Meningitis

An inflammation of pia and arachnoid membranes
caused by bacteria, viruses, fungi, other organisms, or non-infective causes, such as trauma.
90%  of all cases of meningitis occur within the first 5 years of life (the peak 6 to 12 month age range) .

Clinical features and Hx of meningitis

The diagnosis may be more difficult in the very young as history and
presentations can be non-specific
0–2 months
>2 months
  • fever or hypothermia
  • bulging fontanelle
  • irritability
  • high pitched cry
  • lethargy
  • altered mental state
  • seizures
  • apnoea
  • poor feeding
  • vomiting.
  • fever
  • neck stiffness (60- 80%, more useful in children > 3 years)
  • Kernig’s sign
  • Brudzinki’s sign
  • altered mental state a
  • norexia,
  • nausea and/or vomiting  
  • photophobia (older children)
  • seizures

Other features


  • purpuric rash, especially in meningococcal meningitis



  • tachycardia

    History


  • Preceding upper respiratory tract infection



  • age (90% of bacterial meningitis occurs at age < five years)



  • vaccination history



  • recent use of antibiotics



  • Drug allergies.

    just to remember few clinical sings

    Differential diagnosis
    • subarachnoid haemorrhage
    • migraine

    Initial management

    Assessing ABCDE,  ‘Airway, Breathing,Circulation, Disability (level of consciousness) and Environment (presence of rash, temperature control)’

    Airway and Breathing

    • open airway and adequate ventilation
    • respiratory support  (form of bag and mask technique, followed by endotracheal intubation)
    Circulation

    • Patients with shock : rapid infusion intravenous/interosseous crystalloid (Normal saline) 20ml/kg.
    • Fluid restriction (for SIADH) should only be undertaken once the patient is no longer shocked

    Disability (level of consciousness)

    • If there are signs of cerebral oedema : mannitol (0.5–1.5g/kg = 2.5–7.5 mL/kg of 20% solution) should be given.
    • The bed should be elevated to 30° and ventilation controlled to maintain PaCO2 between 30–35mmHg.
    Environment

    image The presence of a rash may be indicative of meningococcal sepsis.
    • Regulationof temperature is important
    Seizures
    • Seizures should be treated immediately with a rapid injection of a benzodiazepine(eg midazolam, 0.15mg/kg, IV).
    • Alternatively, IM midazolam (0.15mg/kg) or rectal diazepam(0.5mg/kg ) could be used.
    • phenytoin (20mg/kg over 20 minutes) should given if seizures continue.
    after stabilized, then the examination should include general assessment looking for features of sepsis and meningitis.

    Diagnostic tests

    Routine investigations

    • Blood tests -FBC, with differential WCC, blood film ,CRP ,Blood urea, electrolytes, glucose, LFTs

    • CSF analysis- Full Report -(includes protein, cell count and gram stain,Glucose,Culture )

    Additional tests
    • Blood-JE serology ,Herpes simplex serology
    • CSF-Bacterial antigen detection,Mycobacterium tuberculosis (AFB, PCR and culture,Cryptococcal stain and antigen- immuno-compromised
      patients,Viral cultures ,Antibodies(JE/HSV Ab ,Mumps Ab Measles Ab )
    • Skin- scrapings of skin lesions for microscopy + culture
    • EEG-for Herpes simplex encephalitis – focal changes specially in the temporal lobe
    • CT brain- when there is doubt about other causes of meningism such as posterior fossa tumour or complications like abscess

    The Lumbar Puncture (LP)

    • performed once the diagnosis of meningitisis suspected and after the patient is stabilised.
    • Antibiotics may sterilise the CSF within one hour in meningococcal meningitis and within four hours in pneumococcal meningitis.
    • However, instituting antibiotics 1–2 hours prior to LP does not decrease the diagnostic sensitivity of the CSF culture if done in
      conjunction with blood cultures and CSF bacterial antigens.

    Indications to delay the LP
    1. Signs of raised intracranial pressure
    2. convulsive seizures
    3. Otherfocal neurological signs—hemi/monoparesis, extensorplantar responses, ocular palsies
    4. Glasgow Coma Score < 13 or deterioratinglevel of consciousness
    5. Strong suspicion of meningococcal infection(typical purpuricrash in an ill child)
    6. State of shock
    7. Localsuperficial infection
    8. Coagulation disorder.
    image
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