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MENINGITIS

Shashi
Shashi Vaish
Vaish
Paediatric
PaediatricSpR
SpR
AMNCH
AMNCH
Tallaght
Tallaght
CAUSES

Bacterial
Viral
Fungal
N.
N.meningitides
meningitides
G-ve
G-vediplococci
diplococci

E.Coli
E.Coli
G-ve
G-vebacilli
bacilli

Streptococci-GBS
Streptococci-GBS
G+ve
G+vecocci
cocci

Strep.
Strep.pneumoniae
pneumoniae
G+ve
G+vediplococci
diplococci
Bacterial Meningitis -
Organisms
Birth - 4 wks: GBS, E.coli

4 - 12 wks: GBS, E.coli, Pneumococcus


Salmonella, Listeria, H. Influenza

3 mths - 3 yrs: Pneumococcus, Meningococcus


H. Influenza

3 yrs+ adult: Pneumococcus, Meningococcus


Bacterial Meningitis -
Pathogenesis

Infection of upper respiratory tract

Invasion of blood stream (bacteraemia)

Seeding & inflammation of meninges


Meningitis: Clinical features
Newborn & Infants: non-specific
Fever
Irritability
Lethargy
Poor feeding
High pitched cry, bulging AF
Convulsions, opisthotonus
Kernigs sign
Brudzinskis sign
Meningitis: older children
Acute Meningococcaemia
Neisseria meningitidis: serotype Grp B
commonest
Endotoxin causes vascular damage
vasodilatation, third spacing, severe shock
Severe complication:
Waterhouse-Friderichsen syndrome: massive
haemorrhage of adrenal glands secondary to
sepsis: adrenal crisis-low B.P, shock, DIC,
purpura, adreno-cortical insufficiency
Septicaemia
Purpura fulminans
Clinical features
Clinical features
Clinical features


Clinical features
Tumbler (glass) test
DIAGNOSIS
Hx & PE

Investigations:
FBC Blood C/S
R/L/B Skin scrapings
CRP PCR
Coag CXR+ Mantoux if
Blood gas TB suspected
Glucose
Diagnosis
CSF FINDINGS
Bacterial Viral TB

Cells 10-100,000 <2,000 250-500

polys lymphs lymphs

Glucose low normal very low

Protein N-INC N-INC N-INC

G-Stain gen +ve -ve +ve Zn


Bacterial Meningitis
Management
Medical emergency
Early diagnosis essential
Immediate optimum treatment
Intensive supportive therapy
Rehabilitation
Prophylaxis to family
Notification to GP & Public Health
Bacterial Meningitis/Meningococcaemia
Management
ABC
PICU
Fluid management: aggressive resuscitation
Dexamethasone: only in Pneumococcal and
HiB, given before antibiotics
Inotropes: increasing aortic diastolic
pressure and improving myocardial
contractility
Antibiotics
Less than 2 months of age:
Ampicillin + Cefotaxime+/- Gentamicin
Treat for 3 weeks (neonate)

Over 2 months:
Cefotaxime
Treat for 7-10 days
Prophylaxis
Rifampicin:
Children 5mg/kg bd x 2/7
Adults: 600 mg bd x 2/7
Pregnant contact:
Cefuroxime IM x 1 dose
OR
Just do T/S and await result
Meningitis - Complications
Septic shock - DIC
Cerebral oedema
Seizures
Arteritis/venous thrombosis
Subdural effusions
Hydrocephalus . Abscess . Brain damage
Deafness
Meningococcaemia - poor
prognosis

Onset of Petechiae within 12 hrs


Absence of meningitis
Shock (BP 70 or less)
Normal or low WCC
Normal or low ESR
Subdural Effusion

Failure of temp to show progressive


reduction after 72 hours
Persistent positive spinal cultures after 72 hr
Occurrence of focal/ persistent convulsions
Persistence/recurrence of vomiting
Development of focal neurological signs
Clinical deterioration after 72 hr especially
ICP
Partially treated meningitis
50% cases prior antibiotic - alters the
findings in bacterial meningitis -
Accurate history vital
CSF mainly lymphocytic [not usual polys]
Can have normal glucose
+ve cultures reduced by 30%
Gram stain reduced by 20%
Viral meningitis
Most common infection of CNS especially in <1yr

Causes: enterovirus (commonest, meningitis


occurring in 50% of children <3mth ) herpes,
influenza, rubella, echo, coxsackie, EBV,
adenovirus
Mononuclear lymphocytes in CSF

Symptomatic treatment. Complications associated


with encephalitis and ICP
TB Meningitis

Usually insidious: difficult to diagnose in early


stages (fever 30%, URTI 20%)
Rare in children in developed countries
If untreated is usually fatal
Meningitis usually occurs 3-6mths after primary
infection
1 stage-lasts 1-2wk, fever malaise, headache
2 stage-+/- suddenly, meningeal signs
3 stage-worsening neurological condition, death
Mortality/Morbidity
Bac meningitis: Overall mortality 5-10%
Neonatal meningitis: 15-20%
Older children: 3-10%
Strep. pneumonia: 26-30%
H. influenza type B: 7-10%
N. meningitidis: 3.5-10%
30% neurological complications
4% Profound b/l hearing loss
(sensorineural) in all bac meningitis
Mortality/Morbidity
Viral meningoencephalitis: Enteroviral
fewer complications
Tuberculous meningitis: related to stage of
disease
Stage I-30% morbidity
Stage II- 56%
Stage III-94%
VACCINATE!