Meningitis In children

Harim Mohsin
02-13
 Definition
Meningitis is the inflammation of the
membranes surrounding the brain & spinal
cord, including the dura, arachinoid & pia
matter.
 Incidence
 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.

 Transmission
 The bacteria are transmitted from person to
person through droplets of respiratory or throat
secretions.

 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.
 Routes of Infection
 Nasopharynx
 Blood stream
 Direct spread (skull fracture, meningo and
encephalocele)
 Middle ear infection
 Infected Ventriculoperitoneal shunts.
 Congenital defects
 Sinusitis
 Signs & Symptoms
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
 Signs & symptoms
Other symptoms of meningitis in Neonates/infants
can include:
 Apnea
 jaundice
 neck rigidity
 Abnormal temperature (hypo/hyperthermia)
 poor feeding /weak sucking
 a high-pitched cry
 bulging fontanelles
 Poor reflexes
 Types
 Bacterial
 Viral (aseptic)
 Fungal
 Parasitic
 Non-infectious
 Pyogenic Meningitis
ETIOLOGY
 ‘Meningococcal’ meningitis- N. meningitidis. A, B, C and W135)
are recognized to cause epidemics

 The commonest organisms according to age groups are:

0-2 months E.Coli, Group B streptococci, S.Aureus, Listeria

Monotocytogenes

2 months- 2yrs H.Influenzae type b, S.Pneumoniae,

N.Meningitides.
2 yrs – 15+yrs N.Meningitides (serotypes A,B,C, Y & W135)
S.Pneumoniae (serotypes 1,3, 6,7)
H.Influenzae
 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).
 Pathogenesis
 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.
 Neonates
 Suspect meningitis with temperature more than
100.7 ‘F(38.2’C).

Risk factors:
 Infective illness in mother
 PROM
 Difficult delivery
 Premature babies
 Spina bifida
 D/D:

Tuberculous Meningitis
Viral /aseptic Meningitis
Brain Abscess
Brain tumor
Cerebral malaria
 Viral meningitis
 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)
 Fungal Meningitis
 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.
 Parasitic Meningitis
 Infection with free-living amoebas is an infrequent
but often life-threatening human illness.

 It’s more common in underdeveloped countries

and usually is caused by parasites found in
contaminated water, food, and soil.

 The most common causative agents are:

Free-living amoebas (ie, Acanthamoeba,
Balamuthia, Naegleria)
Helminthic eosinophilic meningitis
 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)
 Tuberculous meningitis
 It’s a complication of Childhood
tuberculosis & common cause of
prolonged morbidity, handicap &
death.
 Children below 5 years are specially
prone.
 CLINICAL FEATURES
Always sec. to primary tuberculosis.
First Phase: Vague symptoms.
 Child doesn’t play, is irritable, restless or
drowsy.
 Anorexia & vomiting may be present
 Older child may complain of headache.
 Possibly preceding history of Measles or
another illness with incompletely recovery
SECOND PHASE:
Child is drowsy with neck stiffness, &
rigidity.
Kernig & Brudzinski sign may become
positive, anterior fontanels bulges
Twitching of muscles, convulsions, raised
temperature.
strabismus, nystagmus, and papilloedema
may be present.
Fundoscopy: Choroidal TB may be seen
TERMINAL PHASE

Child is characteristically comatose

with opisthotonus, & multiple focal
paresis.
Cranial nerve palsies are present.
High grade fever often occurs
terminally.
 Diagnosis
 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.
 Treatment
 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.
 Treatment
 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.
 D/D
 Partially treated bacterial meningitis
 Viral meningitis
 Cerebral malaria
 Viral encephalitis
 Chronic Meningitis
Chronic meningitis
is a constellation
of signs and
symptoms of
meningeal
irritation
associated with
CSF pleocytosis
that persists for
longer than 4
weeks.
 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)

 Examination
 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 also pneumococcal bacteremia).
 Investigations
 CBC
 Blood 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
 Diagnosis
 CSF picture is quite diagnostic of the kind of
meningitis present.
 Contraindication for LP
 .Increase intracranial pressure.
 .Unstable patient.
 .Skin infection at site of LP.
 .Thrombocytopenia.
 .Papilloedema.
 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

 Treatment
Supportive therapy:
 Maintain fluid & electrolyte balance as
required
 Transfuse whole blood, PRC, FFP or
platelets as required.
 Maintain temperature control
 Monitor OFC
 Treatment
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.
 Treatment

 Initial till results of  Ampicillin

300mg/kg/day+
C/S are known
 Chloramphenicol
75-100mg.kg/day

 Probable/Proved
 Penicillins
Meningococci
2-5 lac units /kg/day
 Treatment
 Probable  Ampicillin +
H.Influenzae chloramphenicol or
3rd generation
cephalosporin
(cefotaxime
200mg/kg/day)

 Probable E.Coli
 Ampicillin +
gentamycin
200mg/kg+2.5-4 mg/kg
IV 12hrly
 Treatment
 Probable group B  Penicillin
streptococci 50,000i.u/kgI.V/4
hourly.
 Other Drugs available
Anti-microbials Anti-Virals
 Ceftriaxone  Acyclovir
 Cefotaxime  Ganciclovir (>3mths)
 Penicillin G
 Vancomycin Anti-fungals
 Ampicillin Amphotericin B
 Gentamicin Fluconazole
 Prevention
 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)

 Prevention
 High-risk children should also be immunized routinely.

 Vaccination before travelling to an endemic area

Chemoprophylaxis for susceptible individuals or close

contacts:
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.
 Complications
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.
 Treatment of Complications:
Convulsions: Diazepam I.V, Can be
repeated q4 hours as required.

Cerebral edema: *I.V Mannitol 1g/kg in

20-30 mins 6-8 hourly given for first few
days.
 IV Dexamethasone can then be used 6
hourly.
 Subdural effusion:
Aspirate subdural effusion if large.

 Shock: Treat with IV Fluids, maintanence of BP.

 SIADH: Increase body weight, decreased serum

osmolality, hyponatremia.
Prevented by fluid restriction to 800-1000ml/m2/24
hours.

 Hyperpyrexia: Tepid sponging, correction of

dehydration.
 Prognosis
 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.
 Prognosis
 A seizure during an episode of meningitis also is
a risk factor for mortality or neurologic sequelae.

 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.
 References
 Nelson textbook
 Basis of pediatrics
 WHO recommendations
 E-medicine