CNS

INFECTIONS
EPIDEMIOLOGY
• Significant cause of mortality and morbisity in children
• Viral is the most common in children
COMMON SIGNS AND SYMPTOMS
• Symptoms: headache, nausea, vomiting, anorexia, photophobia, restlessness, altered consciousness and irritability
• Signs: fever, neck pain and rigidity (12-18 months: absent Kernig and Brudzinski), focal neurologic deficits, seizures, obtundation and coma.
DIAGNOSTICS
• CSF analysis, PCR and imaging
Bacterial Meningitis Viral Meningitis Tuberculous Meningitis
Etiology First 2 months: GBS, G(-) enteric bacilli, L. Enterovirus (most common) Metastatic caseous lesion from primary TB
monocytogenes Parechovirus (cause of aseptic infection
2 months to 12 years: S. pneumonia, H. meningitis/encephalitis in infants)
influenza, N. meninigitidis HSV, VZV, Mumps

Manifestations Common signs and symptoms (see above) More benign course than bacterial cause More rapid progression in infants and
VZV (cerebellar ataxia) children.
Mumps (may cause deafness from CN8 Acute onset of hydrocephalus, seizures and
damage) cerebral edema.
Diagnostic Blood Culture EEG: diffuse slow wave activity Acid fast almost never seen on smear
(see CSF High CRP, ESR Procalcitonin (diff from Viral) Imaging: swelling of the brain parenchyma Ground glass appearance of CSF fluid
analysis Ancillary: PCR, ELISA, Latex Agglutination
below) Cranial Imaging:
• Basilar enhancement,
• Communicating Hydrocephalus
• Cerebral Edema
• Focal Ischemia
Management Antibiotics (see table below) Supportive Anti Koch’s
Dexamethasone (IV) 0.15 mg/kg q 6hr for 2 • IV fluid • Newly diagnosed: 2 HRZE+10HR
days • NSAID for relief of headache • Previously treated DS:
• H.influenza: 1-2 hrs before antibiotics HSV: Acyclovir 2HRZES+1HRZE+9HRE
• Less fever lower CSF protein, reduced Corticosteroid
auditory nerve damage - Improves survival but not severe
disability
Prognosis Appropriate antibiotic therapy and supportive Recovery depends on severity, specific
care reduced the mortality beyond neonatal causative agent and age
period to <10%
Prevention Vaccination and Antibitiotic Prophylaxis Vaccination
PCV, Hib/ Penta (6,10,14 weeks) • Polio (6-10-14)
• MMR (12 months)
• Varicella (12 months)
• JapEn (9 months)
• Vector control (arbovirus)
CSF ANALYSIS
Condition Pressure (cmH2O) Leukocytes (mm3) Protein (mg/dL) Glucose (mg/dL)
Normal <28 cm H20 / 50- 80 mmH20 <5, >75% lymphocytes 20-45 >50 (>75% serum
In neonates: <20 glucose)
Acute Bacterial Usually elevated (100mmH2O) 10-10,000 or more 100-500 Decreased <40 mg/dL
Meninigitis Usually 300-2000 <50% of serum glucose)
PMNs predominance
Partially Treated Normal or elevated 5-10,000 100-500 Normal or decreased
BacMen PMN
Mononuclear cells if pretreated for extended
period of time
Viral Meningitis Normal to slightly elevated Rarely >1000 mm3 50-200 Generally normal
(80-150 mmH2O) PMNs early May be decreased
Mononuclear in most of the course (<40mg/dL) in mumps
Tuberculous Usually elevated 10-500 100-3000 <50 in most cases
Meningitis PMNs early Higher I the
Lymphocytes in most of the course presence of block
ANTIBIOTICS
Empiric Ceftriaxone or Cefatoxime
Vancomycin if PR L. monocytogenes Ampicillin
Chloramphenicol for >1 month old (Pen allergic) Alternative: IV TMP-SMX
Alternative: Vancomycin +rifampin Hib Ampicillin 7-10 days
N meningitides Pen G IV for 5-7days E.coli Cefotaxime or Ceftriaxone for 3 weeks OR at least
Pen Allergic: Meropenem or Vancomycin 2 weeks after CSF sterilization
S pneumonia Vancomycin + 3rd gen Ceph or Pen IV for 10-14 PAe Ceftazidime for 3 weeks OR at least 3 weeks after
days CSF sterilization
Vancomycin is added due to risk of resistance with Partially treated Ceftriaxone or Cefotaxime for 7-10 days
the other antibiotics
Penicillin resistant isolates Vancomycin