Meningitis Encephalitis Brain abscess Myelitis Subdural empyema/abscess Epidural empyema/abscess etc Common bacterial etiologies of meningitis and risk factors Streptococcus Age less than 2 years, Pneumoniae Sickle cell disease, immune-compromised children, children with cochlear implants, unvaccinated Neisseria Viral upper respiratory meningitidis infetions like influenza, smoke exposure Hemophilus Sickle cell disease, influenzae immune-compromised children, asplenia, parental smoking, short duration of breast feeding, EPIDEMIOLOGY
Age distribution H. influenzae, peak age 6months
N. meningitidis, children 5-14 years
S. pneumoniae children<1 year, and adults
EPIDEMIOLOGY, CONTD. Epidemic meningococcal disease in African Meningitis Belt Epidemics occur every 5- 10 years Epidemics occur in dry season Peak age group 5-14 years Epidemic thresholds
15 cases/100,000 population/wk (Population>30,000) 5 cases/wk (Population<30,000) OTHER RISK FACTORS Lack of immunity associated with young age.
Male gender.
Infants & young children with occult
bacteremia
Defects of the complement system (C5-
C8) and OTHER RISK FACTORS T-lymphocyte defects (L. monocytogenes)
Congenital or acquired CSF leak
(pneumococcus)
Lumbosacral dermal sinus and
meningomyelocele (staphylococcal & gram-negative enteric bacteria) PATHOGENESIS The mode of transmission is probably person- to-person contact through respiratory tract secretions or droplets.
Bacteria gain entry to the CSF through choroid
plexus of the lateral ventricles and the meninges and then circulate to the extracerebral CSF and subarachnoid space. Bacteria rapidly multiply because the CSF concentrations of complement and antibody are inadequate to contain bacterial proliferation. PATHOGENESIS A meningeal purulent exudate may be distributed around the cerebral veins, venous sinuses, convexity of the brain, & cerebellum & in the sulci, sylvian fissures, basal cisterns, and spinal cord.
Inflammation of spinal nerves and roots
produces meningeal signs, CLINICAL MANIFESTATIONS Initially - Nonspecific SSx & Signs (fever, URT or GI SSx, lethargy, irritability, tachycardia, hypotension,
cutaneous signs - petechiae)
Meningeal irritation nuchal rigidity + pain, Kernig sign (flexion of the hip 90 degrees with subsequent pain with extension of the leg), and Brudzinski sign (involuntary flexion of the knees and hips CLINICAL MANIFESTATIONS Increased ICP
headache, emesis bulging fontanel or diastasis (widening) of the sutures oculomotor (anisocoria, ptosis) or abducens nerve paralysis, hypertension with bradycardia, apnea or hyperventilation, decorticate or decerebrate posturing, stupor, coma, or CLINICAL MANIFESTATIONS Focal neurologic signs
Cranial neuropathies of CN 2, 3, 6, 7 & 8
Seizures (focal or generalized)
Alterations of mental status
TESTING FOR MENINGEAL IRRITATION DIAGNOSIS LAB DIAGNOSIS CSF analysis Peripheral WBC count + differential Blood & CSF cultures Bacterial antigen testing PCR of CSF & blood CT scan (for dx of complications) CSF EXAMINATION CSF parameter Typical finding Opening pressure 200 - 500mmH2O White blood cell count 1000 - 5000/mm3; %Neutrophils >80% Protein 100-500 mg/dl Glucose <40 mg/dl; CSF:serum glucose<0.4 Gram Stain Positive in 60-90% Culture Positive in 70-85% Detection of bacterial antigen; PCR Form of Opening Leukocytes Protein Glucose Comments meningitis pressure and differential Normal 50 - 80 < 5, >75% 20 - 45 > 50 values mm H2O lymphocytes mg/dl mg/dl Acute Usually usually 300 Usually usually < Organisms bacterial elevated –2,000; 100 – 500 40 usually seen meningitis (100 – PMNs on Gram 300) predominate stain / culture Partially Normal or 5 – 10,000; Usually Normal or treated elevated PMNs usual 100 – 500 decreased bacterial meningitis Viral Normal or Rarely Usually Generally meningitis slightly >1,000 50 – 200 normal elevated cells. (80 – mononuclea 150) r cells predominate TB Usually 10 – 500; 100 – < 50 in Acid-fast meningitis elevated lymphocytes 3,000 most organisms LUMBAR PUNCTURE INDICATIONS To diagnose CNS infections To drain CSF in communicating hydrocephalus associated with intraventricular hemorrhage
To diagnose intracranial hemorrhage
To diagnose CNS involvement with leukemia
To inject chemotherapeutic agents
To instill contrast material for myelography
CONTRAINDICATIONS
Increased intracranial pressure (ICP)
Uncorrected thrombocytopenia/bleeding diathesis
Infection in skin or underlying tissue at/near
puncture site
Lumbosacral anomalies
Cardiorespiratory instability, which may be
PROCEDURE
Have an assistant restrain the infant in the lateral
decubitus or sitting position, with spine flexed. Avoid flexion of the neck, as this increases the chance of airway compromise.
Palpate inter-space that falls immediately above
or below an imaginary line drawn between iliac crests
Clean the lumbar area with antiseptic.
Drape, leaving puncture site & infant's face exposed
Insert the needle in the midline into desired
interspace.
Aim slightly cephalad (on a plane with
the umbilicus) to avoid the vertebral bodies.
Advance the needle slowly to a depth of approx-
imately 1 to1.5 cm in a term infant, less in a preterm infant, until the epidermis and dermis are traversed. COMPLICATIONS of procedure Post-LP headache * Infection * Hypoxemia
Intraspinal epidermoid tumor
Contamination of CSF sample with blood (traumatic
tap)
Aspiration, bleeding, CN 6 palsy, Cardiopulmonary
arrest
Intracranial decompression with cerebral herniation
Spinal cord puncture and nerve damage, deformity of COMPLICATIONS Brain abscess Seizure Raised ICP Hydrocephalus (usually communicating) CN Palsy Subdural effusion SIADH Stroke Cerebral and cerebellar herniation Developmental delay PRINCIPLES OF TREATMENT Agent used must be bactericidal against infecting organism
IV drugs should be used to reach a sufficient CSF concentration
A child with rapidly progressing disease of less than 24 hr
duration, in the absence of increased ICP, should receive antibiotics as soon as possible after an LP is performed
If there are signs of increased ICP or focal neurologic findings,
antibiotics should be given without performing an LP and before obtaining a CT scan TREATMENT – CHOICE OF ANTIBIOTICS S Pneum, H infl & N men – IV penicillin / cephalosporins
CAF – bacteriostatic for GN rods but
bactericidal for S Pneum, H infl, and N meningitis
If GN rods are noted on gram stain – add an
aminoglycoside
For Neonatal bacterial meningitis: IV ampicillin and IV
gentamicin (based on the most common etiologic agents) TREATMENT Duration of treatment
N meningitis 5-7 days
H influenzae 7-10 days S pneumoniae 10-14 days L monocytogenes 14-21 days Enteric GN rods 3 wks PROGNOSIS Poor prognostic factors
ÞPneumococcal meningitis ÞAge younger than 6 months ÞSeizures lasting > 4 days after start of treatment ÞComa at presentation ÞFocal neurologic signs at presentation ÞLow CSF glucose < 20 mg/dL PREVENTION Chemoprohylaxis for “close contacts” H.influenzae N.meningitidis
