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Pyogenic meningitis in child

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Page 1: Pyogenic meningitis in child
Page 2: Pyogenic meningitis in child

Acute CNS infection

Page 3: Pyogenic meningitis in child

• What is it?

• What causes it?

• What happens in the system?

• How to recognize it?

• How to prove it?

• How to treat it?

• How to prevent?

Page 4: Pyogenic meningitis in child

Significance

• Significant morbidity & mortality in children [1.2m cases worldwide]

• Diagnosis, challenging in young children

• High incidence of sequalae

Page 5: Pyogenic meningitis in child

• Fever with altered sensorium

• Virus > bacteria > fungi & parasite

• Meningitis

• Meningoencephalitis

• Brain abscess

• Common symptoms

photophobia, neckpain/rigidity, fits, stupor

• Diagnosis by CSF

Page 6: Pyogenic meningitis in child
Page 7: Pyogenic meningitis in child

Pyogenic meningitis

Page 8: Pyogenic meningitis in child

Etiology

• < 2months• Maternal flora, NICU/PNW flora;

• GBS, GDS, gram-ve, listeria, HIB,

• 2m-12m• Pneumococci, meningococci, HIB[now less]

• Pseudomonos, staph.aureus, CONS.

Page 9: Pyogenic meningitis in child

Reasons for infection

• Less immunity

• Contact with people with invasive disease

• Occult bacteremia [infants]

• Immunodeficiency

• Splenic dysfunction

• CSF leak , Meningomyelocele

• CSF shunt infection

Page 10: Pyogenic meningitis in child

Risk of infection

• Pneumococci OM, sinusitis, pneumonia, CSF rhinorrhea.

• Meningococci contact with adults, nasopharyngeal carriage

• HIBContact in daycare center

Page 11: Pyogenic meningitis in child

Pathogenesis

• Colonisation of nasopharynx

• Prior/concurrent viral URTI

• Bacteremia

• Hematogenous dissemination

• Contiguous spread from sinus, otitis, orbit

vertebral trauma, meningocele.

Page 12: Pyogenic meningitis in child

Why few only get meningitis?

• Defective opsonic phagocytosis– Developmental defects– Absent preformed anticapsular antibodies– Deficient complement/properdin system– Splenic dysfunction

Page 13: Pyogenic meningitis in child

Pathogenesis • Bacteria enter through choroid plexus of

LV

• Circulate to extra cerebral CSF & subarachnoid space

• Rapidly multiply in CSF

• Release of inflammatory mediators

• Neutrophilic infiltrates

• Increase vascular permeability

• Altered BBB

• Vascular thrombosis

Page 14: Pyogenic meningitis in child

Pathology

• Thick exudate covering all areas

• Ventriculitis, arteritis, thrombosis

• Vascular occlusion, sinus occlusion.

• Cortical necrosis, cerebral infarct

• Subarachnoid hemorrhage

• Hydrocephalus

• ICT, inflammation of spinal nerves

Page 15: Pyogenic meningitis in child

Clinical features • Nonspecific

– Fever,anorexia,myalgia,arthralgia,headache,– Purpura , petechiae, rash, photophobia.

• Meningeal signs– Neck rigidity, backache.– Kernig sign

– Brudzinski sign– Crossed leg sign

Page 16: Pyogenic meningitis in child
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Page 18: Pyogenic meningitis in child
Page 19: Pyogenic meningitis in child

ICT signs

Headache, vomiting, drowsy, Fits Ptosis, squint, AF bulge, widened sutures Hypertension, bradycardia Stupor, coma Abnormal posturing Papilloedema [only in chronic ICT]

Page 20: Pyogenic meningitis in child

• Focal neurological deficit

• Cranial neuropathy– 3rd nerve– 6th nerve– 7th nerve– 8th nerve

Page 21: Pyogenic meningitis in child

Diagnosis

• LP & CSF analysis– Gram stain– Culture– Cell count– Glucose, protein

– [Contraindications for LP]

• Blood culture

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CSF analysis• Cell count

– Normal• NB >30/mm3

• Child >5/mm3

– Meningitis >1000/mm3• Turbid 200-400/mm3• Early; lymphocytic predominance• Later; neutrophilic predominance

• low in severe sepsis

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Page 25: Pyogenic meningitis in child
Page 26: Pyogenic meningitis in child
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CSF analysis in prior antibiotic therapy

• Culture, gramstain altered

• Pleocytosis, protein, glucose unaltered

Page 29: Pyogenic meningitis in child

Traumatic LP

• Cell count, protein level altered

• Glucose, bacteriology unaltered.

Page 30: Pyogenic meningitis in child

Condition Pressure mm-h2o

Cell count/mm3 Glucose mg/dl

Protein mg/dl

microbiology

Normal 50-80 <5,lymphocyte >50, 75% of blood level

20-40mg

Bacterial meningitis

100-300 100-1000, >75% neutrophils

<40mg 100-500 Gram stain+ve

Partially treated meningitis

N / elevated

5-1000,Lymphocytes?

N /decreased 100-500 Gramstain ,c/s maybe -veAntigens +ve

Viral meningitis

Normal Less cells,lymphocytes

N, less in mumps

<200

TBM More <500,lymphocytes

<40 100-3000 Stain –veCulture ± ve

Fungal More 5-500 N More? Culture

Page 31: Pyogenic meningitis in child

Treatment • Rapidly progressive [ ~24h]

LP antibiotics

ICT , FND CTbrain & antibiotics

Manage shock, ARDS

• Subacute course [4-7d]

• Assess for ICT, FND

• Antibiotics CT LP

Page 32: Pyogenic meningitis in child

Supportive care• Monitoring

– Vitals– BUN,electrolytes,HCO3,IO, CBC,Platelets,Ca– Periodic neurologic assessment

• PR,sensorium,power,cranial N ex, head circ,

• Supportive care– IVF restrict for ICT,SIADH, more for shock – ICT ETI & ventilation,frusemide,mannitol– Seizures diazepam,phenytoin

Page 33: Pyogenic meningitis in child

Antibiotic therapy• Vancomycin & cefataxime/ceftrioxone

– Pneumococci,meningococci,HIB.

• Ampicillin / cotrimaxazole I.V– Listeria

• Ceftazidime & aminoglycoside– Immunocompromised

Page 34: Pyogenic meningitis in child

Duration of therapy

Pneumococci : 7-10 days Menigococci: 5-7 days HIB; 7-10 days E.coli,Pseudomonos ; 3 weeks Antibiotics started before LP [partially

treated meningitis] ; ceftrioxone 7-10 days.

Page 35: Pyogenic meningitis in child

Repeat LP

• After 48h

• For ; resistant pneumococci, gram-ve meningitis

Page 36: Pyogenic meningitis in child

Corticosteroids

• Rapid bacterial killing

• Cell lysis

• Release of inflammatory mediators

• Edema

• Neutrophilic infiltration

• 1-2h before antibiotics

• Dexamathasone q6h for 2 days.

• Less fever, less deafness.

Page 37: Pyogenic meningitis in child

Complications • ICT, Herniation

• Fits, Cranial N palsy

• Dural Vein sinus thrombosis

• Subdural effusion

• SIADH

• Pericarditis, Arthritis

• Anemia, DIC

Page 38: Pyogenic meningitis in child

Prognosis

• Mortality >10% [more in pneumococci]

• Prognosis poor in– Infants– Fits >4days– Coma, FND on presentation

• Neurological sequalae 20%– Behavior changes 50%– Deafness [pneumo,HIB], visual loss– MR,fits,

Page 39: Pyogenic meningitis in child

Prevention

• Meningococci– Rifampacin for close contacts [10mg/kg/day q12h for

2days]

– Quadrivalent vaccine for high risk children

• HIB– Rifampacin for contacts for 4days

– Conjugate vaccine

• Pneumococci – Heptavalent conjugate vaccine

Page 40: Pyogenic meningitis in child

TBM

• Subacute / ?chronic meningitis

• From lymphohematogenous dissemination

• Caseous lesion in cortex / meninges

• Discharge of TB bacilli in CSF

• Thick exudate infiltrate blood vessels

• Inflammation,obstruction,infarct.

Page 41: Pyogenic meningitis in child

• Brainstem affected

• Cranial N dysfunction

• Hydrocephalus

• Infarcts

• Cerebral edema

• SIADH

• Dyselectrolytemia

Page 42: Pyogenic meningitis in child

Features

• 6m-4yrs

• 3 stages

• Prodrome stage; 1-2 wks, nonspecific symptoms, stagnant development

• Abrupt stage;lethargy,fits,meningeal signs focal ND,cranial neuropathy,hydrocephalus.

Encephalitic picture

• Coma stage; posturing,hemi/paraplegia,poor vital signs

Page 43: Pyogenic meningitis in child

Diagnosis • Contact with adult TB

• Mx nonreactive 50%

• CSF – lymphocytes

• Glucose <40mg/dl

• Protein high: 400-5000mg/dl

• AFB +ve 30%

Page 44: Pyogenic meningitis in child

Thank you

Page 45: Pyogenic meningitis in child

Meningoencephalitis

Page 46: Pyogenic meningitis in child

• Encephalitis

• Encephalopathy

• Meningitis

• Myelitis

• Radiculitis

Page 47: Pyogenic meningitis in child

Meningoencephalitis

• Acute inflammation of meninges & brain tissue

• CSF – pleocytosis

• Gram stain & culture negative

• Mostly self limiting

Page 48: Pyogenic meningitis in child

Etiology

• Enterovirus

• Arbovirus

• Herpes virus

Page 49: Pyogenic meningitis in child
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Pathogenesis • Direct invasion & destruction by virus• Host reaction to viral antigens• Meningeal congestion• Mononuclear infiltration• Neuronal disruption• Neuronophagia• Demyelination

Page 53: Pyogenic meningitis in child

Structures affected

• HSV; temporal lobe

• Arbovirus; entire brain

• Rabies; basal parts

Page 54: Pyogenic meningitis in child

Clinical features• Depends on parenchymal involvement• Preceding mild febrile illness & exantheme• Acute onset of high fever, headache,

irritability,lethargy,nausea,myalgia• Convulsions,stupor,coma• Fluctuating FND,emotional outburst

• Ant.horn cell injuryflaccid paralysis [west nile,entero virus]

Page 55: Pyogenic meningitis in child

DD

• Meningitis of various organisms

Page 56: Pyogenic meningitis in child

Diagnosis • CSF: lymphocytic predominance

– Protein: normal,high in HSV– Glucose: normal,low in mumps– Culture of organism [entero V]– Viral antigen by PCR

– Culture from NPswab,feces,urine• EEG: focal seizures [temporal];HSV• CT/MRI: swollen brain parenchyma

Page 57: Pyogenic meningitis in child

EEG patterns include focal slowing, spiking, and paroxysmal lateralizing epileptiform discharges.13 Focal-temporal or

lateralized polymorphic delta activity is the earliest change. Diffuse slowing soon follows, with a persistence of temporal predominance. Pseudoperiodic complexes, present on serial

EEGs in two-thirds of biopsy-proven cases, appear over temporal regions

Page 58: Pyogenic meningitis in child

MRI brain (T2W image): right temporal lobe high signal in a patient with herpes encephalitis

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Page 60: Pyogenic meningitis in child

Treatment

• Acyclovir for HSV

• Non aspirin analgesic

• Nursing in a quiet room


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