Meningitis In Children

1. Meningitis In childrenMeningitis In children
Harim MohsinHarim Mohsin
02-1302-13

2. DefinitionDefinition
MeningitisMeningitis is the inflammation of the is the inflammation of the
membranes surrounding the brain & spinal membranes surrounding the brain & spinal
cord, including the dura, arachinoid & pia cord, including the dura, arachinoid & pia
matter. matter.

3. IncidenceIncidence
Meningitis can occur at all ages but it is Meningitis can occur at all ages but it is
commonest in infancy. While 95% of the commonest in infancy. While 95% of the
cases take place between 1 month- 5 cases take place between 1 month- 5
years of age. years of age.
It is more common in males than females. It is more common in males than females.

4. TransmissionTransmission
The bacteria are transmitted from person to The bacteria are transmitted from person to
person through droplets of respiratory or throat person through droplets of respiratory or throat
secretions.secretions.
Close and prolonged contact (e.g. sneezing and Close and prolonged contact (e.g. sneezing and
coughing on someone, living in close quarters or coughing on someone, living in close quarters or
dormitories (military recruits, students), sharing dormitories (military recruits, students), sharing
eating or drinking utensils, etc.) eating or drinking utensils, etc.)
The incubation period ranges between 2 -10 The incubation period ranges between 2 -10
days. days.

5. Routes of Infection
NasopharynxNasopharynx
Blood streamBlood stream
Direct spread (skull fracture, meningo and Direct spread (skull fracture, meningo and
encephalocele)encephalocele)
Middle ear infectionMiddle ear infection
Infected Ventriculoperitoneal shunts.Infected Ventriculoperitoneal shunts.
Congenital defectsCongenital defects
SinusitisSinusitis

6. Signs & SymptomsSigns & Symptoms
The symptoms of meningitis vary and depend on the age of the The symptoms of meningitis vary and depend on the age of the
child and cause of the infection. Common symptoms are:child and cause of the infection. Common symptoms are:
Flu-like symptomsFlu-like symptoms
fever fever
lethargy lethargy
Altered consciousnessAltered consciousness
irritability irritability
headache headache
photophobia photophobia
stiff neck stiff neck
Brudzinski signBrudzinski sign
Kernig sign Kernig sign
skin rashes skin rashes
seizures seizures

7. Signs & symptomsSigns & symptoms
Other symptoms of meningitis in Neonates/infants Other symptoms of meningitis in Neonates/infants
can include:can include:
ApneaApnea
jaundicejaundice
neck rigidity neck rigidity
Abnormal temperature (hypo/hyperthermia)Abnormal temperature (hypo/hyperthermia)
poor feeding /weak sucking poor feeding /weak sucking
a high-pitched cry a high-pitched cry
bulging fontanellesbulging fontanelles
Poor reflexes Poor reflexes

8. TypesTypes
BacterialBacterial
Viral (aseptic)Viral (aseptic)
FungalFungal
ParasiticParasitic
Non-infectiousNon-infectious

9. Pyogenic Meningitis Pyogenic Meningitis
ETIOLOGY
‘Meningococcal’ meningitis- N. meningitidis. A, B, C and W135)
are recognized to cause epidemics
The commonest organisms according to age groups are:The commonest organisms according to age groups are:
N.Meningitides (serotypes A,B,C, Y & W135)
S.Pneumoniae (serotypes 1,3, 6,7)
H.Influenzae
2 yrs – 15+yrs
H.Influenzae type b, S.Pneumoniae,
N.Meningitides.
2 months- 2yrs
E.Coli, Group B streptococci, S.Aureus, Listeria
Monotocytogenes
0-2 months

10. Bacterial MeningitisBacterial Meningitis
Pathogenesis: Pathogenesis:
Entry of organism through blood brain barrierEntry of organism through blood brain barrier
release of cell wall & membrane products release of cell wall & membrane products
Outpouring of polymorphs & fibrinOutpouring of polymorphs & fibrin
cytokines & chemokines cytokines & chemokines
Inflammatory mediatorsInflammatory mediators
Inflamed meninges covered with exudate (most Inflamed meninges covered with exudate (most
marked in pneumoccocal meningitis). marked in pneumoccocal meningitis).

11. PathogenesisPathogenesis
Meningeal irritation signs: inflammation of the spinal nerves Meningeal irritation signs: inflammation of the spinal nerves
& roots. & roots.
Hydrocephalus: Adhesive thickening of the arachinoid in Hydrocephalus: Adhesive thickening of the arachinoid in
basal cistern or fibrosis of aqueduct or Foramina of Lushka basal cistern or fibrosis of aqueduct or Foramina of Lushka
or Magendieor Magendie
Cerebral atrophy: thrombosis of small cortical veins Cerebral atrophy: thrombosis of small cortical veins
resulting in necrosis of the cerebral cortex. resulting in necrosis of the cerebral cortex.
Seizures: depolarisation of neuronal membranes as a result Seizures: depolarisation of neuronal membranes as a result
of cellular electrolyte imbalance. of cellular electrolyte imbalance.
Hypoglycorhachia: decreased transport of glucose across Hypoglycorhachia: decreased transport of glucose across
inflammed choroid plexus & increased usage by host. inflammed choroid plexus & increased usage by host.

12. NeonatesNeonates
Suspect meningitis with temperature more than Suspect meningitis with temperature more than
100.7 ‘F(38.2’C).100.7 ‘F(38.2’C).
Risk factors:Risk factors:
Infective illness in motherInfective illness in mother
PROMPROM
Difficult deliveryDifficult delivery
Premature babiesPremature babies
Spina bifidaSpina bifida

13. D/D:D/D:
Tuberculous Meningitis Tuberculous Meningitis
Viral /aseptic MeningitisViral /aseptic Meningitis
Brain AbscessBrain Abscess
Brain tumorBrain tumor
Cerebral malariaCerebral malaria

14. Viral meningitisViral meningitis
Viral meningitis comprises most aseptic Viral meningitis comprises most aseptic
meningitis syndromes. The viral agents for meningitis syndromes. The viral agents for
aseptic meningitis include the following:aseptic meningitis include the following:
Enterovirus (polio virus, Echovirus, Enterovirus (polio virus, Echovirus,
Coxsackievirus )Coxsackievirus )
Herpesvirus (Hsv-1,2, Varicella.Z,EBV )Herpesvirus (Hsv-1,2, Varicella.Z,EBV )
Paramyxovirus (Mumps, Measles)Paramyxovirus (Mumps, Measles)
Togavirus (Rubella)Togavirus (Rubella)
Rhabdovirus (Rabies)Rhabdovirus (Rabies)
Retrovirus (HIV)Retrovirus (HIV)

15. Fungal MeningitisFungal Meningitis
It’s rare in healthy people, but is a higher It’s rare in healthy people, but is a higher
risk in those who have AIDS, other forms risk in those who have AIDS, other forms
of immunodeficiency or of immunodeficiency or
immunosuppression. immunosuppression.
The most common agents are The most common agents are
Cryptococcus neoformans, Candida, H Cryptococcus neoformans, Candida, H
capsulatum. capsulatum.

16. Parasitic MeningitisParasitic Meningitis
Infection with free-living amoebas is an infrequent Infection with free-living amoebas is an infrequent
but often life-threatening human illness.but often life-threatening human illness.
It’s more common in underdeveloped countries It’s more common in underdeveloped countries
and usually is caused by parasites found in and usually is caused by parasites found in
contaminated water, food, and soil. contaminated water, food, and soil.
The most common causative agents are:The most common causative agents are:
Free-living amoebas (ie, Free-living amoebas (ie, Acanthamoeba, Acanthamoeba,
Balamuthia, Naegleria)Balamuthia, Naegleria)
Helminthic eosinophilic meningitisHelminthic eosinophilic meningitis

17. Non-infectious meningitisNon-infectious meningitis
Rarely, meningitis can be caused by exposure to certain Rarely, meningitis can be caused by exposure to certain
medications, such as the following: medications, such as the following:
Immune globulinImmune globulin
Levamisole Levamisole
MetronidazoleMetronidazole
Mumps and rubella vaccinesMumps and rubella vaccines
Nonsteroidal anti-inflammatory drugs (e.g., ibuprofen, Nonsteroidal anti-inflammatory drugs (e.g., ibuprofen,
diclofenac, naproxen)diclofenac, naproxen)

18. Tuberculous meningitisTuberculous meningitis
It’s a complication of Childhood It’s a complication of Childhood
tuberculosis & common cause of tuberculosis & common cause of
prolonged morbidity, handicap & prolonged morbidity, handicap &
death.death.
Children below 5 years are specially Children below 5 years are specially
prone.prone.

19. CLINICAL FEATURES
Always sec. to primary tuberculosis.Always sec. to primary tuberculosis.
First PhaseFirst Phase:: Vague symptoms. Vague symptoms.
Child doesn’t play, is irritable, restless or Child doesn’t play, is irritable, restless or
drowsy.drowsy.
Anorexia & vomiting may be presentAnorexia & vomiting may be present
Older child may complain of headache.Older child may complain of headache.
Possibly preceding history of Measles or Possibly preceding history of Measles or
another illness with incompletely recoveryanother illness with incompletely recovery

20. SECOND PHASESECOND PHASE::
Child is drowsy with neck stiffness, & Child is drowsy with neck stiffness, &
rigidity.rigidity.
Kernig & Brudzinski sign may become Kernig & Brudzinski sign may become
positive, anterior fontanels bulgespositive, anterior fontanels bulges
Twitching of muscles, convulsions, raised Twitching of muscles, convulsions, raised
temperature.temperature.
strabismus, nystagmus, and papilloedema strabismus, nystagmus, and papilloedema
may be present.may be present.
Fundoscopy:Fundoscopy: Choroidal TB may be seen Choroidal TB may be seen

21. TERMINAL PHASETERMINAL PHASE
Child is characteristically comatose Child is characteristically comatose
with opisthotonus, & multiple focal with opisthotonus, & multiple focal
paresis.paresis.
Cranial nerve palsies are present.Cranial nerve palsies are present.
High grade fever often occurs High grade fever often occurs
terminally.terminally.

22. DiagnosisDiagnosis
Lumbar PunctureLumbar Puncture:: pressure usually raised, pressure usually raised,
10-500 PMNs early but later lymphocytes 10-500 PMNs early but later lymphocytes
predominatepredominate
Protein- 100-500,raisedProtein- 100-500,raised
Glucose less than 50mg/dl in most casesGlucose less than 50mg/dl in most cases
Culture for tubercle bacilli.Culture for tubercle bacilli.
Presence of tuberculous focus elsewhere in the Presence of tuberculous focus elsewhere in the
body is strong supportive diagnosis.body is strong supportive diagnosis.
CXR.CXR.
Tuberculin skin testTuberculin skin test..

23. TreatmentTreatment
Antituberculous Therapy:Antituberculous Therapy: Includes Includes
simultaneous administration of 4 drugs simultaneous administration of 4 drugs
(Isoniazid, rifampicin,streptomycin , (Isoniazid, rifampicin,streptomycin ,
pyrazinamide) for first 3 months, followed pyrazinamide) for first 3 months, followed
by 2 drugs for another 15 months usually by 2 drugs for another 15 months usually
Rifampicin & INH.Rifampicin & INH.
Total period:Total period: 18 months. 18 months.

24. TreatmentTreatment
STEROIDS:STEROIDS: to reduce cerebral edema and to reduce cerebral edema and
to prevent subsequent fibrosis & to prevent subsequent fibrosis &
subsequent obstruction to CSFsubsequent obstruction to CSF
2mg/kg/24 hours of prednisolone for 6-8 2mg/kg/24 hours of prednisolone for 6-8
weeks at the start of treatment starting 3 weeks at the start of treatment starting 3
days after initiation of anti tuberculous days after initiation of anti tuberculous
therapy.therapy.

25. D/D D/D
Partially treated bacterial meningitisPartially treated bacterial meningitis
Viral meningitisViral meningitis
Cerebral malariaCerebral malaria
Viral encephalitisViral encephalitis

26. Chronic MeningitisChronic Meningitis
Chronic meningitis Chronic meningitis
is a constellation is a constellation
of signs and of signs and
symptoms of symptoms of
meningeal meningeal
irritation irritation
associated with associated with
CSF pleocytosis CSF pleocytosis
that persists for that persists for
longer than 4 longer than 4
weeks. weeks.

27. ExaminationExamination
General physical- General physical- Check for Consciousness level according to GCS
scoring, jaundice or irritability.
Resuscitation:Resuscitation: incase of septic shock, or DIC. incase of septic shock, or DIC.
Vitals:Vitals: temperature , HR, B.P., R/R. temperature , HR, B.P., R/R.
Signs of Increased ICP-Signs of Increased ICP- Bulging fontanelle, headache, nausea, Bulging fontanelle, headache, nausea,
vomiting, ocular palsies, altered level of consciousness, and vomiting, ocular palsies, altered level of consciousness, and
papilledema papilledema
Fundus:Fundus: papilloedema papilloedema
CN palsies:CN palsies: (esp. occulomotor, facial, and auditory) (esp. occulomotor, facial, and auditory)

28. ExaminationExamination
Meningismus - check for nuchal rigidity with passive Meningismus - check for nuchal rigidity with passive
neck flexion (gives 'involuntary resistance).neck flexion (gives 'involuntary resistance).
Brudzinski sign (hip & knee flexion with neck Brudzinski sign (hip & knee flexion with neck
movement) movement)
Kernig sign (extend knee with hip flexed)Kernig sign (extend knee with hip flexed)
Hemiparesis.Hemiparesis.
Rash:Rash: petechial or purpuric rash (not only in petechial or purpuric rash (not only in
meningococcal but also pneumococcal bacteremia).meningococcal but also pneumococcal bacteremia).

31. InvestigationsInvestigations
CBCCBC
Blood cultureBlood culture
Gram stainingGram staining
LP- D/r, C/s (color, leukocyte count, differential, glucose, LP- D/r, C/s (color, leukocyte count, differential, glucose,
protein)protein)
ElectrolytesElectrolytes
PCRPCR
Coagulation profile Coagulation profile
liver and kidney function liver and kidney function
Chest X-rayChest X-ray
CT/ MRICT/ MRI
Blood gasesBlood gases
EEGEEG
ECGECG

32. DiagnosisDiagnosis
CSF picture is quite diagnostic of the kind of CSF picture is quite diagnostic of the kind of
meningitis present. meningitis present.

33. Contraindication for LPContraindication for LP
.Increase intracranial pressure.
.Unstable patient.
.Skin infection at site of LP.
.Thrombocytopenia.
.Papilloedema.

34. DiagnosisDiagnosis
Latex particle agglutination: Latex particle agglutination: detects presence of detects presence of
bacterial antigen in the spinal fluid. useful for detection bacterial antigen in the spinal fluid. useful for detection
of H.influenzae type b, S.Pnemoniae, N.Meningitidis, of H.influenzae type b, S.Pnemoniae, N.Meningitidis,
E.ColiE.Coli
Concurrent immuno-electrophoresis (CIE)-used for Concurrent immuno-electrophoresis (CIE)-used for
rapid detection of H.influenza, S.pneumoniae & rapid detection of H.influenza, S.pneumoniae &
N.meningitides. N.meningitides.
Smears:Smears: taken from purpuric spots may show taken from purpuric spots may show
meningococci in Meningococcaemiameningococci in Meningococcaemia
DNA sequences :DNA sequences : are helpful in identifying bacteria are helpful in identifying bacteria

35. TreatmentTreatment
Supportive therapy:Supportive therapy:
Maintain fluid & electrolyte balance as Maintain fluid & electrolyte balance as
requiredrequired
Transfuse whole blood, PRC, FFP or Transfuse whole blood, PRC, FFP or
platelets as required.platelets as required.
Maintain temperature controlMaintain temperature control
Monitor OFCMonitor OFC

36. TreatmentTreatment
SteroidsSteroids::
Dexamethasone useful for H.influenzae type b, Dexamethasone useful for H.influenzae type b,
First dose should be given 1 hr prior to starting First dose should be given 1 hr prior to starting
antibiotics.antibiotics.
Antibiotics IVAntibiotics IV..
Duration:1-3 weeks depending on age & type of Duration:1-3 weeks depending on age & type of
organisms.organisms.

37. TreatmentTreatment
Initial till results of Initial till results of
C/S are knownC/S are known
Probable/Proved Probable/Proved
MeningococciMeningococci
Ampicillin Ampicillin
300mg/kg/day+300mg/kg/day+
ChloramphenicolChloramphenicol
75-100mg.kg/day75-100mg.kg/day
Penicillins Penicillins
2-5 lac units /kg/day2-5 lac units /kg/day

38. TreatmentTreatment
Probable Probable
H.InfluenzaeH.Influenzae
Probable E.ColiProbable E.Coli
Ampicillin + Ampicillin +
chloramphenicol or chloramphenicol or
33
rdrd
generation generation
cephalosporincephalosporin
(cefotaxime (cefotaxime
200mg/kg/day)200mg/kg/day)
 Ampicillin + Ampicillin +
gentamycingentamycin
200mg/kg+2.5-4 mg/kg 200mg/kg+2.5-4 mg/kg
IV 12hrlyIV 12hrly

39. TreatmentTreatment
Probable group B Probable group B
streptococcistreptococci
Penicillin Penicillin
50,000i.u/kgI.V/4 50,000i.u/kgI.V/4
hourly.hourly.

40. Other Drugs availableOther Drugs available
Anti-microbialsAnti-microbials
CeftriaxoneCeftriaxone
CefotaximeCefotaxime
Penicillin G Penicillin G
VancomycinVancomycin
AmpicillinAmpicillin
Gentamicin Gentamicin
Anti-ViralsAnti-Virals
Acyclovir
Ganciclovir (>3mths)Ganciclovir (>3mths)
Anti-fungals
Amphotericin B
Fluconazole

41. PreventionPrevention
The vaccines against Hib, measles, mumps, polio, The vaccines against Hib, measles, mumps, polio,
meningococcus, and pneumococcus can protect against meningococcus, and pneumococcus can protect against
meningitismeningitis
Hib vaccine: Hib vaccine: all infants should receive at 2,4,6 months of all infants should receive at 2,4,6 months of
age & booster 1 year later.age & booster 1 year later.
After 1 year 1 dose is given till the age of 5 years.After 1 year 1 dose is given till the age of 5 years.
Pneumococcal vaccine: Pneumococcal vaccine: 0.5 ml is given IM (<2 yrs)0.5 ml is given IM (<2 yrs)

42. PreventionPrevention
High-risk children should also be immunized routinely.High-risk children should also be immunized routinely.
Vaccination before travelling to an endemic areaVaccination before travelling to an endemic area
Chemoprophylaxis for susceptible individuals or close Chemoprophylaxis for susceptible individuals or close
contacts:contacts:
H influenzaeH influenzae type b : Rifampin(20 mg/kg/d) for 4 days type b : Rifampin(20 mg/kg/d) for 4 days
N meningitidis: Rifampin (600 mg PO q12h) for 2 days upto N meningitidis: Rifampin (600 mg PO q12h) for 2 days upto
10weeks10weeks
Ceftriaxone (250 mg IM) single dose or Ceftriaxone (250 mg IM) single dose or
Ciprofloxacin(500-750 mg) single dose. Ciprofloxacin(500-750 mg) single dose.

43. ComplicationsComplications
Bacterial meningitis may result inBacterial meningitis may result in
Cranial nerve palsies Cranial nerve palsies
Subdural empyema Subdural empyema
Brain abscess Brain abscess
Hearing loss Hearing loss
Obstructive hydrocephalus Obstructive hydrocephalus
Brain parenchymal damage: Learning disability, CP, Brain parenchymal damage: Learning disability, CP,
seizures, Mental retardation.seizures, Mental retardation.
Septic shock/ DIC Septic shock/ DIC
AtaxiaAtaxia
StrokeStroke
SIADH (Na+ <130 mE/l), puffiness of face, dec UO.SIADH (Na+ <130 mE/l), puffiness of face, dec UO.

44. Treatment of Complications:Treatment of Complications:
Convulsions:Convulsions: Diazepam I.V, Can be Diazepam I.V, Can be
repeated q4 hours as required.repeated q4 hours as required.
Cerebral edema:Cerebral edema: *I.V Mannitol 1g/kg in *I.V Mannitol 1g/kg in
20-30 mins 6-8 hourly given for first few 20-30 mins 6-8 hourly given for first few
days.days.
IV Dexamethasone can then be used 6 IV Dexamethasone can then be used 6
hourlyhourly. .

45. Subdural effusion:Subdural effusion:
Aspirate subdural effusion if large.Aspirate subdural effusion if large.
Shock:Shock: Treat with IV Fluids, maintanence of BP. Treat with IV Fluids, maintanence of BP.
SIADH:SIADH: Increase body weight, decreased serum Increase body weight, decreased serum
osmolality, hyponatremia.osmolality, hyponatremia.
Prevented by fluid restriction to 800-1000ml/m2/24 Prevented by fluid restriction to 800-1000ml/m2/24
hours.hours.
Hyperpyrexia:Hyperpyrexia: Tepid sponging, correction of Tepid sponging, correction of
dehydration.dehydration.

46. PrognosisPrognosis
It depends on the age of the patient, the duration of the It depends on the age of the patient, the duration of the
illness, complications, micro-organism & immune status. illness, complications, micro-organism & immune status.
Patients with viral meningitis usually have a good Patients with viral meningitis usually have a good
prognosis for recovery.prognosis for recovery.
The prognosis is worse for patients at the extremes of age The prognosis is worse for patients at the extremes of age
(ie, <2 y, >60 y) and those with significant comorbidities (ie, <2 y, >60 y) and those with significant comorbidities
and underlying immunodeficiency.and underlying immunodeficiency.
Patients presenting with an impaired level of Patients presenting with an impaired level of
consciousness are at increased risk for developing consciousness are at increased risk for developing
neurologic sequelae or dying.neurologic sequelae or dying.

47. PrognosisPrognosis
A seizure during an episode of meningitis also is A seizure during an episode of meningitis also is
a risk factor for mortality or neurologic sequelae.a risk factor for mortality or neurologic sequelae.
Acute bacterial meningitis is a medical Acute bacterial meningitis is a medical
emergency and delays in instituting effective emergency and delays in instituting effective
antimicrobial therapy result in increased morbidity antimicrobial therapy result in increased morbidity
and mortality. and mortality.
The prognosis of meningitis caused by The prognosis of meningitis caused by
opportunistic pathogens depends on the opportunistic pathogens depends on the
underlying immune function of the host as may underlying immune function of the host as may
require lifelong suppressive therapy. require lifelong suppressive therapy.

48. ReferencesReferences
Nelson textbookNelson textbook
Basis of pediatricsBasis of pediatrics
WHO recommendationsWHO recommendations
E-medicine E-medicine