY
• HEADACHE
• PHOTOPHOBIA
• STIFF NECK
• BRUDZINSKI SIGN
• KERNIG SIGN
• SKIN RASHES,SEIZURES

8. OTHER SYMPTOMS OF MENINGITIS IN NEONATES/INFANTS CAN INCLUDE:
APNEA
JAUNDICE
NECK RIGIDITY
ABNORMAL TEMPERATURE (HYPO/HYPERTHERMIA)
POOR FEEDING /WEAK SUCKING
HIGH-PITCHED CRY
BULGING FONTANELLES
POOR REFLEXES

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11. BACTERIAL MENINGITIS
PATHOGENESIS:
ENTRY OF ORGANISM THROUGH BLOOD BRAIN BARRIER
RELEASE OF CELL WALL & MEMBRANE PRODUCTS
OUTPOURING OF POLYMORPHS & FIBRIN
CYTOKINES & CHEMOKINES
INFLAMMATORY MEDIATORS
INFLAMED MENINGES COVERED WITH EXUDATE (MOST MARKED IN PNEUMOCCOCAL
MENINGITIS).

12. MENINGEAL IRRITATION SIGNS: INFLAMMATION OF THE SPINAL NERVES &
ROOTS.
HYDROCEPHALUS: ADHESIVE THICKENING OF THE ARACHINOID IN BASAL
CISTERN OR FIBROSIS OF AQUEDUCT OR FORAMINA OF LUSHKA OR
MAGENDIE
CEREBRAL ATROPHY: THROMBOSIS OF SMALL CORTICAL VEINS RESULTING IN
NECROSIS OF THE CEREBRAL CORTEX.
SEIZURES: DEPOLARISATION OF NEURONAL MEMBRANES AS A RESULT OF
CELLULAR ELECTROLYTE IMBALANCE.HYPOGLYCORHACHIA: DECREASED
TRANSPORT OF GLUCOSE ACROSS INFLAMMED CHOROID PLEXUS &
INCREASED USAGE BY HOST.

13. VIRAL MENINGITIS COMPRISES MOST ASEPTIC MENINGITIS SYNDROMES.
THE VIRAL AGENTS FOR ASEPTIC MENINGITIS INCLUDE THE FOLLOWING:
ENTEROVIRUS (POLIO VIRUS, ECHOVIRUS, COXSACKIEVIRUS )
>HERPESVIRUS (HSV-1,2, VARICELLA.Z,EBV )
PARAMYXOVIRUS (MUMPS, MEASLES)
TOGAVIRUS (RUBELLA)
RHABDOVIRUS (RABIES)
RETROVIRUS (HIV)

14. • IT’S RARE IN HEALTHY PEOPLE, BUT IS A HIGHER RISK IN THOSE WHO HAVE
AIDS, OTHER FORMS OF IMMUNODEFICIENCY OR IMMUNOSUPPRESSION.
• THE MOST COMMON AGENTS ARE
• CRYPTOCOCCUS NEOFORMANS,
• CANDIDA,
• H CAPSULATUM.

15. . NON-INFECTIOUS MENINGITIS
RARELY, MENINGITIS CAN BE CAUSED BY EXPOSURE TO CERTAIN MEDICATIONS,
SUCH AS THE FOLLOWING:
IMMUNE GLOBULIN
LEVAMISOLE
METRONIDAZOLE
MUMPS AND RUBELLA VACCINES
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
(E.G., IBUPROFEN, DICLOFENAC, NAPROXEN)

16. TUBERCULOUS MENINGITIS
• IT’S A COMPLICATION OF CHILDHOOD TUBERCULOSIS & COMMON CAUSE
OF PROLONGED MORBIDITY, HANDICAP & DEATH.
• CHILDREN BELOW 5 YEARS ARE SPECIALLY PRONE.

17. LUMBAR PUNCTURE : PRESSURE USUALLY RAISED,
10-500 PMNS EARLY BUT LATER LYMPHOCYTES PREDOMINATE
PROTEIN- 100-500,RAISED
GLUCOSE LESS THAN 50MG/DL IN MOST CASES
CULTURE FOR TUBERCLE BACILLI.
PRESENCE OF TUBERCULOUS FOCUS ELSEWHERE IN THE BODY IS STRONG
SUPPORTIVE DIAGNOSIS.
CXR.
TUBERCULIN SKIN TEST

18. • ANTITUBERCULOUS THERAPY: INCLUDES SIMULTANEOUS ADMINISTRATION OF
4 DRUGS (ISONIAZID, RIFAMPICIN,STREPTOMYCIN , PYRAZINAMIDE) FOR
FIRST 3 MONTHS, FOLLOWED BY 2 DRUGS FOR ANOTHER 15 MONTHS
USUALLY RIFAMPICIN & INH.
• TOTAL PERIOD: 18 MONTHS.
• STEROIDS: TO REDUCE CEREBRAL EDEMA AND TO PREVENT SUBSEQUENT
FIBROSIS & SUBSEQUENT OBSTRUCTION TO CSF
• 2MG/KG/24 HOURS OF PREDNISOLONE FOR 6-8 WEEKS AT THE START OF
TREATMENT STARTING 3 DAYS AFTER INITIATION OF ANTI TUBERCULOUS
THERAPY.

19. EXAMINATION
GENERAL PHYSICAL- CHECK FOR CONSCIOUSNESS LEVEL ACCORDING TO GCS
SCORING, JAUNDICE OR IRRITABILITY.
RESUSCITATION: INCASE OF SEPTIC SHOCK, OR DIC.
>VITALS: TEMPERATURE , HR, B.P., R/R.
SIGNS OF INCREASED ICP- BULGING FONTANELLE, HEADACHE, NAUSEA,
VOMITING, OCULAR PALSIES, ALTERED LEVEL OF CONSCIOUSNESS, AND
PAPILLEDEMA
FUNDUS: PAPILLOEDEMA CN PALSIES: (ESP. OCCULOMOTOR, FACIAL, AND
AUDITORY)
>MENINGISMUS - CHECK FOR NUCHAL RIGIDITY WITH PASSIVE NECK FLEXION
(GIVES 'INVOLUNTARY RESISTANCE).
BRUDZINSKI SIGN (HIP & KNEE FLEXION WITH NECK MOVEMENT)
KERNIG SIGN (EXTEND KNEE WITH HIP FLEXED)
HEMIPARESIS.
RASH: PETECHIAL OR PURPURIC RASH (NOT ONLY IN MENINGOCOCCAL BUT

22. CBC
IBLOOD CULTURE
GRAM STAINING
LP- D/R, C/S (COLOR, LEUKOCYTE COUNT, DIFFERENTIAL, GLUCOSE, PROTEIN)
ELECTROLYTES
PCR
COAGULATION PROFILE
LIVER AND KIDNEY FUNCTION
CHEST X-RAY,CT/ MRI
BLOOD GASES
EEG
ECG

23. • INCREASE INTRACRANIAL PRESSURE.
• UNSTABLE PATIENT.
• SKIN INFECTION AT SITE OF LP
• THROMBOCYTOPENIA.
• PAPILLOEDEMA

24. • CSF PICTURE IS QUITE DIAGNOSTIC OF THE KIND OF MENINGITIS PRESENT.

25. • DIAGNOSIS
• LATEX PARTICLE AGGLUTINATION:
• DETECTS PRESENCE OF BACTERIAL ANTIGEN IN THE SPINAL FLUID. USEFUL FOR
DETECTION OF H.INFLUENZAE TYPE B, S.PNEMONIAE, N.MENINGITIDIS, E.COLI
• CONCURRENT IMMUNO-ELECTROPHORESIS (CIE)-USED FOR RAPID DETECTION
OF H.INFLUENZA, S.PNEUMONIAE & N.MENINGITIDES.
• SMEARS: TAKEN FROM PURPURIC SPOTS MAY SHOW MENINGOCOCCI IN
MENINGOCOCCAEMIA
• DNA SEQUENCES : ARE HELPFUL IN IDENTIFYING BACTERIA

26. SUPPORTIVE THERAPY:
MAINTAIN FLUID & ELECTROLYTE BALANCE AS REQUIRED TRANSFUSE WHOLE
BLOOD, PRC, FFP OR PLATELETS AS REQUIRED.
MAINTAIN TEMPERATURE CONTROL
MONITOR OFC

27. • STEROIDS :
• DEXAMETHASONE USEFUL FOR H.INFLUENZAE TYPE B,
• FIRST DOSE SHOULD BE GIVEN 1 HR PRIOR TO STARTING ANTIBIOTICS.
• ANTIBIOTICS IV .
• DURATION:1-3 WEEKS DEPENDING ON AGE & TYPE OF ORGANISMS.

28. • INITIAL TILL RESULTS OF AMPICILLIN
C/S ARE KNOWN 300MG/KG/DAY+
• CHLORAMPHENICOL
75-100MG.KG/DAY
• PROBABLE/PROVED MENINGOCOCCI PENICILLINS
2-5 LAC UNITS
/KG/DAY
PROBABLE E.COLI AMPICILLIN + GENTAMYCIN
200MG/KG+2.5-4 MG/KG IV 12HRLY

29. • PROBABLE H.INFLUENZAE AMPICILLIN + CHLORAMPHENICOL OR
• 3 RD GENERATION
CEPHALOSPORIN
• (CEFOTAXIME 200MG/KG/DAY)
• PROBABLE GROUP B STREPTOCOCCI PENICILLIN 50,000I.U/KGI.V/4 HOURLY

30. OTHER DRUGS AVAILABLE
• ANTI-MICROBIALS ANTI FUNGAL
• CEFTRIAXONE AMPHOTERICIN B
GENTAMYCIN FLUCONAZOLE
• CEFOTAXIME
• PENICILLIN G
• VANCOMYCIN
• AMPICILLIN
ANTI VIRAL
• ACYCLOVIR
• GANCICLOVIR

31. • THE VACCINES AGAINST HIB, MEASLES, MUMPS, POLIO, MENINGOCOCCUS,
AND PNEUMOCOCCUS CAN PROTECT AGAINST MENINGITIS
• HIB VACCINE: ALL INFANTS SHOULD RECEIVE AT 2,4,6 MONTHS OF AGE &
BOOSTER 1 YEAR LATER.
• AFTER 1 YEAR 1 DOSE IS GIVEN TILL THE AGE OF 5 YEARS
• PNEUMOCOCCAL VACCINE: 0.5 ML IS GIVEN IM (<2 YRS)

32. • HIGH-RISK CHILDREN SHOULD ALSO BE IMMUNIZED ROUTINELY.
• VACCINATION BEFORE TRAVELLING TO AN ENDEMIC AREA
• CHEMOPROPHYLAXIS FOR SUSCEPTIBLE INDIVIDUALS OR CLOSE
• H INFLUENZAE TYPE B : RIFAMPIN(20 MG/KG/D) FOR 4 DAYS
• N MENINGITIDIS: RIFAMPIN (600 MG PO Q12H) FOR 2 DAYS UPTO
10WEEKS
• CEFTRIAXONE (250 MG IM) SINGLE DOSE OR CIPROFLOXACIN(500-750
MG) SINGLE DOSE.

33. BACTERIAL MENINGITIS MAY RESULT IN
●CRANIAL NERVE PALSIES
●SUBDURAL EMPYEMA
●BRAIN ABSCESS
●HEARING LOSS
●OBSTRUCTIVE HYDROCEPHALUS
●BRAIN PARENCHYMAL DAMAGE: LEARNING DISABILITY, CP, SEIZURES, MENTAL
RETARDATION.
●SEPTIC SHOCK/ DIC
●ATAXIA
●STROKE
●SIADH (NA+ <130 ME/L), PUFFINESS OF FACE, DEC UO.

34. • IT DEPENDS ON THE AGE OF THE PATIENT, THE DURATION OF THE ILLNESS,
COMPLICATIONS, MICRO-ORGANISM & IMMUNE STATUS.
• PATIENTS WITH VIRAL MENINGITIS USUALLY HAVE A GOOD PROGNOSIS FOR
RECOVERY.
• THE PROGNOSIS IS WORSE FOR PATIENTS AT THE EXTREMES OF AGE (IE, <2 Y,
>60 Y) AND THOSE WITH SIGNIFICANT COMORBIDITIES AND UNDERLYING
IMMUNODEFICIENCY.
• PATIENTS PRESENTING WITH AN IMPAIRED LEVEL OF CONSCIOUSNESS ARE AT
INCREASED RISK FOR DEVELOPING NEUROLOGIC SEQUELAE OR DYING
• SEIZURE DURING AN EPISODE OF MENINGITIS ALSO IS A RISK FACTOR FOR
MORTALITY OR NEUROLOGIC SEQUELAE.

35. • ACUTE BACTERIAL MENINGITIS IS A MEDICAL EMERGENCY AND DELAYS IN
INSTITUTING EFFECTIVE ANTIMICROBIAL THERAPY RESULT IN INCREASED
MORBIDITY AND MORTALITY.
• THE PROGNOSIS OF MENINGITIS CAUSED BY OPPORTUNISTIC PATHOGENS
DEPENDS ON THE UNDERLYING IMMUNE FUNCTION OF THE HOST AS MAY
REQUIRE LIFELONG SUPPRESSIVE THERAPY.

36. • NELSON TEXTBOOK
• BASIS OF PEDIATRICS
• WHO RECOMMENDATIONS
• E-MEDICINE