•Ac PME is a dreadful infection, associated with high rates of chronic morbidity and
mortality.
Despite the modern antibiotic therapy, the mortality rate for bacterial M-E remains high.
- In neonates: the mortality is 40-50%, being highest with G- ve bacilli infection
- In children > 2 mo of age: it is 8-25%, being 8% for H.Influenza, 15%
formeningococcal and 25% for pneumococcal infections.As many as 35-40% of the
survivors, particularly of pneumococcal infection, have some sequelae. Severe
neurodevelopmental sequelae may occur in 10-20% of pats such as:
🔸
-Deafness, seizures, learning disabilities, blindness, paresis, ataxia, or hydrocephalus.
Poor prognosis: is associated with:
1-Young age, <6 months.
Prognosis
2-Long duration of illness before effective antibiotic therapy.
3-Infection with G-ve enteric bacilli, or pneumococci.
4-Late-onset seizures (after 4 days of therapy), persisted and refractory seizures.
5-Presentation with: coma, focal neurological signs, or shock GENERAL CONSIDERATIONS:
6-CSF with: high number of organisms, low glucose level, and low or absent WBC
count in thepresence of + ve G.stain.
🔸 Definition:
an acute inflammation of the brain and the meninges due to infection with pyogenic bacteria, resulting in a" PMN" reaction
7-Immunocompromised status. in the "CSF".
>It is one of the most potentially serious infections in infants and children.
>It is commonly associated with a high rate of acute complications and risk of chronic morbidity and may result in the death
of a child within hours of onset.
🔶 (II) Symptomatic / Supportive:
1- Nothing by mouth initially. 🔸
"Untreated it is usually fatal".
The incidence:
2-"IV" fluids, if the patient is normovolemic and has normal BP:
› Restriction to one-half to two thirds of maintenance, or 800-1000 ml/m²/24 hr, until it can be established that 🔸
is sufficiently high, generally it accounts for about 2-5% of pediatric admissions.
Bacterial ME:
-Occurs at all ages, but is common in the first 3 yrs of life (80% of cases), andcommonest in neonates and infants.
increased ICP or ISADH is not present, usually 2-3 days.
>Then, when the s.sodium levels are normal: normal daily requirement 1500 ml/m²/24 hr). -Affects males more than females (2.7:1).
>Fluids should contain daily requirements of electrolytes and 5-10% of glucose. -Occurs more frequently in the winter and spring months.
3-Control of active seizures:
Definitions:
>Diazepam "IV" 0.2-0.3 mg/kg/dose, immediately. Then
>Phenytoin, 15-20 mg/kg, loading dose, 5-6 mg/kg/24 hr maintenance.
4-Adequate oxygenation, suction of mouth secretions, antipyretic measures for highgrade fever, and treatment
►ESSENTIALS: management should be immediate, accurate, individualized and multimeasures.
1-Immediate antibiotic therapy and consider the principles.
2-Immediate, concomitant, treatment of ↑↑ICP or associated organ failure (shock, RDS, etc).
▪️ MENINGITIS:
RISK/PREDISPOSING FACTORS:
🔸mayBacterial "ME"
of other associated problems.
5-Corticosteroids:
Dexamethasone, in children older than 6 wk. It has several advantages. 0.3 mg/kg/starting dose, then 0.15 mg/kg/dose 6
3-Symptomatic and supportive treatment for active seizures, dehydration, high fever...etc.
4-Daily critical assessment for common and serious complications, which should be treated.
5- Preventive measures.
▪️
Is an inflammation of the membranes covering the brain and spinal cord.
MENINGO-ENCEPHALITIS:
Is an inflammation of the brain and the meninges covering the brain and
occur without warning in a perfectly normal infant or child, but there are a number of circumstances in which there is increased risk of the disease:
1- In neonates: Risk factors of sepsis such as prematurity, LBW, maternal infection (UTI), prolonged rupture of membranes, complicated labor, instrumental delivery....etc.
2-Lack of immunity to specific pathogens associated with young age (an absence of IgM and or Ig anticapsular antibodies) is a major risk factor.
hourly for 2 days. 3- Close contact (e.g. households, daycare centers, schools) with individuals having invasive disease (H.Infl uenza-B, or meningococcal infections).
6-Long-term follow up. spinal cord.
5-Good nursing care is essential.
🔶 🔶
🔸 (1) Antibiotic Therapy: ►It is a better nomenclature /"term".
4- Occult bactremia or septicemia with neurovirulent agents.
5- Systemic or parameningeal infection: non or inadequately treated.
🔸
(III) Repeated Medical and Neurological Assessments:
These are essential, to identify early signs of CNS, cardiovascular and metabolic complications.
A- Clinical:
A-Principles:
1-Immediate antibiotic therapy:
1.1-After performing an LP (if there is no contraindication).
🔻 Types:
1-PYOGENIC/BACTERIAL/SEPTIC/PURULENT...
6- Additional risks include:
6.1- Crowding, poverty, epidemics.
6.2- Lack of breast-feeding during the first 5 months of life.
1- Neurologic:- Level of consciousness -Evaluation of seizures -Pupillary reflexes -Cranial nerve signs - Head 1.2-Without performing LP if there is (are) contraindication(s) 7-Others:
circumference Motor strength 2- The initial (empirical) antibiotic choice is usually:
2-ASEPTIC: 7.1-Immunological deficiencies:
🔸
2- Systemic: Pulse rate, RR, BP, temperature, input and output....etc.
B-Paraclinical:
- Blood glucose, blood urea, S. sodium, potassium, chloride, and bicarbonate, - Blood count, platelets count and
>Based on age of the patient and the suspected agent.
>Influenced by by severity of the condition and antibiotic susceptibilities of the organisms.
1- Viral (common)
2- Tuberculous.
Acquired or congenital such as:
› Splenic dysfunction (SCA) or asplenia (due to trauma or congenital defect).
3- Stepwise choice and rational use of drugs. › Agamma or hypogammaglobulinemia,
coagulation factors if indicated. 3- Fungal.
🔶(IV) Treatment of Complications:
🔸1-increased ICP:
4-The selected antibiotics should penetrate well, or at least suffi ciently the BBB and achieve bactericidal levels in
the CSF. 4- Protozoal ...etc.
› Malignancies...etc.
7.2- Broken local barriers:
› Congenital: meningomyelocele and Cong. dermal sinus.
5-Start always in combination, not antagonistic with proper dosages and frequency.
- Furosemide, 1 mg/kg/dose, IV, 1-2 doses initially.
- Mannitol infusion, 0.5-1 g/kg, over 30 min, 6-8 hourly for 3 days. - Dexamethasone: "IV", 0.3 mg/kg/dose: start, then 0.15
mg/kg dose, 6 hourly for 2 days.
🔸
6-Use only "IV" route until the pat becomes afebrile for 3 days or for a duration of 10 days
🔸 B- Initial Antibiotic therapy: according to age and suspected agent:
1-Under 2 mo of age:
› Acquired: skull fracture
ROUTES OF INFECTION:
🔸
-Intensive care, endotracheal intubation and hyperventilation for some pats.
2- Seizures (repeated or persisted):
- Immediate, IV, Diazepam (0.2 mg/kg/dose) or Lorazepam (0.05 mg/kg/dose).
1.1-Ampicillin 200-300 mg/kg/24 hr "IV" in 4 DD + Gentamycine 6-7 mg/kg/24 hr "IV" 2-3DD.Or
1.2-Ampicillin + Cefotaxime ( 200 mg/kg/24 hr "IV" in 3-4 DD/Ceftazidime (150mg/kg/24hr in 3DD)
Or
🔸 1- Hematogenous:
The commonest.Bacteremia usually precedes meningitis or occurs concomitantly.
Then Phenytoin (15-20 mg/kg loading dose, 5-6 mg/kg/24 hr maintenance). 1.3-Vancomycin(30-45mg/kg/24hr in 2-3 DD) + Cefotaxime/Ceftazidime for serious conditions caused >The microorganisms are acquired by aerosol or droplets.
🔸
- Assess for precipitating factors: blood glucose, s.calcium, and sodium.
3-Hypoglycemia:
-10% dextrose, 2 ml/kg loading dose, then infusion of 5-10% dex (respect the Dr. A. Latifhydration state), and regular
bystaphylococci.
1.4-Duration:
-Gram-ve bacilli and L. Monocytogenes for 21 days.
🔸
This leads to nasopharyngeal colonization, replication, invasion and bacteremia.
2-Other routs (rare):
2.1-Bacterial invasion from a contiguous focus of infection such as: Otitis media, Para nasal sinusitis, orbital cellulitis, mastoiditis...etc.
Management
🔸
assessment of blood glucose.
4- Subdural effusion: 🔹
-GRS and other agents for 14-21 days.
remember:
2.2-Direct implantation: in patients with cong. dermal sinus, meningomyelocele, or penetrating cranial trauma.
🔸
If symptomatic, CT & MRI scanning, Subdural up and aspiration.
🔸 5. DIC: Blood transfusion or exchange transfusion (fresh) and heparin may be used
6- Septic shock:
1- combination of Ampicillin + Gentamycine is highly recomendded if gram-ve enterococci or L. Monocytogenes are
suspected because the synergetic action of two drugs
2-GBS usually rseponds dramatically to a combination containing penicilinG "IV"within 24-48 hr The etiology is determined by several factors:
🔹
general measures, fluid resuscitation, and vasoactive agents.
🔹 Prolonged or reappearance of fever: look for the cause and treat.
Indications to repeat LP:
3- cephalosporins should not be used as empirical monotherapy because L.Monocytogenes and enterococci are
🔸
resistant to these drugs
2-Two mo-12 yr:
→Age.
→Underlying condition.
1- Neonates with G - ve bacilli infection, after 48 hr. 2.1-If HIB is suspected start with: → Predisposing factors.
2- Poor or non response to treatment. Start with Ampicillin + Chloramphenicol, or Ampicillin + Cefotaxime/Ceftriaxone →Immunity state of the patient.
3- No obvious cause for prolonged or secondary fever. 2.2-If Pneumococcus or N.Meningitidis is suspected:
Start with C.Penicillin + Chloramphenicol, or + Cefotaxime, or + Ceftriaxone 🔸
→Epidemiology of the pathogens
A limited number of bacteria is associated with meningitis in normal hosts
🔶 (V) Prevention:
Vaccination and antibiotic prophylaxis of susceptible, at risk-contacts represent the two available means of reducing
>If there is very serious condition or insufficient or poor response, consider the use of:Vancomycin + Cefotaxime/
Ceftriaxone or Ceftazidime.
🔶 (1) During the first 2 Months of life:
The bacteria that cause "M-E" in normal neonates reflect the maternal fl ora or theenvironment of the infant
>>Duration:
🔸
the likelihood of bacterial ME.
1-H.Influenza-B:
>Chemoprophylaxis: Rifamp 20 mg/kg/dose OD, (max = 600 mg) for 4 days.
>Pneumococci for 14 days.
>H.Influenza-B for 10 days.
1- Gram-ve enteric bacilli (E.Coli)
🔸
2- Group-B streptococci (GBS)
(The commonest, account for 75% of cases- Neurovirulance =EColi+GBS)
→For the index case, before discharge.
→For all close household contacts.
🔥
>N. Meningitidis for 7-10 days
>>In successful therapy, the CSF is usually sterile within 36-48 hr of initiation of antibiotics.
3-Group-D streptococci (GDS).
4-Others:
>Other Gram-ve enteric bacilli
🔸
Vaccination: routine immunization for all infants at 2, 4, 6, and 15 mo of age
2- S.Pneumonia:
►Drugs dosages:
🔹 >Staphylococci aureus.
•No chemoprophylaxis or vaccination is required for normal hosts.
•Pat with SCA should receive chemoprophylaxis with oral daily penicillin or amoxicillin. 🔹
🔹
Ampicillin: 300-400 mg/kg/24 hr "IV" In 6 DD
Chloramphenicol: 100 mg/kg/24 hr, IV, in 4 DD
>Listeria Monocytogenes.
>H. Influenza (non typable)
🔸
• Vaccination with heptavalent conjugate vaccine if it is available.
🔹
🔹
Cefotaxime: 200mg/kg/24 hrs in 4 DD.
Vancomycin: 60 mg/kg/24 hr "IV" in 4 DD. 🔶 (II) Two Months - 12 Years: The disease is usually caused by 3 common bacteria:
3-N.Meningitidis:
Chemoproph:
🔹 C.penicilin : 400000U/kg/24hr"IV" in 6 DD 🔸 1-Pneumococci:
•For all close contacts of the pat, regardless of age or immunization status
•Rifamp 10 mg/kg/dose 12 hourly (max = 600 mg) for 2 days. 🔹Cefftriaxone: 100mg/kg/24hr in 2 DD
Ceftazidime: 150mg/kg/24 hr in3 DD
•Gram+ve and diplococci. Neuroinvasive serotypes.
•Common under 2 yrs of age and in older children. Peaks at: 6-12months of age.
• Vaccination: is recommended for high risk children > 2 yr of age. •Affect males > females.
🔶 (VI) Long Term Follow-Up:
>All patients with bacterial ME should undergo careful audiologic, visual and neurologic assessment before and after
ETIOLOGY •Occurs sporadic, Peak incidence at midwinter.
High risks: Children with anatomic or functional asplenia (SCA), nephrotic syndrome, pneumonia, otitis media, sinusitis, CSF otorrhea.. etc.
Note: In developed countries it become much less common after the widespread use ofheptavalent conjugate vaccine against S.
🔸
discharge from the hospital.
Follow-up after discharge:
- Every two wk for 3 months 🔸
pneumonia.
2-N. Meningitidis:
•Gram- and diplococci, neuroinvasive serotypes.
- Every month for 3 months,- Every 3 mo for 1 year.
ACUTE BACTERIAL •Five serotypes of this agent (A, B, C, Y, and W) are responsible for the disease.
•Common under 2 yrs and in older children. Peak: 6-12 mo. and in adolescence.
MENINGO- •Infection may be sporadic or may occur in epidemics.
•It occurs throughout the year but more common (peak) in the winter and spring.
All patients are at risk of complications, but the risk is higher among patients with:
ENCEPHALITIS 🔸
•High risk: contact with colonized or infected adults (family, daycare centers..).
3-H.Influenza-B (HIB):
-Young age. •Gram-ve coccobacilli, neurovirulance.
-Pneumococcal infection. •Common under 5 yrs, more common between 2 mo 2 yrs of age.
-Late diagnosis and treatment. •Peak incidence: at 6-9 months of age.
-Immunocompromised conditions. •High monthly incidence: between Nov.-Jan.
🔶 (1) Early or acute: •High risks: Incompletely vaccinated or non-vaccinated infants and young children, chronic Otitis media, orbital cellulitis, "HIV" infection,
CSF leaks....etc.
🔸A-Neurologic:
During the course and treatment of the disease acute complications (neurologic and systemic) are common, particularly the following: Note: It was the commonest cause, but it has become much less common since the introduction of universal immunization against HIB,
particularly in developed countries.
1-↑↑↑ ICP: The commonest and the most serious. It may results in herniation.
>Occurs early and may be seen at presentation. It is suggested by: Headache, vomiting, bulging fontanel or diastasis, seizures (refractory), coma, cranial nerve palsies,
🔶
🔸(III) Children over 12 yrs of age:
focal neurological signs, bradycardia, irregular respiration, hypertension, decorticate or decerebrate posture.
2-"ISADH":
🔸1-2- N.Pneumococci.
Meningitidis
Occurs in the majority of patients, (70-80%), usually within the first 72 hrs of therapy. ►Children with anatomic defects or immune deficits are at high risk of infection from uncommon bacteria such as: Staph. aureus,
> It is producing excessive water retention, resulting in Hyponatremia in 30-50% of cases. Pseudomonas, Salmonella, L. monocytogenes, GABHS and others
> It may exacerbate cerebral edema and hyponatremic seizures.
3-Seizures:
Focal or generalized, repeated seizures, which are refractory to therapy, appeared after initiation of proper treatment, or re-appeared after initial control are
considered complications.
-Common, occur in about 30% of patients, most frequently in neonates and infants, within the first 48-72 hrs of hospitalization ►Early diagnosis and early proper treatment are essential to reduce the risk of serious neurological complications and death.
- Due to cerebritis, infarctions, electrolyte disturbances and other complications.
4-Subdural effusion:
🔶 (I)Clinical manifestations:
a high degree of suspicion is necessary, particularly in neonates and infants where the features are mostly non-specific.
>Common. Occurs in about 20-30% of cases. It is asymptomatic in 85-90%.
> It is most common in infants with H.Influenza-B infection. 🔶
🔸 (II)Laboratory findings:
1- Lumber puncture (LP):
> It is indicated by: Fever (prolonged or reappearance), vomiting, seizures (persisted or reappeared), bulging fontanel, diastasis, enlarging head, and abnormal cranial
transillumination.
› The diagnosis is confirmed by CT or MRI scanning. 🔹
Immediate LP is a "must" in any suspected patient (under strict aseptic condition). The diagnosis is confirmed by analysis of the CSF.
🔹 Appearance: Turbid or cloudy or purulent.
5-Cranial nerve palsies:
- Due to focal inflammation and increased ICP. Common with pneumococcal infection. 🔹
🔹
Pressure: Elevated in the majority of cases.
Leukocytes: > 1000, range 100-20000/mm².: PMN predominance (>90%).
- Occular, oculomotor, abducents, facial, and auditory nerves.
6-Focal neurological signs: Complications 🔹
🔹
Protein:> 100, range: 100-500 mg/dl.
Glucose: Reduced(always), <40 mg/dl, Or 50% of blood glucose.
• Occur in 10-20% of patients, more frequent with pneumococcal infection (30%).
7-Ventriculitis: Characteristic frequent complication in neonates. 🔹 Gram stain: +ve in 70-90% of cases.
🔸Culture:+ve in > 60% of cases.
2- Rapid diagnostic method for etiology:
8-Hydrocephalus: It can occur as an acute complication in 10-15% of cases, commonly in neonates and in infants, and most often as a communicating form.
9-Others: Latex agglutination tests or counter current immunoelectrophorosis.Used to detect antigens of: H.Influenza, S.Pneumonia, N. meningitides
Thrombosis of dural venous sinuses.
-Transverse myelitis. 🔸
and GBS.
🔸 3- Blood for: Hb, WBC, Mps, ESR.
- Ataxia...etc.
🔸 B-Systemic:
🔸
🔸
4- Blood glucose: for comparison with CSF glucose and assessment of hypoglycemia.
5- Blood culture: for all patients, it is + ve in 70-90% of cases.
1-Hypoglycemia: common, early and may precipitate refractory seizures.
2-DIC, septic shock, and Water house fred. syndrome: common with N.Meningitidis
🔸
🔸
6- Culture for any focus of sepsis or purpuric lesions.
7-CSF C-reactive protein, if available, is a sensitive test for bacterial MΕ.
8-Other tests for assessment: Electrolytes, BUN,.....etc.
3-Anemia: it may be due to hemolysis or bone marrow suppression.
4-Aspiration pneumonia. 🔸 * Notes:
1-Contraindications of LP should be considered in each patient, such as:Increased ICP (signs of pending herniation: coma of an abrupt
🔸
►Other common problems:
fever: >10 days, is noted in about 10-15% of cases. It usually is due to:
>Intercurrent viral infection. Nosocomial or secondary bacterial infection.
onset or profound, abnormal postures, abnormalities of pupil size and reaction, FNS or CNP, abnormal respiration...etc). active seizures (until
they are controlled), shock, cardiopulmonary compromise...etc.>In cases of transient causes of contraindication, LP should be performed
after they arecontrolled.
🔸
>Drug reaction. Subdural effusion. Pericarditis. Arthritis....
Secondary fever (reappearance after control) mostly due to:
Nosocomial infection and or subdural effusion.
2-Some of the CSF findings may not be typical (in neonates, in early stage and in partially treated>CSF leukocyte count <250/mm³ may
be seen in as many as 20% of patients.>Lymphocytes predominate in newborns, in L. monocytogenes infection (Characteristic), and in some
partially treated pyogenic ME.
🔶 (II) Late or long term sequelae: Occur in about 35-40% of patients.
1- Hearing loss (sensoneural): The commonest, more frequent with pneumococcal infection (30%).
3- Traumatic LP: may occur in > 10% of pats.Should be analyzed for glucose, neutrophils, Gram stain, and culture.If it is not possible or the
results are not conclusive, should be repeated after 18-24 hr
4- If LP is delayed by any factor, appropriate empiric treatment should be started.
2- Hydrocephalus: common in young infants.
3- Cerebral palsy and mental retardation: more in neonates and infants.
4- Epilepsy. Differential Diagnosis:
5- Behavioral problems
6- Visual impairment, speech impairment, hemiparesis, motor deficits, ataxia.
Diagnosis 1- Partially treated P.ME:
many patients (25-40%) are receiving antibiotics (inadequate doses)before their diagnosis. Some features may be masked.
7- Diabetes Insipidus (as a result of hypothalamic or pituitary dysfunction)...etc.
→Some changes in CSF cells and biochemistry results.
→CSF + ve G. stain and culture are reduced.
2- Viral ME:
>Associated specific features of viral infection.
> Occur more frequently in winter, epidemics.
The onset may be: >CSF profile is commonly differentiating.
- Sudden, more dramatic, fortunately less common, is seen most often with meningococcal and pneumococcal 3- TB ME:
infections. Insidious onset, prolonged course which occur in stages.
🔸
-Acute non-dramatic (common) is preceded in 2-3 days by URI or GIT symptoms, common with H.Influenza-B infection.
Clinical manifestations are varied with age and other factors. →Absence of vaccination, and history of contact with active cases.
🔶 (I) Neonates:
usually non-specific features and history of risk factors is helpful.
→ Skin test, chest x-ray and CSF findings are of great help
4. Cerebral malaria:
-Specific features of malaria, endemic area or epidemic crises.
1-Fever is usually common, but severe cases and preterms may not have fever. - Positive Mps test and -ve CSF findings.
2-Refuse to suck or poor feeding. 5 .Febrile convulsion:
3-Vomiting: frequent and persisted. -Criteria for diagnosis and - ve CSF findings.
4-Irritability alternates to lethargy. 6- Others: brain abscess, parameningeal abscess, tetanus, poliomyelitis...etc.
5-Seizures: focal/generalized/subtle, are common early feature. • CSF findings in CNS infections:ConditionPressure (mm H₂O)
6-High pitched or poor cry.
7-Vacant star.
8-Bulging fontanel in 40% of cases (initially full or tense and later is bulging).
9-Neonatal reflexes are absent or abnormal.
10-Irregular respiration.
11-Signs of sepsis may be seen
🔶 (II) Infants:
Mostly non-specific features and signs of meningeal irritation are minimal.
1-Fever is common (80-90%).
2- Poor or refused feeding. CLINICAL MANIFESTATIONS:
3-Vomiting: is frequent and persisted.
4-Alteration of consciousness: (early and suggestive): Irritability, lethargy, drowsiness, stupor or coma.
5- Seizures: focal/generalized: common early features, and may be the first sign.
by fatema okoff
6- High pitched shrill cry.
7- Bulging fontanel: in 40-50% of cases, usually is a late feature.
8- Neck stiffness: in about 20%. It is a late feature.
9- Focal neurological signs and or cranial nerve palsies: in about 20% of cases.
10- Abnormal posture: decerebration/ decortication (a late feature).
🔶 (III) Children: Features are almost typical
1- Fever is common and high grade (90-95%).
2- Headache: intense / bursting, frontal / retro bulbar.
3- Vomiting: spontaneous, projectile and persistent.
4- Photophobia: marked, the child resents light.
5- Neck or back pain.
6- Alteration of consciousness: irritability, lethargic, drowsiness, stupor or coma.
7- Seizures in about 20%.
8- The patient resents being disturbed.
9- Lies in fl exion posture and may develop decerebration or decortication.
10- Classical signs of meningeal irritation: Neck rigidity, Kernig sign, and Brudzinski signare + ve.
11- Focal neurological signs, cranial nerve palsies (3rd and 6th CN palsy is common) in 20-30%.
12-Petechiae/purpura/erythema: common in meningococcal infection.
mortality.
Despite the modern antibiotic therapy, the mortality rate for bacterial M-E remains high.
- In neonates: the mortality is 40-50%, being highest with G- ve bacilli infection
- In children > 2 mo of age: it is 8-25%, being 8% for H.Influenza, 15%
formeningococcal and 25% for pneumococcal infections.As many as 35-40% of the
survivors, particularly of pneumococcal infection, have some sequelae. Severe
neurodevelopmental sequelae may occur in 10-20% of pats such as:
🔸
-Deafness, seizures, learning disabilities, blindness, paresis, ataxia, or hydrocephalus.
Poor prognosis: is associated with:
1-Young age, <6 months.
Prognosis
2-Long duration of illness before effective antibiotic therapy.
3-Infection with G-ve enteric bacilli, or pneumococci.
4-Late-onset seizures (after 4 days of therapy), persisted and refractory seizures.
5-Presentation with: coma, focal neurological signs, or shock GENERAL CONSIDERATIONS:
6-CSF with: high number of organisms, low glucose level, and low or absent WBC
count in thepresence of + ve G.stain.
🔸 Definition:
an acute inflammation of the brain and the meninges due to infection with pyogenic bacteria, resulting in a" PMN" reaction
7-Immunocompromised status. in the "CSF".
>It is one of the most potentially serious infections in infants and children.
>It is commonly associated with a high rate of acute complications and risk of chronic morbidity and may result in the death
of a child within hours of onset.
🔶 (II) Symptomatic / Supportive:
1- Nothing by mouth initially. 🔸
"Untreated it is usually fatal".
The incidence:
2-"IV" fluids, if the patient is normovolemic and has normal BP:
› Restriction to one-half to two thirds of maintenance, or 800-1000 ml/m²/24 hr, until it can be established that 🔸
is sufficiently high, generally it accounts for about 2-5% of pediatric admissions.
Bacterial ME:
-Occurs at all ages, but is common in the first 3 yrs of life (80% of cases), andcommonest in neonates and infants.
increased ICP or ISADH is not present, usually 2-3 days.
>Then, when the s.sodium levels are normal: normal daily requirement 1500 ml/m²/24 hr). -Affects males more than females (2.7:1).
>Fluids should contain daily requirements of electrolytes and 5-10% of glucose. -Occurs more frequently in the winter and spring months.
3-Control of active seizures:
Definitions:
>Diazepam "IV" 0.2-0.3 mg/kg/dose, immediately. Then
>Phenytoin, 15-20 mg/kg, loading dose, 5-6 mg/kg/24 hr maintenance.
4-Adequate oxygenation, suction of mouth secretions, antipyretic measures for highgrade fever, and treatment
►ESSENTIALS: management should be immediate, accurate, individualized and multimeasures.
1-Immediate antibiotic therapy and consider the principles.
2-Immediate, concomitant, treatment of ↑↑ICP or associated organ failure (shock, RDS, etc).
▪️ MENINGITIS:
RISK/PREDISPOSING FACTORS:
🔸mayBacterial "ME"
of other associated problems.
5-Corticosteroids:
Dexamethasone, in children older than 6 wk. It has several advantages. 0.3 mg/kg/starting dose, then 0.15 mg/kg/dose 6
3-Symptomatic and supportive treatment for active seizures, dehydration, high fever...etc.
4-Daily critical assessment for common and serious complications, which should be treated.
5- Preventive measures.
▪️
Is an inflammation of the membranes covering the brain and spinal cord.
MENINGO-ENCEPHALITIS:
Is an inflammation of the brain and the meninges covering the brain and
occur without warning in a perfectly normal infant or child, but there are a number of circumstances in which there is increased risk of the disease:
1- In neonates: Risk factors of sepsis such as prematurity, LBW, maternal infection (UTI), prolonged rupture of membranes, complicated labor, instrumental delivery....etc.
2-Lack of immunity to specific pathogens associated with young age (an absence of IgM and or Ig anticapsular antibodies) is a major risk factor.
hourly for 2 days. 3- Close contact (e.g. households, daycare centers, schools) with individuals having invasive disease (H.Infl uenza-B, or meningococcal infections).
6-Long-term follow up. spinal cord.
5-Good nursing care is essential.
🔶 🔶
🔸 (1) Antibiotic Therapy: ►It is a better nomenclature /"term".
4- Occult bactremia or septicemia with neurovirulent agents.
5- Systemic or parameningeal infection: non or inadequately treated.
🔸
(III) Repeated Medical and Neurological Assessments:
These are essential, to identify early signs of CNS, cardiovascular and metabolic complications.
A- Clinical:
A-Principles:
1-Immediate antibiotic therapy:
1.1-After performing an LP (if there is no contraindication).
🔻 Types:
1-PYOGENIC/BACTERIAL/SEPTIC/PURULENT...
6- Additional risks include:
6.1- Crowding, poverty, epidemics.
6.2- Lack of breast-feeding during the first 5 months of life.
1- Neurologic:- Level of consciousness -Evaluation of seizures -Pupillary reflexes -Cranial nerve signs - Head 1.2-Without performing LP if there is (are) contraindication(s) 7-Others:
circumference Motor strength 2- The initial (empirical) antibiotic choice is usually:
2-ASEPTIC: 7.1-Immunological deficiencies:
🔸
2- Systemic: Pulse rate, RR, BP, temperature, input and output....etc.
B-Paraclinical:
- Blood glucose, blood urea, S. sodium, potassium, chloride, and bicarbonate, - Blood count, platelets count and
>Based on age of the patient and the suspected agent.
>Influenced by by severity of the condition and antibiotic susceptibilities of the organisms.
1- Viral (common)
2- Tuberculous.
Acquired or congenital such as:
› Splenic dysfunction (SCA) or asplenia (due to trauma or congenital defect).
3- Stepwise choice and rational use of drugs. › Agamma or hypogammaglobulinemia,
coagulation factors if indicated. 3- Fungal.
🔶(IV) Treatment of Complications:
🔸1-increased ICP:
4-The selected antibiotics should penetrate well, or at least suffi ciently the BBB and achieve bactericidal levels in
the CSF. 4- Protozoal ...etc.
› Malignancies...etc.
7.2- Broken local barriers:
› Congenital: meningomyelocele and Cong. dermal sinus.
5-Start always in combination, not antagonistic with proper dosages and frequency.
- Furosemide, 1 mg/kg/dose, IV, 1-2 doses initially.
- Mannitol infusion, 0.5-1 g/kg, over 30 min, 6-8 hourly for 3 days. - Dexamethasone: "IV", 0.3 mg/kg/dose: start, then 0.15
mg/kg dose, 6 hourly for 2 days.
🔸
6-Use only "IV" route until the pat becomes afebrile for 3 days or for a duration of 10 days
🔸 B- Initial Antibiotic therapy: according to age and suspected agent:
1-Under 2 mo of age:
› Acquired: skull fracture
ROUTES OF INFECTION:
🔸
-Intensive care, endotracheal intubation and hyperventilation for some pats.
2- Seizures (repeated or persisted):
- Immediate, IV, Diazepam (0.2 mg/kg/dose) or Lorazepam (0.05 mg/kg/dose).
1.1-Ampicillin 200-300 mg/kg/24 hr "IV" in 4 DD + Gentamycine 6-7 mg/kg/24 hr "IV" 2-3DD.Or
1.2-Ampicillin + Cefotaxime ( 200 mg/kg/24 hr "IV" in 3-4 DD/Ceftazidime (150mg/kg/24hr in 3DD)
Or
🔸 1- Hematogenous:
The commonest.Bacteremia usually precedes meningitis or occurs concomitantly.
Then Phenytoin (15-20 mg/kg loading dose, 5-6 mg/kg/24 hr maintenance). 1.3-Vancomycin(30-45mg/kg/24hr in 2-3 DD) + Cefotaxime/Ceftazidime for serious conditions caused >The microorganisms are acquired by aerosol or droplets.
🔸
- Assess for precipitating factors: blood glucose, s.calcium, and sodium.
3-Hypoglycemia:
-10% dextrose, 2 ml/kg loading dose, then infusion of 5-10% dex (respect the Dr. A. Latifhydration state), and regular
bystaphylococci.
1.4-Duration:
-Gram-ve bacilli and L. Monocytogenes for 21 days.
🔸
This leads to nasopharyngeal colonization, replication, invasion and bacteremia.
2-Other routs (rare):
2.1-Bacterial invasion from a contiguous focus of infection such as: Otitis media, Para nasal sinusitis, orbital cellulitis, mastoiditis...etc.
Management
🔸
assessment of blood glucose.
4- Subdural effusion: 🔹
-GRS and other agents for 14-21 days.
remember:
2.2-Direct implantation: in patients with cong. dermal sinus, meningomyelocele, or penetrating cranial trauma.
🔸
If symptomatic, CT & MRI scanning, Subdural up and aspiration.
🔸 5. DIC: Blood transfusion or exchange transfusion (fresh) and heparin may be used
6- Septic shock:
1- combination of Ampicillin + Gentamycine is highly recomendded if gram-ve enterococci or L. Monocytogenes are
suspected because the synergetic action of two drugs
2-GBS usually rseponds dramatically to a combination containing penicilinG "IV"within 24-48 hr The etiology is determined by several factors:
🔹
general measures, fluid resuscitation, and vasoactive agents.
🔹 Prolonged or reappearance of fever: look for the cause and treat.
Indications to repeat LP:
3- cephalosporins should not be used as empirical monotherapy because L.Monocytogenes and enterococci are
🔸
resistant to these drugs
2-Two mo-12 yr:
→Age.
→Underlying condition.
1- Neonates with G - ve bacilli infection, after 48 hr. 2.1-If HIB is suspected start with: → Predisposing factors.
2- Poor or non response to treatment. Start with Ampicillin + Chloramphenicol, or Ampicillin + Cefotaxime/Ceftriaxone →Immunity state of the patient.
3- No obvious cause for prolonged or secondary fever. 2.2-If Pneumococcus or N.Meningitidis is suspected:
Start with C.Penicillin + Chloramphenicol, or + Cefotaxime, or + Ceftriaxone 🔸
→Epidemiology of the pathogens
A limited number of bacteria is associated with meningitis in normal hosts
🔶 (V) Prevention:
Vaccination and antibiotic prophylaxis of susceptible, at risk-contacts represent the two available means of reducing
>If there is very serious condition or insufficient or poor response, consider the use of:Vancomycin + Cefotaxime/
Ceftriaxone or Ceftazidime.
🔶 (1) During the first 2 Months of life:
The bacteria that cause "M-E" in normal neonates reflect the maternal fl ora or theenvironment of the infant
>>Duration:
🔸
the likelihood of bacterial ME.
1-H.Influenza-B:
>Chemoprophylaxis: Rifamp 20 mg/kg/dose OD, (max = 600 mg) for 4 days.
>Pneumococci for 14 days.
>H.Influenza-B for 10 days.
1- Gram-ve enteric bacilli (E.Coli)
🔸
2- Group-B streptococci (GBS)
(The commonest, account for 75% of cases- Neurovirulance =EColi+GBS)
→For the index case, before discharge.
→For all close household contacts.
🔥
>N. Meningitidis for 7-10 days
>>In successful therapy, the CSF is usually sterile within 36-48 hr of initiation of antibiotics.
3-Group-D streptococci (GDS).
4-Others:
>Other Gram-ve enteric bacilli
🔸
Vaccination: routine immunization for all infants at 2, 4, 6, and 15 mo of age
2- S.Pneumonia:
►Drugs dosages:
🔹 >Staphylococci aureus.
•No chemoprophylaxis or vaccination is required for normal hosts.
•Pat with SCA should receive chemoprophylaxis with oral daily penicillin or amoxicillin. 🔹
🔹
Ampicillin: 300-400 mg/kg/24 hr "IV" In 6 DD
Chloramphenicol: 100 mg/kg/24 hr, IV, in 4 DD
>Listeria Monocytogenes.
>H. Influenza (non typable)
🔸
• Vaccination with heptavalent conjugate vaccine if it is available.
🔹
🔹
Cefotaxime: 200mg/kg/24 hrs in 4 DD.
Vancomycin: 60 mg/kg/24 hr "IV" in 4 DD. 🔶 (II) Two Months - 12 Years: The disease is usually caused by 3 common bacteria:
3-N.Meningitidis:
Chemoproph:
🔹 C.penicilin : 400000U/kg/24hr"IV" in 6 DD 🔸 1-Pneumococci:
•For all close contacts of the pat, regardless of age or immunization status
•Rifamp 10 mg/kg/dose 12 hourly (max = 600 mg) for 2 days. 🔹Cefftriaxone: 100mg/kg/24hr in 2 DD
Ceftazidime: 150mg/kg/24 hr in3 DD
•Gram+ve and diplococci. Neuroinvasive serotypes.
•Common under 2 yrs of age and in older children. Peaks at: 6-12months of age.
• Vaccination: is recommended for high risk children > 2 yr of age. •Affect males > females.
🔶 (VI) Long Term Follow-Up:
>All patients with bacterial ME should undergo careful audiologic, visual and neurologic assessment before and after
ETIOLOGY •Occurs sporadic, Peak incidence at midwinter.
High risks: Children with anatomic or functional asplenia (SCA), nephrotic syndrome, pneumonia, otitis media, sinusitis, CSF otorrhea.. etc.
Note: In developed countries it become much less common after the widespread use ofheptavalent conjugate vaccine against S.
🔸
discharge from the hospital.
Follow-up after discharge:
- Every two wk for 3 months 🔸
pneumonia.
2-N. Meningitidis:
•Gram- and diplococci, neuroinvasive serotypes.
- Every month for 3 months,- Every 3 mo for 1 year.
ACUTE BACTERIAL •Five serotypes of this agent (A, B, C, Y, and W) are responsible for the disease.
•Common under 2 yrs and in older children. Peak: 6-12 mo. and in adolescence.
MENINGO- •Infection may be sporadic or may occur in epidemics.
•It occurs throughout the year but more common (peak) in the winter and spring.
All patients are at risk of complications, but the risk is higher among patients with:
ENCEPHALITIS 🔸
•High risk: contact with colonized or infected adults (family, daycare centers..).
3-H.Influenza-B (HIB):
-Young age. •Gram-ve coccobacilli, neurovirulance.
-Pneumococcal infection. •Common under 5 yrs, more common between 2 mo 2 yrs of age.
-Late diagnosis and treatment. •Peak incidence: at 6-9 months of age.
-Immunocompromised conditions. •High monthly incidence: between Nov.-Jan.
🔶 (1) Early or acute: •High risks: Incompletely vaccinated or non-vaccinated infants and young children, chronic Otitis media, orbital cellulitis, "HIV" infection,
CSF leaks....etc.
🔸A-Neurologic:
During the course and treatment of the disease acute complications (neurologic and systemic) are common, particularly the following: Note: It was the commonest cause, but it has become much less common since the introduction of universal immunization against HIB,
particularly in developed countries.
1-↑↑↑ ICP: The commonest and the most serious. It may results in herniation.
>Occurs early and may be seen at presentation. It is suggested by: Headache, vomiting, bulging fontanel or diastasis, seizures (refractory), coma, cranial nerve palsies,
🔶
🔸(III) Children over 12 yrs of age:
focal neurological signs, bradycardia, irregular respiration, hypertension, decorticate or decerebrate posture.
2-"ISADH":
🔸1-2- N.Pneumococci.
Meningitidis
Occurs in the majority of patients, (70-80%), usually within the first 72 hrs of therapy. ►Children with anatomic defects or immune deficits are at high risk of infection from uncommon bacteria such as: Staph. aureus,
> It is producing excessive water retention, resulting in Hyponatremia in 30-50% of cases. Pseudomonas, Salmonella, L. monocytogenes, GABHS and others
> It may exacerbate cerebral edema and hyponatremic seizures.
3-Seizures:
Focal or generalized, repeated seizures, which are refractory to therapy, appeared after initiation of proper treatment, or re-appeared after initial control are
considered complications.
-Common, occur in about 30% of patients, most frequently in neonates and infants, within the first 48-72 hrs of hospitalization ►Early diagnosis and early proper treatment are essential to reduce the risk of serious neurological complications and death.
- Due to cerebritis, infarctions, electrolyte disturbances and other complications.
4-Subdural effusion:
🔶 (I)Clinical manifestations:
a high degree of suspicion is necessary, particularly in neonates and infants where the features are mostly non-specific.
>Common. Occurs in about 20-30% of cases. It is asymptomatic in 85-90%.
> It is most common in infants with H.Influenza-B infection. 🔶
🔸 (II)Laboratory findings:
1- Lumber puncture (LP):
> It is indicated by: Fever (prolonged or reappearance), vomiting, seizures (persisted or reappeared), bulging fontanel, diastasis, enlarging head, and abnormal cranial
transillumination.
› The diagnosis is confirmed by CT or MRI scanning. 🔹
Immediate LP is a "must" in any suspected patient (under strict aseptic condition). The diagnosis is confirmed by analysis of the CSF.
🔹 Appearance: Turbid or cloudy or purulent.
5-Cranial nerve palsies:
- Due to focal inflammation and increased ICP. Common with pneumococcal infection. 🔹
🔹
Pressure: Elevated in the majority of cases.
Leukocytes: > 1000, range 100-20000/mm².: PMN predominance (>90%).
- Occular, oculomotor, abducents, facial, and auditory nerves.
6-Focal neurological signs: Complications 🔹
🔹
Protein:> 100, range: 100-500 mg/dl.
Glucose: Reduced(always), <40 mg/dl, Or 50% of blood glucose.
• Occur in 10-20% of patients, more frequent with pneumococcal infection (30%).
7-Ventriculitis: Characteristic frequent complication in neonates. 🔹 Gram stain: +ve in 70-90% of cases.
🔸Culture:+ve in > 60% of cases.
2- Rapid diagnostic method for etiology:
8-Hydrocephalus: It can occur as an acute complication in 10-15% of cases, commonly in neonates and in infants, and most often as a communicating form.
9-Others: Latex agglutination tests or counter current immunoelectrophorosis.Used to detect antigens of: H.Influenza, S.Pneumonia, N. meningitides
Thrombosis of dural venous sinuses.
-Transverse myelitis. 🔸
and GBS.
🔸 3- Blood for: Hb, WBC, Mps, ESR.
- Ataxia...etc.
🔸 B-Systemic:
🔸
🔸
4- Blood glucose: for comparison with CSF glucose and assessment of hypoglycemia.
5- Blood culture: for all patients, it is + ve in 70-90% of cases.
1-Hypoglycemia: common, early and may precipitate refractory seizures.
2-DIC, septic shock, and Water house fred. syndrome: common with N.Meningitidis
🔸
🔸
6- Culture for any focus of sepsis or purpuric lesions.
7-CSF C-reactive protein, if available, is a sensitive test for bacterial MΕ.
8-Other tests for assessment: Electrolytes, BUN,.....etc.
3-Anemia: it may be due to hemolysis or bone marrow suppression.
4-Aspiration pneumonia. 🔸 * Notes:
1-Contraindications of LP should be considered in each patient, such as:Increased ICP (signs of pending herniation: coma of an abrupt
🔸
►Other common problems:
fever: >10 days, is noted in about 10-15% of cases. It usually is due to:
>Intercurrent viral infection. Nosocomial or secondary bacterial infection.
onset or profound, abnormal postures, abnormalities of pupil size and reaction, FNS or CNP, abnormal respiration...etc). active seizures (until
they are controlled), shock, cardiopulmonary compromise...etc.>In cases of transient causes of contraindication, LP should be performed
after they arecontrolled.
🔸
>Drug reaction. Subdural effusion. Pericarditis. Arthritis....
Secondary fever (reappearance after control) mostly due to:
Nosocomial infection and or subdural effusion.
2-Some of the CSF findings may not be typical (in neonates, in early stage and in partially treated>CSF leukocyte count <250/mm³ may
be seen in as many as 20% of patients.>Lymphocytes predominate in newborns, in L. monocytogenes infection (Characteristic), and in some
partially treated pyogenic ME.
🔶 (II) Late or long term sequelae: Occur in about 35-40% of patients.
1- Hearing loss (sensoneural): The commonest, more frequent with pneumococcal infection (30%).
3- Traumatic LP: may occur in > 10% of pats.Should be analyzed for glucose, neutrophils, Gram stain, and culture.If it is not possible or the
results are not conclusive, should be repeated after 18-24 hr
4- If LP is delayed by any factor, appropriate empiric treatment should be started.
2- Hydrocephalus: common in young infants.
3- Cerebral palsy and mental retardation: more in neonates and infants.
4- Epilepsy. Differential Diagnosis:
5- Behavioral problems
6- Visual impairment, speech impairment, hemiparesis, motor deficits, ataxia.
Diagnosis 1- Partially treated P.ME:
many patients (25-40%) are receiving antibiotics (inadequate doses)before their diagnosis. Some features may be masked.
7- Diabetes Insipidus (as a result of hypothalamic or pituitary dysfunction)...etc.
→Some changes in CSF cells and biochemistry results.
→CSF + ve G. stain and culture are reduced.
2- Viral ME:
>Associated specific features of viral infection.
> Occur more frequently in winter, epidemics.
The onset may be: >CSF profile is commonly differentiating.
- Sudden, more dramatic, fortunately less common, is seen most often with meningococcal and pneumococcal 3- TB ME:
infections. Insidious onset, prolonged course which occur in stages.
🔸
-Acute non-dramatic (common) is preceded in 2-3 days by URI or GIT symptoms, common with H.Influenza-B infection.
Clinical manifestations are varied with age and other factors. →Absence of vaccination, and history of contact with active cases.
🔶 (I) Neonates:
usually non-specific features and history of risk factors is helpful.
→ Skin test, chest x-ray and CSF findings are of great help
4. Cerebral malaria:
-Specific features of malaria, endemic area or epidemic crises.
1-Fever is usually common, but severe cases and preterms may not have fever. - Positive Mps test and -ve CSF findings.
2-Refuse to suck or poor feeding. 5 .Febrile convulsion:
3-Vomiting: frequent and persisted. -Criteria for diagnosis and - ve CSF findings.
4-Irritability alternates to lethargy. 6- Others: brain abscess, parameningeal abscess, tetanus, poliomyelitis...etc.
5-Seizures: focal/generalized/subtle, are common early feature. • CSF findings in CNS infections:ConditionPressure (mm H₂O)
6-High pitched or poor cry.
7-Vacant star.
8-Bulging fontanel in 40% of cases (initially full or tense and later is bulging).
9-Neonatal reflexes are absent or abnormal.
10-Irregular respiration.
11-Signs of sepsis may be seen
🔶 (II) Infants:
Mostly non-specific features and signs of meningeal irritation are minimal.
1-Fever is common (80-90%).
2- Poor or refused feeding. CLINICAL MANIFESTATIONS:
3-Vomiting: is frequent and persisted.
4-Alteration of consciousness: (early and suggestive): Irritability, lethargy, drowsiness, stupor or coma.
5- Seizures: focal/generalized: common early features, and may be the first sign.
by fatema okoff
6- High pitched shrill cry.
7- Bulging fontanel: in 40-50% of cases, usually is a late feature.
8- Neck stiffness: in about 20%. It is a late feature.
9- Focal neurological signs and or cranial nerve palsies: in about 20% of cases.
10- Abnormal posture: decerebration/ decortication (a late feature).
🔶 (III) Children: Features are almost typical
1- Fever is common and high grade (90-95%).
2- Headache: intense / bursting, frontal / retro bulbar.
3- Vomiting: spontaneous, projectile and persistent.
4- Photophobia: marked, the child resents light.
5- Neck or back pain.
6- Alteration of consciousness: irritability, lethargic, drowsiness, stupor or coma.
7- Seizures in about 20%.
8- The patient resents being disturbed.
9- Lies in fl exion posture and may develop decerebration or decortication.
10- Classical signs of meningeal irritation: Neck rigidity, Kernig sign, and Brudzinski signare + ve.
11- Focal neurological signs, cranial nerve palsies (3rd and 6th CN palsy is common) in 20-30%.
12-Petechiae/purpura/erythema: common in meningococcal infection.
