MENINGITIS IN CHILDREN

2008
Sileshi Mulatu
(BSC N, MSC N)

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 OUTLINE OF PRESENTATION
• Anatomy and physiology
• Introduction
• Epidemiology
• Pathophysiology
• Types
• MOT
• Etiology
• CF
• Dx
• Rx
• DDX

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 Anatomy and Physiology
• To understand bacterial meningitis, we should
first understand the relatedanatomy and
physiology of a healthy individual.

• Meningitis, in general, is theinflammation of the

protective membranes surrounding the brain and
spinal cord.
• In order to inflame these protective membranes,
the bacteria mustsomehow enter the
bloodstream and bypass the blood-brain barrier.
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 Blood-Brain Barrier/BBB

• The BBB mainly consists of tight junctions, which seals

the endothelial cells that line the brain capillaries.
• Astrocytes,a type of neuroglia from the brain, closely

attached to the endothelial cells and release chemicals

to regulate the permeability of the tight junctions.
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 PHYSIOLOGY
• The intracranial compartment is protected by the
skull, a rigid structure with a fixed internal volume.
 Brain parenchyma — 80 %
 CSF — 10 %
 Blood — 10 %
• Because the overall volume of the cranial vault
cannot change, an increase in the volume of one
component, or the presence of pathologic
components, necessitates the displacement of other
structures, an increase in ICP, or both

Ward JD

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 Bacterial Virulence Factors

• Bacteria express or secrete virulence factors in

order to achieve:
Host colonization
Cell entry and exit
Immunosuppression, and
Nutrition acquisition.
• Virulence factors are a pathogen's tools of
invasion and a cause of disease.

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 1. Fimbriae

Fimbriae, also known as pili, are bacterial

organelles that mediate adhesion of bacteria to
host cell.
Although fimbriaeoften play a role in initial
adherence within the nasopharynx, their
presence is not necessary for the organism to cause
meningitis.
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 2. Polysaccharide Capsule

• The polysaccharide capsule acts as a virulence

factor because it prevents phagocytosis.

• Because the capsule surface is slippery, the

bacterium slips away from the phagocyte during
phagocytosis.

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 3. IgA1 Proteases
• IgA, a natural antibody type found in mucosal
secretion, inhibits the adherence of
microorganisms to mucosal surfaces.

• Bacterial pathogens (e.g. Neisseria,

Haemophilus, and Streptococcus species)
produce IgA1 proteases which cleave IgA and
facilitate bacterial adherence to mucosal
surfaces .

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 4. Bacteriocins

• Bacteriocinsare toxins produced by bacteria

that inhibit the growth of other bacterial
strains .
• The pathogen expresses bacteriocinsto clear
the area of any competitors for nutrients and
space needed for colonization.

• Hemocinis a bacteriocinproduced byH. influenzae .

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 Introduction

• Infection of the central nervous system is the most

common cause of fever associated with signs and
symptoms of CNS disease in children.

• Bacteria meningitis is one of the most potentially

serious infections occurring in infants and older
children.

• This infection is associated with a high rate of acute

complications and risk of long term morbidity.
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 Introduction…

• Annual incidence in the developed countries is

approximately 5-10 per 100,000.

• 30000 infants and children develop bacterial

meningitis in United States each year.

• Approximately 90 per cent of cases occur in

children during the first 5 years of life.
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 Introd…
• Despite the effectiveness of current antibiotics
in clearing bacteria from the cerebrospinal
fluid (CSF), bacterial meningitis continues to
cause significant morbidity and mortality
worldwide.

Up to date

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Intro….

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 Epidemiology
• After the introduction of the Hib and pneumococcal
conjugate vaccines to the infant immunization
schedule, the incidence of bacterial meningitis
declined in all age groups except children younger
than two months.
• The peak incidence continues to occur in children
younger than two months.

Thigpen MC, Whitney CG, MessonnierNE, et al 2011

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 Epidemiology …
• The highest incidence is among neonates, who are
usually infected by bacteria found in the birth canal
at the time of parturition.
– 90% of cases occur before 5 yr.
– Mortality 20-40% in neonates
– Mortaility5-10% in infants and children.

? Group B streptococci account for the majority of

cases (50%), followed by E. coli (25%)

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Epi…

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 Pathogenesis
• Susceptibility of bacterial infection on CNS in
the children
– Immaturity of immune systems
• Nonspecific immune
– Insufficient barrier(Blood-brain barrier)
– Insufficient complement activity
– Insufficient chemotaxis of neutrophils
– Insufficient function of monocyte-macrophage system
– Blood levels of diminished interferon (INF)
-γand interleukin -8 ( IL-8 )
 Pathogenesis…

• Susceptibility of bacterial infection on CNS in the

children
– Specific immune
• Immaturity of both the cellular and humoralimmune
systems
– Insufficient antibody-mediated protection
– Diminished immunologic response
– Bacterial virulence
 Pathogenesis
Offending bacterium from blood invades the meninges.
• Bacterial toxins and Inflammatory mediators are
released.
– Bacterial toxics
• Lipopolysaccharide, LPS
• Teichoicacid
• Peptidoglycan
 Overview of How Meningitis Occurs

• Pathophysiology
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 Risk factors of meningitis
• Extremes of age (< 5 or >60 years)
• Immunosuppression, which increases the risk of
opportunistic infections and acute bacterial meningitis

• HIV infection, which predisposes to bacterial meningitis

caused by encapsulated organisms,

• Crowding (such as that experienced by military recruits

and college dorm residents), which increases the risk of
outbreaks of meningococcal meningitis

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 Risk factors
• Recent exposure to others with meningitis,
with or without prophylaxis
• Contiguous infection (eg, sinusitis)
• Dural defect (eg, traumatic, surgical, or
congenital)
• Bacterial endocarditis

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 Types of meningitis

1.Bacterial meningitis bacterial infection.

2.Viral meningitis: caused by viruses

(enterovirus)
3.Tuberculosis meningitis: Tuberculosis
infection due to M. tuberculosis
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 Types …

4. Cryptococcal meningitis: Infection from a

Yeast called Cryptococcus. Often associated
with AIDS.
5.Neoplastic meningitis: spread of solid
tumors to the brain or spinal cord
6.Syphilitic meningitis: due to infection with the
bacterium that causes syphilis.
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 MODES OF TRANSMISSION:
 Close contact with a person who is sick with the
disease
 Contact with carriers
 Living in close quarters, such as college
dormitories
 Being in crowded situations for prolonged periods of
time
 Sharing drinking glasses, water bottles, or eating
utensils
 Kissing, sharing a cigarette

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 Etiology
• Causative agent is age dependent
Neonates and infants
• Escherichia coli
• B-haemolytic streptococci
• Staphylococcus aurous
• Staphylococcus epidermidis
• Listeria monocytogenes

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 Etiology
I2mth-2yrs
• Hib,
• Strep pneumoniae &
• Neisseria meningitis

2-21yrs
• Neisseria meningitis /A, B, C, Y, and W 135,
• Hiband
• Strep pneumoniae,

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 Etiology…
There are 3 main bacterial species that
contribute to this disease:

 Haemophilus influenzae type b

 Neisseria meningitidis (Meningococcal)
 Streptococcus pneumoniae (Pneumococcal)

 Generaly by Bacteria, viruses, fungi, parasites

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 Clinical features

• Regardless of etiology, most patients with CNS

infection have similar clinical manifestations.

• Common symptoms include headache, nausea,

vomiting, anorexia, restlessness, altered state of
consciousness, and irritability; most of these
symptoms are nonspecific.
Pong A, Bradley JS, 2010

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 Clinical features…

 High grade fever

 Feeding problems
 Irritability
 Seizures:is correlative with the inflammation of brain
parenchyma, cerbral infarction and electrolyte disturbances.
 High-pitched crying
 Bulging fontanels
 Severe, persistent headache
 Neck stiffness : Infants may not develop a stiff
neck
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 Clinical features…
 Nausea and vomiting, sometimes along with
diarrhea
 Confusion and disorientation (acting "goofy")
can progress to stupor, coma, and death
 Drowsiness or sluggishness
 Eye pain or sensitivity to bright light
 Numbness and tingling

Pong A, Bradley JS, 2010

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 Clinical features…
– Increased intracranial pressure
• Headache
• Projectile vomiting
• Hypertension
• Bulging fontanel
• Cranial sutures diastasis/separation
• Coma
• Cerebral hernia

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 Clinical features…

BRUDZINSKI SIGN is +ve

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 Clinical features…

• The Kernig sign is +ve

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 Diagnosis (Investigations)

• CM
• INVESTIGATIONS
 CSF analysis
 Blood test
 Chest X-ray
 CT scan or MRI
 Cultures of samples of CSF, blood, urine, mucus
from the nose and throat, and pus from skin
infections.

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 Dx…
CSF ANALYSIS:
LP -A thin needle is inserted between L4/L5
to withdraw a sample of CSF.
– It will help to distinguish between the
different type of meningitis.
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 Laboratory Findings

• Examination of cerebrospinal fluid (CSF)

– Increased pressure of cerebrospinal fluid
– Cloudiness
– Evident Increased total WBC count (>1000×109 /L)
– Evident Increased neutrophils in leukocyte differential count
– Evident Decreased glucose (<1.1mmol/l)
– Evident Increased protein level
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 Treatment
Antibiotic Therapy
• Therapeutic principle
– Good permeability for Blood-brain barrier
– Drug combination
– Full dosage
– Full course of treatment
 Treatment of acute bacterial meningitis in
children
• Suspected bacterial meningitis is a medical
emergency, and immediate diagnostic steps must be
taken to establish the specific cause so that
appropriate antimicrobial therapy can be initiated.

• The mortality rate of untreated bacterial meningitis

approaches 100 % and, even with optimal therapy,
morbidity and mortality may occur.
• Neurologic sequelae are common among survivors.

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 Cont…
• Despite the effectiveness of current antibiotics in
clearing bacteria from the CSF, bacterial meningitis
continues to cause significant morbidity and
mortality worldwide.

• Empiric treatment should be begun as soon as the

diagnosis is suspected using bactericidal agent(s)
that achieve significant levels in the CSF

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 Empiric treatment

•Ceftriaxone 50-100 mg/kg/day IV/IM q12 hr

•Vancomycin 60 mg/kg/day IV q6h.

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 Convulsive management
• Diazepam
• Phenobarbital

• Treatment of increased intracranial pressure

– Dehydration therapy
• 20%Mannitol 5ml/kg iv q6h
• Lasix1-2mg/kg iv

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General and Supportive Measures
– Treatment of septic shock and DIC
• Volume expansion
• Dopamine
• Corticosteroids
• Heparin
• Fresh frozen plasma
• Platelet transfusions
 THERAPY FOR SPECIFIC PATHOGENS
Microorganism Recommended Duration of
therapy treatment

Streptococcus Penicillin G or Ampicillin 2 weeks

pneumoniae OR
Vancomycin+ Third-
generation cephalosporin
(eg, ceftriaxoneor
cefotaxime)
Neisseria Penicillin G 7 days
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meningitidis OR
Third-generation
cephalosporin (eg,
eftriaxone or cefotaxime)
 Haemophilus Third-generation ays
influenzae cephalosporin (eg,
ceftriaxoneor cefotaxime)
3 weeks
Listeria Ampicillinor Penicillin G
monocytogenes
scherichia coli Third-generation 21 days or 2 weeks
cephalosporin (eg,
ceftriaxone or cefotaxime)

Group B Ampicillinor Penicillin G 14-21 days

streptococci
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 Drug of choice according to the culture isolates
r. B strep coccus Organism efotaxim Drug of choice
eftriaxone and
. Monocytogenes mpicillin
.Influenzae efotaxim
eftriaxone and CAF
.Meningitides enzile pens, Ceftriaxone
.pneumoniae ancomicin, Benzile pens,
eftriaxone
.Aureus eftazidime, Vancomicin
seudomonas eftazidime
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 Differential Dx

 Cerebral malaria
 TBc meningitis
 Aseptic meningitis
 Brain abscess
 Brain tumer
 Bacterial infections
 Viral infections
 Trauma
 Malignancy

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 COMPLICATIONS OF BACTERIAL MENINGITIS

• Complications due to bacterial meningitis can

be divided into systemic and neurologic.
Systemic complications such as septic shock,
disseminated intravascular coagulation, acute
respiratory distress syndrome, and septic or
reactive arthritis, are usually the consequence
of the bacteremiathat frequently
accompanies meningitis

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 Complication
• Subdural effusion
– Subdural effusions occur in about 10%-30% of children with
bacterial meningitis.
– Subdural effusions appear to be more frequent in the
children under the age of 1 year and in haemophilus
influenzae and pneumococalinfection.
– Clinical manifestations are enlargement in head
circumference, bulging fontanel, and cranial sutures
diastasis
– Subdural effusions may be diagnosed by the examination of
CT or MRI.
 Prognosis
• Appropriate antibiotic therapy reduces the mortality
rate for bacterial meningitis in children, but mortality
remain high.

• Overall mortality in the developed countries ranges

between 5% and 30%.

• 50 percent of the survivors have some sequelae of the

disease.
 Prognosis
• Prognosis depends upon many factors:
– Age
– Causative organism
– Number of organisms and bacterial virulence
– Duration of illness prior to effective antibiotic therapy
– Presence of disorders that may compromise host
response to infection
 Read about ????
• Role of corticosteroid
• Vaccine for prevention
• Nursing interventions
• Complications(acute and late)
• The Monro-Kellie hypothesis

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 Complications
Acute :
 Increased ICP
 Hydrocephalus
 Hypoglycemia
 Myocarditis
 Brain damage
 Severe diarrhea and vomiting
 Internal bleeding
 Low blood pressure
 Shock
 Death

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 Complications

Late compications:
• Development delay
• Cerebral palsy
• Microcephaly
• Hemiparesis
• Hearing loss
• Blindness
• Seizure disorder

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