Meningitis beyond the neonatal age

Outline
Definition
Epidemiology
Etiology
Pathophysiology
Clinical
presentation
Diagnosis
Treatment
Complication
Prognosis
Introduction
 Meningitis refers to inflammation of the leptomeninges, and
subarachidonic space including the ventricles.

 Meningitis can be caused by infectious and non infectious

causes

 Ingeneral infectious causes are ,viruses > bacteria > fungi >
parasites, in terms of causing CNS infection.

 Noninfectiouscauses: Inflammatory disorders (e.g., SLE or

Kawasaki disease) and neoplasia (e.g., leukemic meningitis)
Anatomy
BACTERIAL
MENINGITIS
IS A MEDICAL EMERGENCY
Epidemiology
After the introduction of the Hib and
pneumococcal conjugate vaccines the
incidence of bacterial meningitis declined
in all age.

The peak incidence continues to occur in

children younger than two months
Etiology
≥1 month and <3 months – Group B streptococcus gram-
negative bacilli , Streptococcus pneumoniae , Neisseria
meningitidis

≥3 months and <3 years – S. pneumoniae , N.

meningitidis , group B streptococcus , gram-negative
bacilli

≥3 years and <10 years – S. pneumoniae , N. meningitidis

≥10 years and <19 years – N. meningitidis

General risk factors
Recent exposure to someone with
meningococcal or Hib meningitis.
Lack of immunity associated with young
age.
Recent infection (especially respiratory or
otic infection)
Recent travel to areas with endemic
meningococcal disease, such as sub-
Saharan Africa.
 General risk factors
Penetrating head trauma CSF otorrhea or CSF rhinorrhea.

Cochlear implant devices.

Anatomic defects (eg, dermal sinus ) or urinary tract anomaly).

Recent neurosurgical procedure (eg, ventricular shunt

placement) may predispose to meningitis with Staphylococcus
aureus , coagulase-negative staphylococcus, and enteric gram-
negative organisms, such as Escherichia coli and Klebsiella
species.
 Specific risk factors
Common bacterial etiologies of meningitis and risk factors

Streptococcus age less than 2 years; sickle cell

Pneumoniae disease; immune-compromised
children; children with cochlear
implants; unvaccinated
Neisseria viral URTIs like influenza; smoke
meningitidis exposure; dry, hot season; over-
crowding; age < 1 yr; underlying
chronic illnesses
Hemophilus sickle cell disease; immune-
influenzae compromised children; asplenia;
parental smoking; short duration of
breast feeding; unvaccinated
Pathogenesis
Colonization
Carriage
blood-brain barrier (blood-CSF
barrier)
TNF Blood-brain barrier

astrocyte processes

tight junctions
CSF:
few cells: < 5 lymphocytes/mm3
small amount of protein
C 3b
Case 1
A 2 years old male who was well 4 days
back , presented with high grade
intermittent fever , vomiting of ingested
matter which initially non projectile ,then
becomes projectile ,became sleepy.
PE: sleepy, with tachycardia and
Temperature of 39 Celsius, has neck
stiffness
 Clinical features
 Acute bacterial meningitis has two patterns of presentation
 In the first, meningitis develops progressively over one or several
days and may be preceded by a febrile illness.

 In the second, the course is acute and fulminant, with

manifestations of sepsis and meningitis developing rapidly over
several hours.
 Nonspecific SSx - fever, poor feeding, headache, URTI SSx,

myalgias, arthralgias, photophobia, nausea back pain

 Tachycardia, hypotension, and cutaneous signs, such as petechiae,

purpura, or erythematous macular rash (meningococcemia)
Meningeal signs - more likely to be observed in
older children (present in 65-80 % of patient
with initial presentation)
 Nuchal rigidity,
 Kernig sign (flexion of hip 90o followed by pain
with leg extension,
 Brudzinski sign (involuntary flexion of knees &
hips after passive flexion of the neck while
supine).
TESTING FOR MENINGEAL
IRRITATION With lengthening
of
the spine, nerve
roots are stretched,
=> pain and reflex
spasm => Kernig
& Brudzinski signs.

Spinal rigidity is a
more sensitive sign
of meningeal
irritation than
nuchal rigidity, esp
in young children
Skin lesions in acute meningococcemia can begin as papules but
quickly progress to petechiae & purpura. As seen here, the
purpuric lesions can coalesce
 Clinical features & associated
pathologies
 Headache, emesis, bulging fontanel or diastasis (widening)
of the sutures, CN 3 or 6 paralysis, hypertension with
bradycardia, apnea or hyperventilation, decorticate or
decerebrate posturing, stupor, coma … Raised ICP

 Cranial neuropathies (CN 2, 3, 6, 7, 8) … Focal inflammation

 Seizures-cortical

 Altered mental status … Raised ICP, hypotension/cerebritis

Diagnosis

 CSF analysis and culture

 Blood cultures (positive in 80% to 90% of cases)

* When you need to evaluate complications

 Neuro-imaging (Brain U/S, CT, MRI)

 Urinalysis and serum sodium

 CSF analysis
 In bacterial meningitis, CSF shows  pressure,  protein (BBB
inflammation),  glucose (partly resulting from its consumption
as a bacterial nutrient), and many neutrophils.

* Turbid/frank pus – a minimum of 200 cells/mm3

Form of Opening WBCs & Protein Glucose Comments
meningitis pressure differential

Normal values 50 - 80 < 5, >75% 20 - 45 > 50 mg/dl

mm H2O lymphocytes mg/dl
Acute Usually  Usually 300 – Usually Usually Organisms
bacterial (100 to 2,000; PMNs 100 – 500 < 40 usually seen
meningitis 300) predominate on Gram
stain / culture
Partially treat- Normal or 5 – 1000; Usually Normal or
ed bacterial elevated PMNs usual 100 – 500 decreased
meningitis

Viral Normal or Rarely >1,000 Usually Generally

meningitis slightly  cells. Mono- 50 – 200 normal
(80 – 150) nuclear cells
predominate

TB meningitis Usually 10 – 500; 100 – < 50 in Acid-fast org-

elevated lymphocytes 3,000 most cases anisms
predominate almost never
seen on
smear
CSF analysis

 Cultures often are negative if the patient has been

treated with antibiotics prior to culture.

 Detection of capsular polysaccharide antigens by rapid

latex agglutination tests in CSF can support diagnosis in
such cases.
S Pneumoniae
H influenzae

N meningitidis
Principles of treatment

 IV antibiotics as soon as the LP is done

 IV antibioticsas soon as possible if there are

contraindications for LP; then do a CT scan

 IV dexamethasone QID for 2 days (for those older than

6 wks of age) - give 1-2 hr before antibiotics are
initiated or concurrently with the 1st dose of antibiotics.
 Treat raised ICP and seizures (if present)
 Choice of antibiotics
Identified Primary treatment Alternative
organism treatment

Streptococcus 3rd generation cephalosporin, Vancomycin

pneumoniae Penicillin
Neisseria Penicillin Cefotaxime,
meningitidis Ceftriaxone
Hemophilus Ceftriaxone Cefotaxime
influenzae
Listeria Ampicillin & an
monocytogenes aminoglycoside

Gram negative Cefotaxime, Ceftriaxone,

rods Ampicillin & an
aminoglycoside
 Treatment
 Duration of treatment

 N meningitidis 5-7 days

 H influenzae 7-10 days
 S pneumoniae 10-14 days
 L monocytogenes 14-21 days
 Enteric GN rods 3 wks
 Acute
complications
 Seizures
 Raised ICP
 Cranial nerve palsies
 Stroke
 Cerebral or cerebellar

herniations
 Thrombosis of the dural
 venous sinuses
 Subdural effusion
 Ventriculitis with hydrocephalus
 SIADH
Chronic complications

 Visualimpairment
 Sensorineural hearing loss
 Behavioral problems
 Cognitive dysfunction
 Recurrent seizures
 Poor prognostic factors
 Pneumococcal meningitis

 Infants younger than 6 mo

 Those with high concentrations of bacteria or bacterial

products in their CSF.

 Those with seizures occurring more than 4 days into therapy

 Coma or focal neurologic signs on presentation.

Prevention

 Conjugate pneumococcal vaccines (Eg PCV10)

 Conjugate hemophilus influenzae type b vaccine

 Conjugate meningococcal vaccine (MCV4)

contains capsular polysaccharides from serogroups A, C,

W-135, and Y conjugated to diphtheria toxoid.

 Contact prophylaxis against
meningococcal meningitis
 Prophylaxis not routinely recommended for medical personnel
except those with intimate exposure (mouth-to-mouth resusci-
tation, intubation, suctioning before antibiotic therapy was begun.

 Children may be given Rifampin or Ceftriaxone

Contact prophylaxis against H influenzae
type b meningitis
 Rifampin prophylaxis should be given

 To all household contacts of patients with invasive disease

caused by H. influenzae type b,

 If any close family member younger than 48 mo has not been

fully immunized or

 If an immunocompromised person, of any age, resides in the

household.
VIRAL MENINGITIS
Etiologies

 Commonest etiology of viral meningitis

= Enteroviruses

 Other etiologies of viral meningitis

= Herpes = Mumps = VZV

= CMV = Lymphocytic chorio-meningitis virus
= Adenovirus
Pathology

 Meningeal congestion and mononuclear infiltration

 The cerebral cortex, especially the temporal lobe, is

often severely affected by HSV (In addition to the
meninges)

 Arboviruses tend to affect the entire brain

Clinical features

 The onset of illness is generally acute

 Characterized in children by fever, abrupt onset of

headaches, vomiting, irritability, and physical findings
of meningeal irritation such as Kernig and Brudzinski
signs.

 Infantspresent with a mild syndrome without the

physical findings found in older children.
Diagnosis
 CSFanalysis (including detection of viral DNA or RNA by
polymerase chain reaction especialy for HSV and enteroviruses)

 EEG

* diffuse slow-wave activity, usually without focal changes

 Neuro-imaging (CT, MRI)

* swelling of the brain parenchyma; focal findings on CT or

MRI, especialy involving the temporal lobes in HSV encephalitis
 Principles of treatment
 With the exception of the use of acyclovir for HSV
encephalitis, treatment of viral meningitis is supportive.

 Treatment of mild disease may require only symptomatic relief.

 Headache & hyperesthesia are treated with rest, non-aspirin-

containing analgesics, a reduction in room light, noise, & visitors.

 Acetaminophen is recommended for fever.

 Treat cerebral edema or seizures if present

Complications

 Motor incoordination
 Convulsive disorders
 Deafness
 Behavioral disturbances
 Visual disturbances
Poor prognostic factors

Severe illness

Substantial parenchymal involvement

HSV
Prevention

 Viral vaccines for

 polio,
 measles,
 mumps,
 rubella, and
 varicella
Summary Questions
Define meningitis and causes of meningitis
What makes meningitis a medical emergency
What is the most common cause of bacterial
meningitis
Five complications of bacterial meningitis
Write empirical treatment for B.meningitis
The most common cause of viral meningitis
Referencee
Nealson text book of pediatrics 21st
edition
Up to date 21.3
Thank you