MENINGITIS
Shashi Vaish
Paediatric SpR
AMNCH
Tallaght
CAUSES
Bacterial
Viral
Fungal
N. meningitides
G-ve diplococci
E.Coli
G-ve bacilli
Streptococci-GBS
G+ve cocci
Strep. pneumoniae
G+ve 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
Kernig’s sign
Brudzinski’s 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!
