MENINGITIS Shashi Vaish Paediatric SpR AMNCH Tallaght Con Samaan                                         Shashi Vaish Paediatric SpR AMNCH Tallaght Con Samaan

Con Samaan Bacterial Viral Fungal CAUSES Bacterial Viral Fungal Con Samaan

N. meningitides G-ve diplococci E.Coli G-ve bacilli Streptococci-GBS Con Samaan N. meningitides G-ve diplococci E.Coli G-ve bacilli                                                                                                                Streptococci-GBS G+ve cocci Strep. pneumoniae G+ve diplococci Con Samaan

Bacterial Meningitis - Organisms Con Samaan Bacterial Meningitis - Organisms • Birth - 4 wks: GBS, E.coli 4 - 12 wks: GBS, E.coli, Pneumococcus Salmonella, Listeria, H. Influenza 3 mths - 3 yrs: Pneumococcus, Meningococcus H. Influenza 3 yrs+ adult: Pneumococcus, Meningococcus Con Samaan

Bacterial Meningitis - Pathogenesis Con Samaan Bacterial Meningitis - Pathogenesis Infection of upper respiratory tract Invasion of blood stream (bacteraemia) Seeding & inflammation of meninges Con Samaan

Meningitis: Clinical features Con Samaan Meningitis: Clinical features Newborn & Infants: non-specific Fever Irritability Lethargy Poor feeding High pitched cry, bulging AF Convulsions, opisthotonus Con Samaan

Kernig’s sign

Brudzinski’s sign

Meningitis: older children Con Samaan Meningitis: older children Con Samaan

Acute Meningococcaemia Con Samaan Acute Meningococcaemia Neisseria meningitidis: serotype Grp B commonest Endotoxin causes vascular damage vasodilatation, third spacing, severe shock Severe complication: Waterhouse-Friderichsen syndrome: massive haemorrhage of adrenal glands secondary to sepsis: adrenal crisis-low B.P, shock, DIC, purpura, adreno-cortical insufficiency Con Samaan

Con Samaan Septicaemia                                                                                                                       Con Samaan

Con Samaan Purpura fulminans Con Samaan

Con Samaan Clinical features Con Samaan

Con Samaan Clinical features                                                            Con Samaan

Con Samaan Clinical features Con Samaan

Con Samaan Clinical features Con Samaan

Con Samaan Tumbler (glass) test Con Samaan

DIAGNOSIS Hx & PE Investigations: FBC Blood C/S R/L/B Skin scrapings Con Samaan DIAGNOSIS Hx & PE Investigations: FBC R/L/B CRP Coag Blood gas Glucose Blood C/S Skin scrapings PCR CXR+ Mantoux if TB suspected Con Samaan

Con Samaan Diagnosis LP Con Samaan

CSF FINDINGS Con Samaan · Bacterial Viral TB ·        Cells 10-100,000 <2,000 250-500 ·        polys lymphs lymphs ·        Glucose low normal very low ·        Protein N-INC N-INC N-INC ·        G-Stain gen +ve -ve +ve Zn Con Samaan

Bacterial Meningitis Management Con Samaan Bacterial Meningitis Management •  Medical emergency •  Early diagnosis essential Immediate optimum treatment Intensive supportive therapy Rehabilitation Prophylaxis to family Notification to GP & Public Health Con Samaan

Bacterial Meningitis/Meningococcaemia Management Con Samaan Bacterial Meningitis/Meningococcaemia Management ABC PICU Fluid management: aggressive resuscitation Dexamethasone: only in Pneumococcal and HiB, given before antibiotics Inotropes: increasing aortic diastolic pressure and improving myocardial contractility Con Samaan

Antibiotics Less than 2 months of age: Con Samaan Antibiotics Less than 2 months of age: Ampicillin + Cefotaxime+/- Gentamicin Treat for 3 weeks (neonate) Over 2 months: Cefotaxime Treat for 7-10 days Con Samaan

Prophylaxis Rifampicin: Children 5mg/kg bd x 2/7 Con Samaan Prophylaxis Rifampicin: Children 5mg/kg bd x 2/7 Adults: 600 mg bd x 2/7 Pregnant contact: Cefuroxime IM x 1 dose OR Just do T/S and await result Con Samaan

Meningitis - Complications Con Samaan Meningitis - Complications Septic shock - DIC Cerebral oedema Seizures Arteritis/venous thrombosis Subdural effusions Hydrocephalus . Abscess . Brain damage Deafness Con Samaan

Meningococcaemia - poor prognosis Con Samaan Meningococcaemia - poor prognosis • Onset of Petechiae within 12 hrs • Absence of meningitis • Shock (BP 70 or less) • Normal or low WCC • Normal or low ESR Con Samaan

Con Samaan Subdural Effusion Failure of temp to show progressive reduction after 72 hours Persistent positive spinal cultures after 72 hr Occurrence of focal/ persistent convulsions Persistence/recurrence of vomiting Development of focal neurological signs Clinical deterioration after 72 hr especially ICP Con Samaan

Partially treated meningitis Con Samaan Partially treated meningitis 50% cases prior antibiotic - alters the findings in bacterial meningitis - Accurate history vital CSF mainly lymphocytic [not usual polys] Can have normal glucose +ve cultures reduced by 30% Gram stain reduced by 20% Con Samaan

Viral meningitis Most common infection of CNS especially in <1yr Con Samaan Viral meningitis Most common infection of CNS especially in <1yr Causes: enterovirus (commonest, meningitis occurring in 50% of children <3mth ) herpes, influenza, rubella, echo, coxsackie, EBV, adenovirus Mononuclear lymphocytes in CSF Symptomatic treatment. Complications associated with encephalitis and ICP Con Samaan

Con Samaan TB Meningitis Usually insidious: difficult to diagnose in early stages (fever 30%, URTI 20%) Rare in children in developed countries If untreated is usually fatal Meningitis usually occurs 3-6mths after primary infection 1 stage-lasts 1-2wk, fever malaise, headache 2 stage-+/- suddenly, meningeal signs 3 stage-worsening neurological condition, death Con Samaan

Mortality/Morbidity Bac meningitis: Overall mortality 5-10% Neonatal meningitis: 15-20% Older children: 3-10% Strep. pneumonia: 26-30% H. influenza type B: 7-10% N. meningitidis: 3.5-10% 30% neurological complications 4% Profound b/l hearing loss (sensorineural) in all bac meningitis

Mortality/Morbidity Viral meningoencephalitis: Enteroviral fewer complications Tuberculous meningitis: related to stage of disease Stage I-30% morbidity Stage II- 56% Stage III-94%

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