CLINICAL PAEDIATRICS – 2022

NERVOUS SYSTEM LONG

CASES -2
FEBRILE CONVULSIONS
EPILEPSY
MENINGITIS

Aetiology Appearance WBCs Protein Glucose

Normal --- Clear 0 – 5 mm3 0.15–0.4 g/L ≥50% of blood
Bacterial Turbid Neutrophils ↑↑ ↑↑ 
Meningitis Viral Clear Lymphocytes ↑ Normal / ↑ Normal / 
(initially may be
polymorphs)
TB Turbid/clear/ Lymphocytes ↑ ↑↑↑ 
viscous
Encephalitis Viral/unknown Clear Normal/ Normal / ↑ Normal / 
↑ lymphocytes

Dr. Krishan Thalagahage

1
 Febrile Convulsions

Lets plan the history…..

3 years old child presenting with Jerky movements of upper limbs , with fever

Describe the seizure

Describe fever , Associated symptoms

Exclude meningitis clinically

Family History

Development

Birth History

Immunization

Social History

Other components of the History

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 Febrile convulsion

Take personal information – Name , age , where they come from…

1. Describe the type of seizure

a. Describe how the fit happened

i. Fit eka hadichcha widiha mata poddak kiyanna?

ii. Fit vanda widhaththei konjam sollunga

b. Was it focal?
i. Ange eka paththakada gahune naththan depaththada?
ii. Oru pakkam mattuma?

c. Rolling of eyes?
i. As uda giyada?
ii. Kan mela ponada?

d. Frothing of saliva?
i. Katen sema awada?
ii. Vaaiyal nurei vandatha?

e. Bladder and bowel incontinence

i. Kakka choo nikanma giyada?
ii. Malam, mooththiram ponatha?

f. For how long did it last ?

If relevant look for other possibilities ( Ex; Absence seizures, Infantile spasms…. )

2. Is it an absence seizure?
 As hondatam aragena eka paththak witharak diha balan hitiyada?
 Kankalei thirandu oru idaththei mattum paaththu irundaara

3. Is it infantile spasm?
 Babage hitapugaman eka parama bella kadagena wetila, ath deka gassunada?
 Baba thideerendu kaluththu thongi, kai udarinada?
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4. Exclude other d/d
a. Hypoglycaemia
i. Fit eka hadena welawey baba kaala beela nathuwada hitiyay? Drs. La ley
balala kiwwada seeni adui kiyala?
ii. Fit vara mundi baba kudikkaamal, saappidaamal irundaara? Reththatthila
seeni kureivu endu sonnaangalaa?
b. Electrolyte imbalance
i. Mey unath ekka babata digatama wamaney giyada? Wathura wage kakka giyad?
ii. Kaacchaloda babaku vandi vandatha? Malam thanni maari ponada?
c. History of head injury
i. Oluwata monawahari accident ekak wunad?
ii. Thaleikku edavadu accident nadandadaa?
d. Any possibilities of brain tumour
i. Babata udey pandaratama oluwe kakkuma ekka wamaney yanawada?
ii. Babaku adikaaleiyil thala valiyoda vaandi ponadaa?

5. If this is likely a febrile seizure , Ís it a simple/complex febrile convulsion?

a. Duration

i. Kochchara welawak thibbada?

ii. Evvalavu neram valippu irundadu
b. How many episodes per day?
i. Dawasata kee sarayak fit eka hadunada?
ii. Oru naalil evvalavu thadavei nadandathu?
c. Generalised or focal?
i. Eka paththakd naththan depaththada gahune?
ii. Oru pakkam mattumaa? Illa rendu pakkamaa?

6. Describe the fever

a. (How many days?)
i. Una dawas keeyakda?
ii. kaachchal evvalavu naal?
b. (Degree of fever?)
i. Kochcharak una thibbad?
ii. Kaacchal evvalavu irundathu?

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 c. (Did you measure the fever?)
i. Una mannada?
ii. Kaachchalei alandu paaththeengalaa?

d. (Fever with chills and rigor)

i. Unath ekka anga seethala wela anga gahunada? Kaacchaloda udambu kulirnthu
udarinada?

7. Associated symptoms to get a clue for the reason for fever

a. Dysuria
i. Muthra yanakota dawilla gathiyak thibbada
ii. Moothiram pohira neram erivu irundatha?
b. Rash
i. Rash ekak dammada?
ii. Rash irundatha?
c. Joint pain/swelling
i. Handi kakkumak thibbada? Handi idimunada?
ii. Moottu vali irundatha?Moottu veengi irundatha?

8. Exclude meningitis clinically

 Babata una nathi welawata baba hondata nagitala kaama kala innawada?
 Babaku kaacchal illaada neratthil elumbi nalla saappittu irundadaa?

9. Exclude encephalitis (Were there any behavioural changes?)

 Babage hasireemey wenasak therunada?
 Babawin nadatheyyil edhawada maatram irikiradha?

10. Family history

 Paule wena kata hari una walippuwa thiyanawada?
 Kudumpatthil vera yaarukkum kaacchaloda valippu vaaratha?
11. Development
 Baba awidina eka, kathakarana ewa hari wayasata keruwada?

 Baba nadakkiradu, katheikkiradu ellam sariyaana vayathil seidatha?

12. Birth history

a. Gabini awasthaawedhi ledaroga ho salakiya yuthu venaskam thibunadha?

b. Neengal garbamaaga irukum podhe ungaluku edhavedhe noigal sari vera edhum
maatrangal etpattadha?

13. Immunisation history

a. Babata denna ona injection okama hari wayasata widalada thiyenne?
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 b. Babake kuduke vendiye thadippu marandha oosihalei sariyaage neratheke
kuduthe irikiringal-ah?

14. Social history

a) Home and environment safety

a. Gedara awata parisarayai surakshithada?

b. Vidu, mattrum sutrum soolal paadhu kapanadhah?

b) Parental awareness regarding seizure 1st aid

a. Mewani awasthaawakadi karanna oney dhey gana danuwathda?

b. Ippadi nerathil seiya vendiyadhe ennavendru theriyumah?

Other

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 Model Presentation
3 years old Nikhil came to emergency department with one episode of generalized tonic clonic seizure
lasting for 20 minutes on the day of the admission. He has had high fever 40 c and cough and cold one
day prior to the admission. When the seizure happened, patient was unconscious and hands got stiff
and both upper arms and lower limbs started jerking . Eyes glared upward but no foam came out of the
mouth.
There was no bladder or bowel incontinence. Alternate etiology of seizure such as hypoglycemia,
electrolyte imbalances, head trauma or intracranial infection is unlikely as there was no history to
suggest as such.
He was a known patient with previous 2 episodes of febrile seizures at the age of 8 moths with
respiratory infection and at the age of 15 months due to a UTI .No history of afebrile seizures. There was
a positive family history of febrile convulsions in his paternal side.
His immunization is well up to now according to EPI schedule and no history of allergic reaction
following immunization. No known food or drug allergies.
He was a Term baby delivered via C section with the birth weight of 3kg.
His mother’s knowledge about his disease is satisfactory and aware of what to do at the home in case of
seizure and future consequences. However there are several economical issues and safety problems
around the house specially I got know about an unprotected well around his home.so I would like to
discuss about safety measures with his parents as well.
Rest of the history , including development , is normal.

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Summary

Problem List

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 RELEVANT THEORY FOR DISCUSSION

SEIZURE DISORDERS

Clinical Scenario-A 3 years old child presented with Jerky movements of upper limb and lower limbs

A seizure is a clinical event in which there is a sudden disturbance of neurological function caused by an
abnormal or excessive neuronal discharge.

Seizures may be epileptic or non-epileptic.

Causes of seizures:
Epilepsy
• Idiopathic (70–80%) – cause unknown but presumed genetic
• Secondary
– Cerebral dysgenesis/malformation
– Cerebral vascular occlusion
– Cerebral damage, e.g. congenital infection,
hypoxic-ischaemic encephalopathy,
intraventricular haemorrhage/ischaemia
• Cerebral tumour
• Neurodegenerative disorders
• Neurocutaneous syndromes

Non-epileptic
• Febrile seizures
• Metabolic
– Hypoglycaemia
– Hypocalcaemia/hypomagnesaemia
– Hypo/hypernatraemia
• Head trauma
• Meningitis/encephalitis
• Poisons/toxins.

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 Febrile seizures
 A febrile seizure is a seizure accompanied by a fever in the absence of intracranial infection due
to bacterial meningitis or viral encephalitis.
 Commonly occurs between 6 months to 6 yrs of age.
 About 30–40% will have further febrile seizures.
 Generally there is a family history of FC
 Children with febrile convulsions should not have a past history of afebrile seizures
 They generally are developmentally normal
 Two types ; Simple FC and Complex FC

Simple febrile seizures Complex febrile seizures

Generalized Generalized or focal seizures.

< 15 min Can last for > 15 min

Only one episode / day Multiple episodes can occur
May cause residual damage
Risk of subsequent epilepsy is the same as for Increased Risk of subsequent epilepsy (4-12%)
all children (1-2%)

To diagnose a febrile convulsion seizure should be partial or is should last more than 15 minutes or
there should be multiple seizures within 24 hours.

Management:
 Seizure management in acute setting.
 Reassurance of parents
 No need of EEG or prophylactic anticonvulsants.
 The underlying cause for fever should be managed, eg; if fever due to UTI treat the UTI

CLINICAL NOTE

Antipyretics may be given but have not been shown to prevent febrile seizures.
The family should be taught the first aid management of seizures., child kept in left lateral,nothing
should be inserted to mouth .
If there is a history of prolonged seizures (>5 min),should be taken to hospital

Prophylactic anti epileptics in febrile convulsions

In some patients with febrile convulsions prophylactic anti epileptics are given only during the days child
has fever . eg: Clobazam

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 Discussion
1. What are the different types of seizures that you know of ?

2. What are the common causes of seizures in children ?

3. What is the initial assessment you do in a child coming with a seizure?

4. Tell me what do you expect on neurological examination in a child with Seizures?

5. What initial investigations you might order for a child coming with a seizure ?

6. What is a febrile convulsion (FC )?

Seizure due to fever from 6 M to 6 yrs old , not due to CNS infection, head tumor or injury, electrolyte
imbalance or hypoglycemia. No PHx of afebrile convulsions. Generally Child is neurologically &
developmentally normal. There Can be a FHx of FC.

7. How do you classify febrile seizures ?

Simple febrile convulsions - < 15min, generalized seizures, 1 episode per day Complex
febrile convulsions -> 15 min, focal seizures, and multiple episodes per day

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8. How do you clinically differentiate febrile convulsions from meningitis

9. What is your investigation plan in a child with febrile seizures ?

Febrile convulsion is a clinical diagnosis. But to look for etiology for fever need Ix accordingly.

10. How do you manage this child?

 Antipyretics for fever
 parental counselling regarding condition , how to act in emergency situation
 Treat etiology for fever.
 If possible do home & environmental modifications
 Educate parents that child doesn’t need routine neuroimaging & the fact that this condition last
forever.

11. What is the prognosis of Febrile seizures ?

12.What is the place for antiepileptics in febrile convulsions

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Epilepsy – Lets listen to this history from real patient ….
(This part will be done during the class)

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 RELEVANT THEORY FOR DISCUSSION
CHILDHOOD EPILEPSY
 Epilepsy is a chronic neurological disorder characterized by recurrent unprovoked seizures,
consisting of transient signs and/or symptoms associated with abnormal, excessive or
synchronous neuronal activity in the brain.
Classification
Partial /focal Generalised
Seizures arise from one or part of one Arise from both hemispheres.
hemisphere.(usually the temporal lobe)
Only a part of the body is affected. The whole body is affected.
 Simple partial epilepsy ( No impairment in  Grandmal (generalized tonic clonic)-
consciousness ) commonest.
 Petitmal (absence seizures)
 Complex partial epilepsy (reduced level of  Tonic epilepsy
consciousness. )  Clonic epilepsy
 Infantile spasm
 Partial epilepsy with secondary generalization

Focal seizures may be preceded by an aura which

reflects the site of origin In generalised seizure disorders, there is:
• always a loss of consciousness
frontal seizures – involve the motor or pre-motor • no warning
cortex. May lead to clonic movements, which may • symmetrical seizure
travel proximally (Jacksonian march), or a tonic seizure • bilaterally synchronous seizure discharge on EEG
with both upper limbs raised high for several seconds. or varying asymmetry
temporal lobe seizures– may result in strange warning
feelings or aura with smell and taste abnormalities and
distortions of sound and shape.Déjà-vu feelings are
described (intense feelings of having been in the same
situation before)
occipital seizures – cause stereotyped visual
hallucinations
parietal lobe seizures – cause contralateral
dysaesthesias or distorted body image.

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 Important sub types
Name Common age Seizure pattern
Infantile spasms 4-6 months Violent flexor spasms of the head,
trunk and limbs followed by
extension of the arms (so-called
‘salaam spasms’).
Flexor spasms last 1–2 s, often
multiple bursts of 20–30 spasms,
often on waking, but may occur
many times a day.
Social interaction often
deteriorates
Childhood 4-12 yrs Stare momentarily and stop
absence epilepsy moving, may twitch their eyelids or
a hand minimally.
Lasts only a few seconds and
certainly not longer than 30 s.
Child has no recall, except realizes
they have missed something
Developmentally normal but can
interfere with schooling.
Benign Rolandic 4–10 yrs Tonic-clonic seizures in sleep, or
Seizure simple focal seizures with
awareness of abnormal feelings in
the tongue and distortion of the
face (supplied by the rolandic
(centro-temporal) area of the brain
Investigations:
EEG – as it is done after or in between fits, the EEG may be normal
in a child with epilepsy.
If the EEG is normal, a sleep or sleep-deprived record can be helpful. Additional techniques
are 24–h ambulatory EEG or, ideally, video-telemetry.
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Comments
The EEG shows hypsarrhythmia
Treatment is with vigabatrin, ACTH
or corticosteroids
Most will subsequently lose skills
and develop learning disability or
epilepsy
Bad prognosis
Two-thirds are female.
The episodes can be induced by
Hyperventilation,(the child being
asked to blow on a piece of paper
or windmill for 2–3 min, a useful
test in the outpatient clinic.)
The EEG shows generalised 3
spikes/second spike and wave
discharge.
Prognosis is good
15% of all childhood epilepsies.
EEG shows focal sharp waves from
the rolandic area. Important to
recognise as relatively benign and
may not require AEDs. In rare
occasions carbamazepine can be
given
Remits in adolescence.
 CT scan/ MRI - indicated if there are neurological signs between seizures, or if seizures are
focal, in order to identify a tumour, vascular lesion, or area of sclerosis which could be
treatable.

Management:

Anti-epileptic drug (AED) therapy

 Not all seizures require AED therapy.

 This decision should be based on the seizure type, frequency and the social and educational
consequences of the seizures vs. side effects of the drugs.
 Monotherapy at the minimum dosage is the desired goal, although in practice more than one
drug may be required.
 AED levels are not measured routinely, but may be useful to check for concordance (adherence)
or to see if a dose increase could be considered if a high dose is not working.
 AED therapy can usually be discontinued after 2 years free of seizures.

Seizure type First-line Second-line

Generalised Tonic-clonic Sodium Valproate Carbamazepine,Lamotrigine,
topiramate
Absence Ethosuximide Valporate, lamotrigine
Infantile spasm I/M ACTH or prednisolone Valporate, clonazepam
If secondary to Tuberous
sclerosis vigabarin is given
Focal seizures Carbamazepine Valporate, lamotrigine, newer
drugs.

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 Side effects of Antiepileptics

Drug Side effects

 Hepatotoxicity
Sodium valporate  Weight gain
 Acute pancreatitis
 Steven-Johnson syndrome
 Oral and mucosal ulcers
Carbamazepine  Rash
 Liver enzyme induction
 Neutropenia, aplastic anaemia

Phenytoin  Hypertrophy of gingival

 Ataxia
Vigabatrin  Irritability &restriction of visual fields

Lamotrigine  Rash ,insomnia and ataxia

Topiramate  Weight loss,depression,parasthesia,irritability

 Congnitive imparment

Advice and prognosis

 The aim is to promote independence and confidence. Some children with epilepsy and their families
need psychological help to adjust to the condition.
 Relatively few restrictions are required, but situations where having a seizure could lead to injury or
death should be avoided. This includes avoiding deep baths (showers are preferable) and not
swimming unsupervised.
 For adolescents, there will be issues to discuss around driving (only after 1 year free of seizures),
contraception and pregnancy. There may also be issues with concordance (adherence) and the
precipitation of seizures by alcohol and poor sleep routines.

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Seizure Mimicking Conditions

'Blue breathholding' spells-Occur in some toddlers when they are upset. The child cries, holds his breath
in expiration and goes blue. Sometimes children will briefly lose consciousness but rapidly recover fully.
Drug therapy is unhelpful. Attacks resolve spontaneously, but behaviour modification therapy with
distraction, may help.
Reflex asystolic syncope-Also called reflex anoxic seizures. Occur in infants or toddlers. Many have a
first-degree relative with a history of faints. Commonest triggers are pain or discomfort, particularly
from minor head trauma, cold food (such as ice-cream or cold drinks), fright or fever.
Some children with febrile seizures may have experienced this phenomenon. After the triggering event,
the child becomes very pale and falls to the floor.
The hypoxia may induce a generalised tonic–clonic seizure. The episodes are due to cardiac asystole
from vagal inhibition.
The seizure is brief and the child rapidly recovers.
The conditions are also discussed in psychiatry under the chapter of Behavioral problems in children

Benign paroxysmal vertigo-This is characterised by recurrent episodes of vertigo, lasting from one to
several minutes, associated with nystagmus, unsteadiness or even falling. It is a primary headache
disorder of childhood occasionally due to a viral labyrinthitis.

Syncope (transient loss of consciousness)-Children may faint if in a hot and stuffy environment, on
standing for long periods, or from fear. Clonic movements lasting a few seconds are common.
Sandifer Syndrome - In this condition child will go into opisthotonic posture with possible jerky
movement in the limbs . This is secondary to severe Gastro esophageal reflux disease Treating
underlying GORD will relieve this condition.

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 Discussion

What is Epilepsy?

What are the types?

How do you investigate?

What is the Pharmacological and non pharmacological management ?

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 Meningitis
A 3 weeks old baby presenting with poor sucking and fever for one day and a short lasting
generalized seizure. This is his fourth day of his hospital stay
Analyze P/C
1. How high is the fever?

 Keeyakata withara babage una thibunada

 Babawin kachchal ewalowuke irendhedhe?

Was the baby well in between fever?

 Una bassa welawe baba saamanya thathwayata aawada?
 Kachchal kureindhapin baba paleya nilameike wandhadha?

2. Did you notice any other abnormality in the baby (coughing, loose stools, crying while
micturition, ear discharge)
 Babata wena mokuth prashna thibunada e awasthawe? (Kassa, paachanaya,
muthra karaddi andeema, kanen diyara galeema)
 Babake wera edhawadha prechchenei irindhadha andha nereththil?(Irumal,
vaitrepoku, sirinir kalikum podhe aluwaradhe, kaadhaal sel vadeedhede)

3. Ask questions about the seizure

i. Describe the seizure
 Fit eka hadichcha widiha mata poddak kiyanna?
 Fit vanda widhaththei konjam sollunga
ii. Duration
 Kochchara welawak thibbada?
 Evvalavu neram valippu irundadu
iii. Uprolling of eyes
 As uda giyada?
 Kan mela ponada?
iv. Frothing of saliva
 Katen sema awada?
 Vaaiyal nurei vandatha?

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 v. Bladder and bowel incontinence
 Kakka choo nikanma giyada
 Malam, mooththiram ponatha?

4. What was done after admission - were blood tests done, was lumbar puncture done,is
he on IV antibiotics, USS brain
 Ispirithaaleta athulath karaata passe mokkada karey? Le pariksha karaada?
Lumbar puncture karaada? Katten dena beheth dunnada? Moley scan
pareekshanayak karaada?
 Aaspathriyil babawei nippatina piregu enna seidhaargal? Reththamparisodhanei
seidhaargalah? Lumbar puncture seidhaargalah? Oosiyal kodukum marandhei
kuduthaargalah? Moolayei scan panninaargalah?

5. What treatment is he on now? - antibiotics, is he getting better with treatment?

 Danata mona beheth da pawichchi karanne? Beheth patan gaththata passe suwa
athata path unada?
 Ippodheiki babake enna marandha kodukiringa? Marandha koduthapiraha,
kunam adeindhe vittadha?

6. Birth history

Any problems during pregnancy ? NVD or LSCS …

 Pregnant kale ammata mokuth prashana thibunada? Normal delivery da, caesar
karalada babawa gaththe?
 Neengal garbamaaga irukum podhe edhavedhe prechcheneigal irendhadha?
Normal ava pirendhedhe?

7. Immunization history
Is immunization up to date ? In this case , BCG given or not ?
 Babage ennath nisi aakarayata, nisi welawata deelada thiyenne?
 Babake kuduke vendiye thadippu marandha oosihal-ei sariyaage neratheke
kuduthe irikiringal-ah?

8. PMHx
 Meeta amatharawa babata wenath leda roga thiyenawada?
 Idha illamal babaka wera edhaavadhu noi vandha irikiradha?

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9. PSHx
 Babata operations karala thiyenawada?
 Babaka edha kaawadhe operation seidha irikirudha?

10. Family history of seizures

 Pawule kata hari fit eka hadila thiyenawada?
 Kudumpatthil vera yaarukkum kaacchaloda valippu vaaratha?

11. Social history – awareness

 Fit hadunama karanna oney dhey gana danuwathda?
 Ippadi nerathil seiya vendiyadhe ennavendru theriyumah?

12. Growth and development

Summary

Meningitis in older Children – What to ask?

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 Model Presentation

5 years old Master Kavith presented with fever and lethargy for 6 days. His fever was around
39 c at home without any associated chills and rigors. During initial 4 days he had an ear ache
and treated with oral antibiotics by family doctor . Around 3 days ago patient complained
about severe headache and body aches with associated difficulty in looking at light as well.
History reveals Headache was generalized in nature which is not associated with early morning
vomiting. No rashes were noted.
He doesn’t complain of any difficulty in walking , limb weakness , impaired hearing , vision or speech
due to this illness. He didn’t have any seizures either.
After coming to the hospital , he has undergone several investigations including blood and CSF
analysis but no EEG or CTs were done . He is currently on intravenous antibiotics and his fever
and other difficulties are settling.
He was a previously well child delivered via NVD with a birth weight of 3kg . His immunization
was well up-to-date according to EPI Schedule including JE. No history of any other medical
conditions or family history of neurological disabilities .Kavith’s development is age
appropriate
Due to his current situation he missed his school .
His family is having some economic problems and difficulty in traveling in to the hospital
in case of emergency.
Rest of the history is uneventful.

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 RELEVANT THEORY FOR DISCUSSION

MENINGITIS
Meningitis occurs when there is inflammation of the meninges covering the brain.

Causes of meningitis

Organism causing meningitis will depend on childs age

 Bacterial causes:
Neonatal – 3 months Group B streptococcus
E. coli and other coliforms
Listeria monocytogenes
1 month – 6 yrs Neisseria meningitidis
Streptococcus pneumoniae
Haemophilus influenzae
> 6 yrs Neisseria meningitidis
Streptococcus pneumoniae

 Viral causes : most common cause of meningitis, and most are self-resolving.
enteroviruses, Epstein–Barr virus, adenoviruses and mumps.

 Uncommon pathogens : (esp if the child is immunodeficient) Mycoplasma or Borrelia

burgdorferi (Lyme disease), or fungal infections.

Pathophysiology

• Bacterial infection of the meninges usually follows bacteraemia.

• Much of the damage caused by meningeal infection results from the host response to infection and
not from the organism itself.
• The release of inflammatory mediators and activated leucocytes, together with endothelial damage,
leads to cerebral oedema, raised intracranial pressure, and decreased cerebral blood flow.
• The inflammatory response below the meninges causes a vasculopathy resulting in cerebral cortical
infarction, and fibrin deposits may block the resorption of CSF by the arachnoid villi, resulting in
hydrocephalus.

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 Clinical Features
Clinical features of meningitis are highly diverse depending on the age of the child .
Newborns and infants will present with non specific features ,where as older children will have typical
features of meningitis

Symptoms Signs

Depends on age  Fever

 Fever  Purpuric rash (meningococcal disease)
 Headache  Neck stiffness (not always present in infants)
 Photophobia  Bulging fontanelle in infants
 Lethargy  Opisthotonus (arching of back)
 Poor feeding/vomiting  Positive Brudzinski/Kernig signs
 Irritability Brudzinski sign – flexion of the neck with the child supine causes
 Hypotonia flexion of the knees and hips.
 Drowsiness Kernig sign – with the child lying supine and with the hips and
 Loss of consciousness knees flexed, there is back pain on extension of the knee.
 Seizures  Signs of shock (due to septicemia)
 Focal neurological signs
 Altered conscious level
 Papilloedema (rare)

Other causes of Neck Stiffness

1. Sub Arachnoid Haemorrhage

2.Retro-pharyngeal abscess

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Investigations
 FBC & DC
 C-reactive protein
 Blood culture
 Rapid antigen test for meningitis organisms (can be done on blood, CSF, or urine)
 Lumbar puncture for CSF unless contraindicated
 PCR of blood and CSF for possible organisms
 If TB suspected: chest X-ray, Mantoux test, gastric washings or sputum

When to Consider Neuro imaging ?

 If child develops Continuous fever to exclude an Abscess we can do CT/MRI
 Focal neurological signs (focal seizures,paralysis) can do imaging to exclude Subdural effusion or
a haemorrhage

Contraindications for lumbar puncture :

 Cardiorespiratory instability
 Focal neurological signs
 Signs of raised intracranial pressure, e.g. coma, high BP, low heart rate or papilloedema

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  Coagulopathy
 Thrombocytopenia
 Local infection at the site of LP
 If it causes undue delay in starting antibiotics
In these circumstances, a lumbar puncture can be postponed until the child’s condition has stabilized.

Site of LP - Generally depends on child's age , Usual space is L3 -L4 ,puncture is done under strict aseptic
conditions.
Before the procedure child is sedated or held firmly without letting him to move , as it can cause spinal
damage
Samples are taken for full report , sugar , protein and cultures
Extra samples may be taken for PCR and TB testing when relevant .
For best results CSF analysis should be done within one hour of procedure

LP Needles

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 Typical changes in the CSF in meningitis or encephalitis, beyond the neonatal period :

Aetiology Appearance WBCs Protein Glucose

Normal --- Clear 0 – 5 mm3 0.15–0.4 g/L ≥50% of blood
Bacterial Turbid Neutrophils ↑↑ ↑↑ 
Meningitis Viral Clear Lymphocytes ↑ Normal / ↑ Normal / 
(initially may be
polymorphs)
TB Turbid/clear/ Lymphocytes ↑ ↑↑↑ 
viscous
Encephalitis Viral/unknown Clear Normal/ Normal / ↑ Normal / 
↑ lymphocytes

CSF Findings in Partially treated Bacterial Meningitis

High protein,Low sugar & Lymphocytes more than neutrophils

In this condition CSF culture is generally negative therefore CSF antigen test for bacteria is used to
detect the organism.

Management
Monitor vital signs

KUO for cerebral Oedema

Septicaemia can kill in hours, so requires prompt resuscitation and antibiotics

 IV antibiotics for bacterial causes

A 3rd generation cephalosporin ( eg. cefotaxime, ceftriaxone) is commonly used.

 Beyond the neonatal period, dexamethasone administered before the antibiotics reduces
the risk of long-term complications

 General supportive management.

 Any febrile child with a purpuric rash should be given intramuscular benzylpenicillin
immediately and transferred urgently to hospital,as meningococcal meningitis is suspected

• Duration of antibiotics is generally 10 to 14 days

• In some neonatal meningitis conditions antibiotics may be given upto 3 weeks

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Complications of Meningitis :
 Hearing loss (due to damage to cochlear hair cells)
 Local vasculitis  cranial nerve palsies
 Local cerebral infarction  seizures & epilepsy
 Subdural effusion
 Hydrocephalus
 Cerebral abscess
 Generally caused by Staphylococci therefore Vancomycin is generally given
(The child’s clinical condition deteriorates with the emergence of signs of a space occupying
lesion. The temperature will continue to fluctuate. It is confirmed on CT scan. Drainage
of the abscess is required.)

Subdural effusion Intracranial Abscess

Prophylaxis :
 Prophylactic treatment with rifampicin to eradicate nasopharyngeal carriage is given to all
household contacts for meningococcal meningitis
 If an infection of Hib is confirmed in a family or in an orphanage, we need to check the
immunization status of under 4 year olds if any and if not vaccinated all in the household should
be given prohpylaxis with Rifampicin
What are the causes of unresolving fever in Meningitis ?

 Improper antibiotics
 Improper dosage
 Different diagnosis
 Abscess formation

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What is the clinic follow up ?

Need to check Hearing specially following Hib infection ,Head circumference, development assessment
and visual assessment

Summary of Meningitis

Predominantly a disease of infants and children.

• Incidence has been reduced by immunization.
• Clinical features: nonspecific in children under 12 months – fever, poor feeding, vomiting, irritability,
lethargy, drowsiness, seizures, or reduced consciousness; late signs – bulging
fontanelle, neck stiffness, and arched back (opisthotonos).
• Septicaemia can kill in hours; good outcome requires prompt resuscitation and antibiotics.

ENCEPHALITIS

 Whereas in meningitis there is inflammation of the meninges, in encephalitis there is

inflammation of the brain substance, although the meninges are often also affected.

Encephalitis may be caused by:

• direct invasion of the brain by a neurotoxic virus (such as HSV)
• delayed brain swelling following a dysregulated neuroimmunological response to an antigen,
usually a virus (postinfectious encephalopathy), e.g. following chickenpox
• a slow virus infection, such as HIV infection or subacute sclerosing panencephalitis (SSPE)
following measles.

 It may not be possible to clinically differentiate encephalitis from meningitis, and treatment for both
should be started.
 The underlying causative organism is only detected in fewer than half of the cases
 Most children present with fever, altered consciousness and often seizures.
 HSV is a rare cause of childhood encephalitis but it can have devastating long-term consequences
 Treat potential HSV with parenteral high-dose acyclovir until diagnosis is excluded

PCR is used in the majority of laboratories to detect HSV in CSF.

As HSV encephalitis is a destructive infection, the electroencephalogram and CT/MRI scan may show
focal changes, particularly within the temporal lobes either unilaterally or bilaterally .

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Proven cases of HSV encephalitis or cases where there is a high index of suspicion should be treated
with intravenous acyclovir for 3 weeks, as relapses may occur after shorter courses.
Untreated, the mortality rate from HSV encephalitis is over 70% and survivors usually have severe
neurological sequelae.

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 Discussion

1. How will you investigate this child?

2. Describe the procedure of LP. What are the indications and contraindications of
lumbar puncture?

3. What are the common organisms causing meningitis?

4. CSF findings in different types of meningitis ?

5. What are the complications of meningitis?

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6. How do you manage a child with meningitis?

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 Further Scenarios

1. Status Epilepticus
a. Definition of status epilepticus / Emergency management of status - drug doses and
routes

b. If unable to gain IV access , what are the other options available ?

c. If intra-osseous needle is not available in the ward what other needle can be used

d. Where would you insert the intraosseous needle?

e. Initial investigations to be done in status epilepticus

f. Patient has got a seizure on 3rd day after birth - ask about risk factors for seizure
in a neonate

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 g. Please tell me the difference between generalized and focal seizures, treatment,
sideeffects of drugs,

h. Benign rolandic epilepsy.

i. What is the seizure pattern

ii. EEG findings and management ?

2. Previous history of simple febrile convulsion in 3years old child now presenting with an
episode of complex febrile convulsion

a. Please tell me the definitions of complex and simple febrile convulsions

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b. What are the differential diagnoses for convulsions

c. How do you calculate paracetamol dose and what are the different preparations
available

d. Preparations of diazepam, how to give rectal ?

e. What is the dangerous side effect of diazepam? How do you treat it?

f. What are the advices you are giving to mother? Clinic follow up what are you
specifically looking for ?

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g. If the mother far away from hospital thinking this child getting recurrent seizures
what are you considering specifically?

h. What prophylactic drugs given for febrile convulsions?

i. Risk of epilepsy with simple and complex febrile seizures

j. What side effects to look when long term phenytoin and phenobabitone is given?

k. What do u do if child stop breathing when giving phenobarbitone ?

l. Pls tell me how EPI schedule should be adjusted if a child get seizures at 10 months of
age

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3. 5 month old baby presented with the history of poor feeding and irritability. He was
diagnosed as having meningitis . Now baby is on treatment IV antibiotics.

i. Pls tell me the organisms causing meningitis

ii. Complications of meningitis

iii. As a ho what will you look specially on this patient after discharge ,in clinic

iv. Place for the Imaging in meningitis ?

v. antibiotic, treatments

vi. Vaccines available

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vii. EPI schedule and preventable causes of meningitis

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