Meningitis ( Introduction , classification , Pathophysiology , clinical features )

Meningitis in Pediatrics ,

1. Meningitis Presenter : Dr.Hardik Shah Guide: Dr.Mahesh Kamate 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 1

2. Scheme of Presentation Introduction & Definition Types Etiology Dr.Hardik Predisposing/ Risk factor Pathophysiology Clinical features Diagnosis Treatment Complication Dr.Nishant Prognosis 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 2

3. Introduction Meningitis: I nflammation of leptomeninges, with variable involvement of encephalons Encephalitis : I nflammation of Brain Parenchyma. Meningoencephalitis: I nflammation of meninges and Brain Parenchyma. 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 3

4. Ventriculitis : Inflammation of the ventricles in the brain, 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 4

5. Meningitis / Encephalitis Classical triad of Meningitis -Fever -Headache -Neck Stiffness Length and Progression of Symptoms are Slower than encephalitis. 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 5

6. Encephalitis Acute or subacute onset of Symptoms and Present with Neurological deficit Loss of consciousness on presentation, 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 6

7. Classification Based on etiology Infectious Non infectious Based on Duration Acute Subacute Chronic Based on culture report Septic Aseptic 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 7

8. Etiology Based Infectious Non Infectious 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 8

9. Infectious Bacterial Viral Fungal Ricketsial Parasitic/ protozoal 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 9

10. Bacterial Most Common Neisseria Meningitidis (B, C, Y, W 135, Epidemic strain A) Streptococcus Pneumoniae ( 1,5,6,7,14,19 serotype) Hemophilus Influenzae (Commonest , Endemic) Less Common Staphylococcus Coagulase – ve and + ve E.coli , Pseudomonas , Proteus , Enterobacter 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 10

11. 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 11

12. Viral Non-polio enteroviruses Mumps virus Herpesviruses, including , herpes simplex viruses, Measles Influenza Arboviruses such as  West Nile 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 12

13. Non Infectious meningitis can be caused by exposure to certain medications, such as the following: Immune globulin Levamisole Metronidazole Mumps and rubella vaccines Nonsteroidal anti-inflammatory drugs (e.g., ibuprofen, diclofenac, naproxen. 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 13

14. Collagen vascular disease SLE Wegner’s Granulomatosis Polyarteritis Nodosa Sarcoidosis Chemotherapeutic agents Malignancies Leukemia Lymphoma 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 14

15. Based On Duration Of illness Acute : Duration of illness <7days Sub Acute : 1 to 4weeks Chronic : >4weeks 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 15

16. Chronic Meningitis 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 16

17. Septic Vs Aseptic Aseptic meningitis or sterile  meningitis : the layers lining the brain, the  meninges , become inflamed absence of detectable pyogenic bacterial  infection. 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 17

18. Bacterial Meningitis Most Potential serious Infection In infant and older Children. High rate of acute complication and long term morbidity 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 18

19. Predisposing Factors Septicemia Septic focus in Skin , Lung , Bones Trauma Pilonidal Sinus Fracture Base of Skull Neural tube Defect Suppurative ear Or mastoid Infection VP shunts Occult bacteremia 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 19

20. Sickle cell predisposes pneumococcal meningitis Immunocompromised States HIV A/ Hypogamma globulinemia Complement Deficeiency Malnutrition Overcrowding Transmission usually by droplets/ Saliva 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 20

21. Pathogenesis Nasopharyngeal Colonisation 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 21

22. 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 22

23. Pathophysiology Heavy Bacteraemia : Cerebral vein , venous sinuses , Micro arterioles Cerebrum , cerebellum , basal cisterns and Spinal cord With Internal and external Changes 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 23

24. 2. Ventriculitis with Inflammatory cells in CSF Vascular AND Parenchymal Involvement : - Perivascular Inflammatory infiltrates - Disruption of ependymal Membrane - Poly morphonuclear infiltrates 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 24

25. Vasculitis , small cortical vein thrombosis, Occlusion of major venous sinuses Necrotising arteritis Sub arachnoid haemorrhage , cerebral cortical Necrosis, cerebral infarction 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 25

26. Now, Why?? - Meningeal Signs Why? - Raised ICT Why -Hydrocephalus 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 26

27. What is a cause of Raised CSF Protein? What is a cause of Low Glucose in CSF 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 27

28. Raised ICP Cytokine induces increased capillary vascular permeability ( vasogenic Cerebral Oedema) Cellular Death Due to cytotoxic cerebral oedema Obstructed reabsorption of CSF or obstructed its pathway  Increased Hydrostatic pressure (Interstitial cerebral oedema) 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 28

29. Hydrocephalus M/C Communicating Hydrocephalus Adhesive thickening of arachnoid villi Interfere with reabsorption of CSF Followed by gliosis and fibrosis will cause obstructive type of hydrocephalus. 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 29

30. Raised CSF Protein Because of increase vascular permeability of Blood brain Barrier, Loss of albumin rich fluids from the capillaries and veins traversing the subdural space Continuous transudation  Subdural effusion 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 30

31. Low Glucose in CSF Decreased glucose transport by cerebral tissue This all will lead to clinical menifestations . 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 31

32. Why Meningeal signs? Inflammation of spinal nerves and roots produces meningeal irritation, Inflammation of cranial nerves produces cranial nerve neuropathies like optic, oculomotor , facial , Auditory nerves 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 32

33. Temporal lobe compression due to tentorial herniation will cause oculomotor nerve palsy Abducent Nerve palsy will be caused by raised ICT. 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 33

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35. Clinical Features When to suspect ?? Any sick Child with High grade fever With following features : Constitutional Symptoms: Lethargy / Irritability / Neurological symptoms like photophobia , Inconsolable cry Anorexia, Nausea , vomiting Fever may be variable 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 35

36. Symptoms Fever Headache Photophobia Vomiting (without nausea, Projectile) Seizures, partial or generalised 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 36

37. Signs Bulging anterior Fontanelle, If open Sign for meningeal irriatation Neurological focal deficit Papiloedema Hypertonia Extensor plantars Altered sensorium, Drowsy , Stupor Neck rigidity 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 37

38. Signs for Meningeal Irritation 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 38

39. Brudzinski Sign : Leg Sign Neck Sign Symphysial sign Cheek Sign 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 39

40. Benda Sign : TBM Turning the head and chin to one side Observe the shoulder : If upward and forward movement  Positive sign It is because of spasm of trapezius musle . 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 40

41. Features of Parenchymal involvement Altered sensorium Seizures Focal Neurological signs 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 41

42. Extra CNS menifestation Rashes Patechiae Arthralgia DIC Shock Pneumonia 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 42

43. Thank You..!! 21-02-2018 Dept Of Paediatrics , J N Medical College , Belagavi. 43