MENINGITIS IN

CHILDREN
Jwan Ali Ahmed AlSofi
-:Contents
• Meningitis is inflammation of the leptomeninges, can
be caused by bacteria, viruses, or—rarely—fungi.
• The term aseptic meningitis is meningitis with
negative cerebrospinal fluid (CSF) bacterial cultures,
caused by:-
1. Principally refers to viral meningitis
2. May be seen with other infectious organisms (Lyme disease,
syphilis, tuberculosis),
3. Parameningeal infections (brain abscess, epidural abscess,
venous sinus empyema),
4. Chemical exposure (nonsteroidal antiinflammatory drugs,
intravenous immunoglobulin),
5. Autoimmune disorders
6. Kawasaki disease.
-:Bacterial Causes of Meningitis
• Partially treated meningitis refers to bacterial meningitis
complicated by antibiotic treatment before the lumbar puncture
(LP), which may result in negative CSF cultures, although
other CSF findings suggestive of bacterial infection persist. In
this case, the etiology can sometimes be confirmed by
polymerase chain reaction (PCR) of the CSF.
-:Viral Causes of Meningitis
• The most common viruses causing meningitis are
1. Enteroviruses
2. Parechoviruses.
• Other viruses that can cause meningitis include:-
• Herpes simplex virus (HSV),
• Epstein-Barr virus (EBV),
• Cytomegalovirus (CMV),
• lymphocytic choriomeningitis virus (LCMV),
• Arboviruses
• human immunodeficiency virus (HIV).
• The mumps virus can cause meningitis in unvaccinated children.
Less frequent infectious causes of
-:meningitis
• Borrelia burgdorferi (Lyme disease),
• Bartonella henselae (cat-scratch disease),
• Mycobacterium tuberculosis,
• Toxoplasma,
• Fungi (Cryptococcus, Histoplasma, Blastomycosis, and
Coccidioides)
• Parasites (Angiostrongylus cantonensis, Naegleria
fowleri, and Acanthamoeba).
-:Risk factors for Bacterial Meningitis
1. Age:- children < 1 year of age, especially infants <2 months.
2. Acquired or congenital immunodeficiencies,
3. functional or anatomical asplenia,
4. cochlear implantation,
5. penetrating head trauma,
6. recent neurosurgical procedure
7. crowding, such as that which occurs in some daycare centers
or college and military dormitories.
8. A CSF leak (fistula), resulting from congenital anomaly or
following a basilar skull fracture, increases the risk of S.
pneumoniae.
-:CLINICAL MANIFESTATIONS
History:- Examination:-
• Preceding upper respiratory tract • nuchal rigidity,
symptoms may occur • Kernig and Brudzinski signs of
• Rapid onset is typical of meningeal irritation are often
infections with S. pneumoniae positive in children older than 12
and N. meningitidis. months.
• Nausea and vomiting • Focal neurological signs,
• Lethargy,
• Photophobia,.
• Fever is usually present.
• seizures,
• arthralgia,
• myalgia,
• petechial or purpuric lesions,
• sepsis, shock,
• coma.
-:Features of meningitis in young infants
• Signs of meningeal inflammation may be minimal
• Irritability
• Depressed mental status
• Poor feeding present.
• Bulging fontanels.
-: Clinical evidence of increased ICP
1. Headache,
2. Vomiting
3. Diplopia
4. Ptosis
5. Sixth CNV palsy
6. Anisocoria
7. Bradycardia with hypertension
8. Bulging fontanelle may be present in infants.
9. Depression of consciousness,
10. Focal neurological deficits
11. Papilledema is uncommon unless there is occlusion of the
venous sinuses, subdural empyema, or brain abscess.
-:LABORATORY AND IMAGING STUDIES
• If bacterial meningitis is suspected, a LP should be performed
unless there is
1. evidence of cardiovascular instability
2. increased intracranial pressure (due to the risk of herniation).
• Routine CSF examination includes
1. a white blood cell count with differential,
2. Protein levels
3. Glucose levels
4. Gram stain.
• CSF should be cultured for
• bacteria
• Fungi
• Mycobacteria.
• PCR is used to diagnose viral meningitis; it is more sensitive
and rapid than viral culture.
-:LABORATORY AND IMAGING STUDIES
• Peripheral leukocytosis is common
• Blood cultures may be positive depending on the organism
and whether there was antibiotic pretreatment.
• Ideally, CSF should be obtained prior to empiric therapy;
• however, antibiotics should not be delayed if there is an inability to
perform an LP.
• If imaging is required prior to the LP,
• blood cultures should be sent and antibiotics started, prior to a (CT) scan.
• In meningococcal meningitis, CSF can rapidly become sterile,
often within 1-2 hours, and most commonly with a single dose
of therapy.
• Sterilization of the CSF in S. pneumoniae meningitis may also
occur within a few hours.
-:Cerebrospinal Fluid Analysis
• Differentiating hemorrhagic CSF caused by a traumatic
lumbar puncture (LP) from a true subarachnoid
hemorrhage may be difficult.
• In most cases of traumatic LP, the fluid clears significantly as
the sequence of tubes is collected.
• If there is clinical evidence of increased ICP:-
• Caution must be exercised before performing an LP to limit risk of
cerebral herniation.
• A (CT) scan should be performed and confirmed to be normal before the
LP if increased ICP is suspected.
• If increased ICP is present, it must be treated before an LP is performed.
 NORMAL CSF VALUES
CSF FINDING NEWBORN >1 MO OLD

Cell count* 10-25/mm3 5/mm3

Protein 65-150 mg/dL <40 mg/dL

>2/3 blood
>2/3 blood glucose
Glucose glucose
or >60 mg/dL
or >40 mg/dL
*In normal children, cells present should be lymphocytes.
Cerebrospinal Fluid Findings in Various Central Nervous System Disorders
”TREATMENT:- “Antibiotics
• Treatment of bacterial meningitis focuses on
1. sterilization of the CSF by antibiotics
2. maintenance of adequate cerebral and systemic perfusion.
• Empiric therapy:-
• S. pneumoniae  third-generation cephalosporin plus vancomycin.
• N. meningitidis, H. influenzae, and some E. coli  Cefotaxime or ceftriaxone.
• Listeria monocytogenes (For infants younger than 2 months of age) 
ampicillin is added to cover the possibility of.
• Duration of treatment:-
• 5-7 days for N. meningitidis,
• 7-10 days for H. influenzae,
• 10-14 days for S. pneumoniae.
• Meningitis caused by gram-negative bacilli should generally be treated a minimum
of 21 days or 14 days beyond the first negative CSF culture, whichever is longer.
”TREATMENT:- “Dexamethasone
• Used as adjunctive therapy
• Initiated just before or concurrently with the first dose of
antibiotics,
• Significantly diminishes the incidence of hearing loss resulting from H.
influenzae meningitis.
• The role of adjuvant steroids for diminishing neurological sequelae
and mortality for pneumococcal and meningococcal meningitis in
children is less clear.
”TREATMENT:- “Supportive therapy
• treatment of dehydration, shock, disseminated intravascular
coagulation, syndrome of inappropriate antidiuretic hormone (SIADH),
seizures, increased intracranial pressure, apnea, arrhythmias, and
coma.
• Adequate cerebral perfusion must be maintained in the presence of
cerebral edema.
-:COMPLICATIONS
1. SIADH may complicate meningitis and necessitates monitor- ing of
urine output and fluid administration.
2. Deafness
1. All patients with meningitis should have a hearing evaluation before discharge
and at follow-up.
3. Blindness
4. Seizures
5. Paresis
6. Ataxia
7. Hydrocephalus.
8. Learning disabilities and behavioral problems may be more
subtle.
-:Causes of Persistent fever in meningitis
1. Is common during treatment
2. Ineffective treatment
3. immune complex-mediated pericardial or joint effusions,
 Because most patients with meningococcal meningitis become afebrile
by the 7th hospital day, persistence or recrudescence of fever after 5 days
of antibiotics warrants evaluation for immune complex-
mediated complications.
4. thrombophlebitis,
5. Drug fever,
6. Nosocomial infection.
Indications for A repeat LP after 48 hours of
-: therapy

1. those whose condition has not improved or has worsened,

2. gram-negative meningitis
3. for those who received adjunct steroids, which can interfere
with the ability to monitor clinical response.
-:Indications for CNS imaging in Meningitis

1. focal neurologic signs or symptoms

2. persistently positive CSF cultures.
-:Causes of recurrent Meningitis
1. Underlying immunologic defect
2. Underlying Anatomic defect (e.g. trauma)
-:PREVENTION
• Routine immunizations
• Chemoprophylaxis to eradicate the carrier state
and decrease transmission is recommended for:-
• Both for index cases with N. meningitidis and for their
close contacts  rifampin, ciprofloxacin,
azithromycin, or ceftriaxone.
• For invasive H. influenzae type B  prophylaxis
consists of rifampin.