MENINGITITS PEADiatrics clinical medicine.pptx

MENINGITITS

1. MENINGITIS Audience. DCM 3.2

2. Meningitis is an inflammation of the protective membranes covering the brain and spinal cord known as the meninges. Infection of the cerebral spinal fluid. Meningitis is also referred to as spinal meningitis. 2 DEFINITION OF MENINGITIS

3. Acute meningitis ‘ Onset of meningeal symptoms over the course of hours to a few days’ Classic triad of headache/ neckstiffness /photophobia. Chronic meningitis   lasts weeks or months ie symptoms, signs, CSF abnormal for at least 4 weeks) MENINGITIS CAN BE;

4. Incidence The highest incidence of meningitis is between birth and 2 years, with the greatest risk immediately following birth and at 3-8 months of age. Increased exposure to infections and underlying immune system problems present at birth increase an infant's risk of meningitis.

5. Incidence cont.. Before the Hib vaccine, H influenzae was the leading cause of bacterial meningitis in children under age 5years . Since the vaccine became available in the Uganda, this type of meningitis occurs much less often in children. H influenzae meningitis may occur after an upper respiratory infection. The infection usually spreads from the lungs and airways to the blood, then the brain area.

6. Etiology Bacteria and viruses are the major causes of meningitis disease in infants and children. Meningitis normally occurs as a complication from an infection in the bloodstream or by the direct spread of a nearby severe infection, such as otitis media or sinusitis. It can also occur following a head injury or after any type of head surgery.

7. Etiology cont.. Immediately after birth, group B Streptococcus , Escherichia coli , and Listeria species are the most common. After about 1 month of age, Streptococcus pneumoniae , Haemophilus influenzae type B ( Hib ), and Neisseria meningitidis are more frequent.

8. Etiology cont. Viral meningitis is less serious than bacterial meningitis. Common cause is enterovirus . Other causative agents are fungi ( cryptococcal meningitis) and parasites. These are rare. The inflammation of the meninges can also be caused by rare conditions, such as cancer, a drug reaction, a disease of the immune system.

9. Age Group Causes Newborns Group B Streptococcus, Escherichia coli, Listeria monocytogenes Infants and Children Streptococcus pneumoniae , Neisseria meningitidis , Haemophilus influenzae type b Adolescents and Young Adults Neisseria meningitidis , Streptococcus pneumoniae Older Adults Streptococcus pneumoniae , Neisseria meningitidis , Listeria monocytogenes BACTERIAL MENINGITIS/CAUSES :

10. Risk factors Attending day care Cancer Ear infection (otitis media) with H influenzae infection Family member with an H influenzae infection Native American race

11. Risk factors cont.. Pregnancy Older age Sinus infection (sinusitis) Sore throat (pharyngitis) Upper respiratory infection Weakened immune system Suppressed immunity.

12. Signs and Symptoms Common symptoms of meningitis in infants younger than 3 months of age may include: Decreased fluid intake/poor feeding Vomiting Lethargy Rash Stiff neck with opisthonos Hypoglycemia Jaundice

13. S &S in infants younger than 3 months of age Increased irritability with high-pitched meningeal cry Fever Bulging fontanelle Seizure activity Hypothermia (low temperature) Shock Hypotonia (floppiness)

14. Classic symptoms in children older than 1 year of age are as follows: Nausea and vomiting Headache Increased sensitivity to light Fever Altered mental status (seems confused or odd) Lethargy Seizure activity Coma

15. Classic symptoms in children older than 1 year of age are as follows: Neck stiffness or neck pain Knees automatically brought up toward the body when the neck is bent forward or pain in the legs when bent (called Brudzinski sign) Inability to straighten the lower legs after the hips have already been flexed 90 degrees (called Kernig sign) Rash

16. Diagnosis History taking Physical examination Investigations Lumbar puncture to obtain CSF: it is checked for white and red blood cells, protein, glucose, and organisms (bacteria, fungus, parasites). The fluid is also sent for culture & gram staining Blood is obtained for culture, full blood count and electrolytes estimation .

17. Diagnosis cont … Urine analysis to rule out urinary tract infection A chest X-ray film may be taken to look for signs of infection in the child's lungs. A CT scan is sometimes necessary if other problems are present or suspected, e.g. trauma, increased brain pressure, neurologic problem, hypothermia, brain abscess etc.

18. Normal Subarachnoid haemorrhage Acute bacterial meningitis Viral Meningitis TB meningitis Multiple sclerosis Pressure 50-250mm of water Increased Normal/decreased Normal Normal/Increased Normal Colour Clear Blood stained xanthochromic Cloudy Clear Clear/cloudy Clear RBC count(x106/L) 0-4 Raised Normal Normal Normal Normal WBC (x 106/L) 0-4 Normal/ slightly raised 1000-5000 polymorphs 10-2000 lymphocytes 50-2000 lymphocytes 0-50 lymphocytes Glucose >60%of blood level Normal Decreased Normal Decreased Normal Protein <0.45g/L Increased Increased Normal/ increased increased Normal/ increased Microbiology sterile sterile Organism on G.Stain /Culture Sterile/ Virus detected ZN/ TB culture positive Sterile Oligoclonal bands Negative Negative Can be positive Can be positive Can be positive Often positive How to interpret CSF results.

19. Brain abscess. Viral heamorrhagic fevers eg Ebola, Space occupying lesions in brain Viral meningo-encaphalitis Other forms of meningitis Drug reactions Differential diagnosis

20. Acute meningitis is a medical emergency and the pt should be Isolated. Causative organism not yet identified (give antibiotic Iv) Ceftriaxone 50mg – 100mg/kg Chloramphenical 25mg/kg Ampicilin with ceftriaxone Benzyl penicilin with ceftriaxone Ampilcilin with gentamicin Management of bacterial meningitis

21. Management of meningitis cont. Bacterial meningitis at any age is considered a medical emergency. The child is admitted in intensive care unit. Burrier nursing may be required to prevent the spread of infection. Because bacterial meningitis is a potentially life-threatening infection, IV antibiotics are started early to clear the infection. Vancomycin plus ceftriaxone or cefotaxime IV are used for about 7 to 21 days depending on type of organism causing the infection.

22. Management of meningitis cont. Light should be dim because of photo phobia If unconscious put in semi prone position Two hourly change of position Four hourly treatment of pressure areas Care of the skin

23. Management of meningitis cont. To prevent convulsions, external stimuli should be eliminated. If the child has respiratory distress, intubation may be needed to provide oxygen. The child's vital signs like respiratory rate, oxygen level, heart rate neurological status and behavior are monitored. Monitor fever and manage accordingly.

24. Management of meningitis cont. IV fluids are given to correct dehydration and help to maintain Bp and good circulation. A catheter may be placed in the bladder to obtain urine and to help accurately measure the child's hydration. Monitor intake and output to assess renal function. Steroids may be given to help minimize inflammation depending on which organism is suspected to be causing the infection.

25. Management of meningitis cont. Fungal or parasitic infections require special drugs to treat these infections. Noninfectious causes of meningitis, which are rare, are treated according to the underlying problem(s) such as cancer, drug-induced, or surgical problems. If tuberculous meningitis the child is treated with anti- Tb drugs

26. Management of meningitis cont. Position semiconscious of unconscious child on side and turn at regular intervals. Remove naso -pharyngeal secretions to prevent aspiration of secretions. Provide oral care to prevent halitosis and oral infection. Measures must be taken to prevent drying of the cornea if the child’s eyes are open. Treatment of pressure area and turning the child regularly to prevent pressure sores.

27. Management of meningitis cont. Assess nutritional status: nasogastric feeding if child is unconscious or lethargic. Passive range of motion exercises may be given after the spastic phase of the disease has passed, and position should be maintained to provide normal alignment.

28. Management of meningitis cont. Provide stimulation as the child progresses with suitable play activities according to age and interest. Support for parents. Encourage their participation in care and provide reassurance. A follow-up visit should be arranged within 24 hours of the child's discharge from hospital.

29. Complications Visual impairment Hearing difficulty Seizures/fits Paralysis Hydrocephalus Decreased mental function.

30. Complications cont. Brain damage Subdural effusion Hydrocephalus Learning disability Encephalitis Sub dural empyema DIC

31. Epilepsy in children Hearing loss Cerebral palsy Cerebral abscess Vision loss Memory deficiency Kidney failure Complications cont.

32. Prevention Immunization with Hib , meningococcal, and pneumococcal and the antiviral vaccines. Close contacts in the same household, school, or day care center should be watched for early signs of the disease as soon as the first person is diagnosed. All unvaccinated family members and close contacts of this person should begin antibiotic treatment as soon as possible to prevent spread of the infection. Always use good hygiene habits, such as washing hands before and after changing a diaper, and after using the bathroom.

33. Vaccination Measles Mumps Chicken pox Menigococcal groups A and B but not C, Hib Avoid kissing when one is sick. Good nutrition Prevention cont..

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