meningitis case presentation in pediatric Deapetment

1. NAME : Tanushka
CLASS : PharmD 3 rd. year
Roll no:1339215

2. The brain and spinal cord is
covered by connective
tissue layers which is
collectively known as
meninges(it contain cerebro
spinal fluid) which form
the blood brain barriers:-
Dura mater pia mater and
arachnoid mater.
Meningitis is an
inflammation of meninges
it is a life threating diseases
categories under medical
emergency

3.  Tuberculous meningitis is
caused by Mycobacterium
tuberculosis. This is the
bacteria that causes
tuberculosis (TB). The
bacteria spread to the
brain and spine from
another place in the body.

6.  Name : xyz
 Sex: female
 Age :9 yrs
 Weight :26 kg
 Date of admission:16/9/15
 c/c: asymptomatic from 4 days ,fever from last 4 days
(fever99.8 F is not rigor and chills) and vomiting from
last day(no blood seen in vomiting)
 Medical history :no similar episode in past.
 Medication history : vaccination upto the mark
 n/k/d/a

7.  BP=100/60 mmhg
 Heart rate=160/min
 RR=18/min
 Pupil-b/l equal reaction to light
 Chest-B/l no added sound
 Cvs-s1s2 normal
 P/A-soft non tendon no hepatomegaly /
splenomegaly
 Stiff neck

8. parameter observation Normal range
bun 10mg 5-17mg/dl
Sr.crt 0.7mg 0.8-1.3mg/dl
Calcium 8.9 mg/dl 9.2-11.0mg/dl
Sodium 139mEq/dl 135-
155mEq/dl
Chloride 110mEq/dl 98-107mEq/dl
Potassium 5.6 mEq/dl 3.5-5.5mEq/dl
Ast 25 IU/L 5-40 IU/L
Alt 30IU/L 5-40 IU/L
alp 385mg/dl 60-150 IU/L
neutrophills 80% 40-70%
Eosinophils 04% 1-4%
Basophils 00% 0-0.5%
Monocytes 04% 2-8%
lymphocytes 16% 20-45%
Platelets 1.54
lakh/cum
m
1.5-4.0
lakh/cum
m
Hemoglobu
lin
11.9 g/dl 12-16 g/dl
On the next day Platelets
were reduced in number –
thrombocytopenia
Peripheral blood smear
examined is negative for
malaria parasites
Fungal sepsis was founded
in her hand and legs .

9.  Ct –scan :supratentorial (The tentorium is a membrane just under the brain) =
mild increases enhancement ,correlated for meningitis.
 CSF for routing examination ADA(Adenosine Deaminase) CSF=80 u/l
Reference value : Normal : <10U/L
positive:>10U/L
Smear shows no WBCs cell are seen , no neutrophils 2 lymphocytes are seen only
rare RBCs are seen .
*Increase level are found in various form of TB .
ADA is also increses in various infected diseases (Cryptococcal
Meningitis etc)
Final diagnosis :
Meningitis confirmed by CT-
scan.
?Tuberculous
meningitis/?Cryptococcal
Meningitis: patient might be
suffering from TBM by examine
the CSF .

10. BRAND
NAME
GENERIC
NAME
DOSE ROUT
E
FREQUE
NCY
moa
Inj. Atcef ceftriaxone 1.3g I.V Bd antibacterial
Inj. Rantac Ranitidine 25mg i.V bd H2 antagonist
Inj. Pantap Pantoprazole 20mg i.V Od ppi
Inj. Mefast Mefenamic
acid
26mg i.V Sos Inhibit
prostaglandin
synthetase
Inj.emset ondansetron 2 mg i.v Sos 5 HT3 antagonist
Inj. Eptoin Phenytoin i.v Bd anticonvulsant
Inj.Artesunate artesunate 2.4 mg i.v Od Inhibit the dna
replication
Patient is on oxygen mask
INFUSION:
Ivf.NS-200ml bolous
Ivf DNS + 5 ml kcl -1.8 ml/hr

11. BRAND
NAME
GENERIC
NAME
DOSE ROUTE FREQUENC
Y
moa
Inj mero meropenem 500mg Iv Tds antibacterial
Inj dexa Dexamethas
one
4mg Iv Tds antiinflamm
atory
Inj eptoin phenytoin 104 mg Iv Bd Anti-
convulsant
Inj.rantac ranitidine 25mg Iv Bd H2
antagonist
Tab
pyridoxine
Pyridoxine
(vitamin b 6)
40 mg oral Od Synthesis of
rbcs
Inj.amikacin amikacin 400mg iv od antibacterial
Tab.fludroco
rtisone
fludrocortiso
ne
1 tab oral od adrenocortic
osteroid
Syp glycerol glycerol 10 ml oral tds

12.  Infusion
 Dns(1850)+5ml kcl+ml calcium gluconate =24
hrs
 NS bolous (normal saline)-3ml/hrs
 Ivf dopamine-400mg/day
 Ivf adrenaline-1.8ml/hrs

13.  Same medication
 Dots category-1:
 *Newly diagnosed sputum positive pulmonary tuberculosis
 *Sputum negative pulmonary tuberculosis with extensive
 parenchymal involvement.
 *Severe form of extra pulmonary tuberculosis.
 In patients with TB meningitis on Category I treatment, the four
drugs used during the intensive phase should be HRZ(isoniazid,
rifampin , pyrazinamide )along with Streptomycin (S) as
Ethambutol does not penetrate the CSF well.
 Continuation phase of treatment in TB meningitis and spinal TB
with neurological complications should be given for 6-7 months,
extending the total duration of treatment to 8-9 months.

14. BRAND
NAMES
GENERIC
NAME
DOSE ROUTE FREQUENCY
Inj mero meropenem 500mg Iv Tds
syp
eptoin
phenytoin 8.5 ml orally Bd
Syp
glycerol
glycerol 10 ml oral tds
Tab
pyridoxi
ne
Pyridoxine
(vitamin b 6)
40 mg oral Od
Tab
clonex
clonazepam 0.2 mg oral Hs
Tab.ezee
pam
Escitalopram 10mg
(½)
oral Hs
Dots cat 1

15.  Antibiotics for bacterial meningitis :Type vary
depending on the bacteria causing the infection
 immunization is very effective at preventing
pneumococcal meningitis
 Steroids [dexamethasone] :Shortly before or along
with antibiotics. Do not give steroids after
antibiotic treatment.
 Empiric treatment should be begun as soon as the
diagnosis is suspected using bactericidal agent(s)
that achieve significant levels in the CSF .Selected
third generation cephalosporins such as cefotaxime
and ceftriaxone, have emerged as the beta-lactams
of choice in the empiric treatment of meningitis.

16.  empiric treatment is warranted when clinical features
and CSF findings are suggestive of TBM even before
microbiologic confirmation. The recommended
treatment regimen for presumed drug-susceptible TBM
consists of two months of daily INH, rifampin (RIF),
pyrazinamide (PZA), and either streptomycin (SM), or
ethambutol (EMB), followed by 7–10 months of INH
and RIF.
 Other medications and intravenous fluids will be used
to treat symptoms such as brain swelling, shock,
and seizures.
 Phenytoin is used to control seizures.

17.  The rationale behind the use of adjuvant
corticosteroids lies in reducing the harmful effects of
inflammation as the antibiotics kill the organisms.
 seizure precautions should be considered, seizures
should be treated and airway protection should be
considered ,oxygen should be administered.

18.  TB is almost always curable if the patient
adheres to the treatment regimen of taking
several special medications. The medication
must be taken continuously for the duration of
treatment.
 Patient was made aware of adverse effects of
anti TB drugs like blurt vision ( INH, E)
Monitor & test eyes monthly
 TB is infectious disease advising patient not to
spit in the surroundings and cough in the open
air as it may infect the healthy person

19.  ceftriaxone + amikacin / ceftriaxone +streptomycin
=Amikacin /streptomycin can sometimes cause kidney
damage, and using it with a cephalosporin antibiotic like
cefTRIAXone may increase that risk.monitor closely.
 rifampin + ondansetron=Using rifampin together with
ondansetron may decrease the effects of ondansetron.
 phenytoin +dopamine=DOPamine together with
phenytoin, this can lower your blood pressure and slow
your heart rate.
 phenytoin + dexamethasone=phenytoin together with
dexamethasone can make dexamethasone less effective.
 rifampin + phenytoin =phenytoin together with
ranitidine may increase the effects of phenytoin

20.  phenytoin +ondansetron =phenytoin together
with ondansetron can decrease the effects of
ondansetron.
 isoniazid + phenytoin /ranitidine +phenytoin
=phenytoin together with isoniazid/ranitidine
may increase the effects of phenytoin.
 Sr.cret should be regular monitor
 A TB skin test (Mantoux) was not performed