CHILDHOOD SEIZURES AND

MENINGITIS
(PART-2)

DR.M.ASHFAQ. BURNEY

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 Case No. 2
4 ½ month old male child presents to the
ER with one week history of high grade
fever and 3 days history of focal fits?

– How will you further evaluate this patient?

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 Childhood Meningitis
Meningitis:
– Inflammation of leptomeninges
Incidence
– It is by large the disease of childhood
– 2/3 cases below 15 years
– Neonates and children (6 mo-12 mo) are at
greatest risk

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 Causative agents
NEONATES
Group B Streptococci
Bacteria Escherichia coli
Listeria Monocytogenes
Viruses INFANTS
Neisseria Meningitidis
Haemophilus Influenzae
Rickettsiae Streptococcus Pneumoniae
CHILDREN
Fungi N. Meningitidis
S. pneumoniae
Aseptic meningitis
•Certain drugs
•Diseases that can cause
inflammation of tissues of the
body without infection

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 Risk Factors
– Age
– Low family income
– Attendance at day care
– Head trauma
– Splenectomy
– Chronic disease
– Children with facial cellulitis, periorbital cellulitis,
sinusitis, and septic arthritis have an increased risk of
meningitis.
– Maternal infection and pyrexia at the time of delivery
are associated with neonatal meningitis.
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 Routes Of Infection
Nasopharynx
Blood stream
Direct spread from skull fracture,
meningo/encephalocele
Middle ear infection
Mastoiditis
Infected ventriculo-peritoneal shunts

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 Clinical Features
Infants:
– <3 months of age, very nonspecific symptoms,
including hyperthermia or hypothermia, change
in sleeping or feeding habits, irritability or
lethargy, vomiting, high pitched cry, or seizures
– After 3 months of age, the child may display
symptoms more often associated with bacterial
meningitis, with fever, vomiting, irritability,
lethargy, or any change in behavior.
– After 2-3 years of age, children may complain
of headache, stiff neck, and photophobia
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 Differentials
TBM
Viral
Brain abscess
Brain hemorrhage
Meningismus

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 Investigations
Complete blood count (CBC) with differential
Blood cultures
Coagulation studies
Serum glucose
Erythrocyte sedimentation rate (ESR)
Electrolytes
Serum and urine osmolalities
Bacterial antigen studies can be performed on
urine and serum; they are mostly useful in cases
of pretreated meningitis.

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 Imaging studies
Imaging studies rarely are required in the initial
management of meningitis or encephalitis when
the clinical presentation is typical. Exceptions
include the need to rule out other pathology
before performing an LP or when focal
neurological signs are present.

Imaging may be useful to check for abscesses,

subdural effusions, empyema, or hydrocephalus.

Normal CT scan findings do not rule out

increased intracranial pressure (ICP).
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 Procedures
The most important laboratory study is
examination of CSF. The lumbar puncture (LP)
should include opening and closing pressure in
the cooperative patient.
– Cell count
– Gram stain
– Culture and sensitivity
– Glucose
– Protein and antigen
– Acid-fast bacillus
– Fungal stains

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 CSF findings in CNS disorders
cmH20 Leukocytes Protein (mg/dl) Glucose

Normal 50-80 5-75% lymphos 20-45 >50mg/dl or

75%of SBG

ABM Usually raised 100-60,000+ Usually 100-500 Decreased,

PMNs usually around
predominate 40 mg/dl

Partly treated Normal or raised 1-10,000 PMNs 100+ Decreased or

but monos normal
predominate

TBM Usually raised, 10-500, lymphos 100-500 <50 in most

maybe low predominate cases

Viral Normal or Mononuclear 50-200 Generally

slightly raised cells normal
meningitis
predominate

Brain Usually raised 10-200 75-500 Normal unless

abscess
abscess
ruptures 12
 Case 2 continued
The child’s LP D/R showed 100-60,000+ PMNs
predominate, with 100-500 proteins and blood
glucose <40 mg/dl.

– What is the diagnosis in this case?

– What is the treatment for it? Acute Bacterial
Meningitis

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 Treatment
Intravenous fluids (as per
General supportive need)
•Dexamethasone 0.6mg/kg
Antibiotics Q6H for 48 hours

Treatment of complications

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 Neisseria meningitides
– 7-day of IV antibiotics
Streptococcus Pneumonia •Penicillin Sensitive
– 2-week of IV antibiotics PenicillinG/Ampicillin
•Penicillin Resistant
Listeria Monocytogenes •Penicillin /cefotaxime
Ceftriaxone Sensitive
– 3-week of IV Antibiotics •Prophylaxis
Penicillinof
G close contacts
•Penicillin Intermediate
Gram negative bacilli /H. Influenzae
Rifampin 10mg/kg
Ceftriaxone /cefotaxime
Ciprofloxacin
– Ceftriaxone and Cefotaxime •Penicillin Resistant
Azithromycin
Staphylococcus Aureus Ceftriaxone/Cefotaxime
Ceftriaxone
Streptococcus agalactiae +Vancomycin
– Penicillin G or Ampicillin
•Methilicillin Sensitive
Nafcillin
Ampicillin + •Methicillin resistant
Gentamicin Vancomycin
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 Complications
Convulsions
Cerebral edema
Subdural effusions
Shock
Inappropriate ADH secretion
Hyperpyrexia
Hydrocephalus

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 Prognosis
Long term sequelae occurs in younger age
group when treatment has been delayed
for some reason
Hearing assessment mandatory for those
with bacterial meningitis on discharge or
soon after.

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 Case No. 3
Early one evening, a 2-y-old girl is noted by the
mother to be less active than usual and felt to be
warm. Shortly thereafter, she had a brief,
generalized seizure and was rushed to the
emergency department. Upon arrival (5 min later),
she was awake but somewhat drowsy. Her rectal
temperature was 39.4 C?

– What is the most probable diagnosis in this

case?
– How would you progress?

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 History & Exam
How long the episode lasted?
Associated history of URTI, CNS, GI, or
GU systems
Previous history
Family history
Socioeconomic history

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 Febrile seizures
Seizures associated with fever in the
absence of central nervous system
infection or acute electrolyte imbalance in
a young child.
Prevalence - 3% to 8% up to 7 years of
age

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Benign with normal cognitive outcome
Recurrence – 1/3 with associated low risk of
epilepsy
Prolonged in 9% of cases

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Of all children, 3 to 5 percent will have a single
febrile seizure in the first five years of life

30 percent will have additional febrile seizures

3 to 6 percent of those with febrile seizures will

develop a febrile seizures or epilepsy

There is a 3.6 percent risk of experiencing at

least one seizure in an 80-year lifespan

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Why and at what age do children have
febrile seizures

Genetic and environmental factors

Occurring between 6 months and 6
years of age

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 CLASSIFICATION

Febrile seizures
– Simple
75% of attacks
– Complex
increased risk of epilepsy
duration longer than 15 minutes
multiple seizures within 24 hours
focal features

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When do febrile seizures recur?
30% - recurrent febrile seizures during
subsequent illnesses
Risk factors for recurrence
– onset before 18 months
– lower temperature close to 38°C
– shorter duration of fever (<1 hour) before the
seizure
– family history of febrile seizures

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What is the risk of epilepsy occurring

Majority do not develop epilepsy.

Risk factors for epilepsy
– Neurological abnormality
– A family history of epilepsy
– Short duration of fever (<1 hour) before the
seizure
– Complex febrile seizures

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Relation of the fever to the seizure

Fever - temperature of at least 38°C

Febrile seizures may occur before the
fever is apparent and early or late in the
course of a febrile illness

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Features and duration of febrile
seizures
Predominantly brief, generalized tonic-
clonic seizures
Febrile myoclonic seizures
Duration - 87% < 10 minutes
- 9% > 15 minutes
- 5% > 30 minutes
(Febrile status epilepticus)

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Do febrile seizures affect cognition
and behavior?

Excellent outcome with normal intellect

and behavior, even with complex febrile
seizures

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What investigations should be done?

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 Management

Immediate management
– Acute treatment
Rectal Diazepam (0.5 mg/kg)
Buccal (0.4-0.5 mg/kg) Midazolam
Intranasal (0.2 mg/kg) Midazolam
– Paracetamol and Ibuprofen- although no
evidence to suggest that this decreases
recurrences.

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 Management Cont:
Prophylactic treatment
– No evidence to suggest that continuous
anticonvulsant drugs reduce the risk of
epilepsy
– In recurrent prolonged febrile seizures,
Diazepam given during a fever reduces
recurrence of febrile seizures

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THANK YOU
(END OF PART-2)

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