Meningitis

MENINGITIS Shashi VaishPaediatric SpRAMNCHTallaght

CAUSESBacterialViralFungal

N. meningitidesG-ve diplococciStreptococci-GBSG+ve cocciStrep. pneumoniaeG+ve diplococciE.ColiG-ve bacilli

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 featuresNewborn & Infants: non-specificFever IrritabilityLethargyPoor feedingHigh pitched cry, bulging AFConvulsions, opisthotonus

Kernigs sign

Brudzinskis sign

Meningitis: older children

Acute MeningococcaemiaNeisseria 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

DIAGNOSISHx & PE

Investigations:FBCR/L/BCRPCoagBlood gasGlucose

Blood C/S Skin scrapingsPCR CXR+ Mantoux if TB suspected

Diagnosis

CSF FINDINGS

Bacterial Viral TB

Cells10-100,000

Bacterial Meningitis Management

Medical emergencyEarly diagnosis essentialImmediate optimum treatmentIntensive supportive therapyRehabilitationProphylaxis to familyNotification to GP & Public Health

Bacterial Meningitis/Meningococcaemia ManagementABCPICUFluid management: aggressive resuscitationDexamethasone: only in Pneumococcal and HiB, given before antibioticsInotropes: increasing aortic diastolic pressure and improving myocardial contractility

AntibioticsLess than 2 months of age:Ampicillin + Cefotaxime+/- GentamicinTreat for 3 weeks (neonate)

Over 2 months:CefotaximeTreat for 7-10 days

ProphylaxisRifampicin:

Children 5mg/kg bd x 2/7Adults: 600 mg bd x 2/7Pregnant contact:Cefuroxime IM x 1 dose ORJust do T/S and await result

Meningitis - Complications

Septic shock - DICCerebral oedemaSeizuresArteritis/venous thrombosisSubdural effusionsHydrocephalus . Abscess . Brain damageDeafness

Meningococcaemia - poor prognosis Onset of Petechiae within 12 hrs Absence of meningitis Shock (BP 70 or less) Normal or low WCCNormal or low ESR

Subdural Effusion

Failure of temp to show progressive reduction after 72 hoursPersistent positive spinal cultures after 72 hrOccurrence of focal/ persistent convulsionsPersistence/recurrence of vomitingDevelopment of focal neurological signsClinical deterioration after 72 hr especially ICP

Partially treated meningitis50% cases prior antibiotic - alters the findings in bacterial meningitis - Accurate history vitalCSF mainly lymphocytic [not usual polys]Can have normal glucose+ve cultures reduced by 30%Gram stain reduced by 20%

TB Meningitis

Usually insidious: difficult to diagnose in early stages (fever 30%, URTI 20%)Rare in children in developed countriesIf untreated is usually fatalMeningitis usually occurs 3-6mths after primary infection1 stage-lasts 1-2wk, fever malaise, headache2 stage-+/- suddenly, meningeal signs3 stage-worsening neurological condition, death

Mortality/MorbidityBac 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 complications4% Profound b/l hearing loss (sensorineural) in all bac meningitis

Mortality/Morbidity Viral meningoencephalitis: Enteroviral fewer complicationsTuberculous meningitis: related to stage of diseaseStage I-30% morbidityStage II- 56%Stage III-94%

VACCINATE!

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