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1. NEONATAL MENINGITIS BY: DR AMADU JALLOH

2. PRESENTATION OUTLINE INTRODUCTION CAUSES SIGNS AND SYMPTOMS PATHOGENESIS DIFFERENTIAL DIAGNOSIS EXAMINATION INVESTIGATIONS COMPLICATIONS TREATMENT AND MANAGEMENT PREVENTIONS

3. INTRODUCTION Neonatal meningitis is a serious medical condition in infants. It is an inflammation of the meninges and is more common in the neonatal period (infants less than 44 days old ) than any other time in life

4. CAUSES The most common causes of neonatal meningitis is bacterial infection of the blood, known as bacteremia. (1) EARLY ONSET NEONATAL MENINGITIS : Bacteria is from the mother before the baby is born or during birth. The most common bacteria found here are: Group B streptococcus. Escherichia coli. Listeria monocytogenes. Gram – ve enteric(gut) bacteria.

5. CAUSES ( 2) LATE –ONSET NEONATAL MENINGITIS Most likely infection from the community. Caused by (a) Gram negative bacteria. (b) Staphylococcal species. (c) Streptococcus pneumoniae. (3) HERPES SIMPLEX VIRUS DERIVED MENINGITIS Is a rare cause of meningitis. HSV is transmitted to the neonate mainly during delivery when infected maternal secretions come into contact with the baby (85% of cases )

6. SIGNS FEVER POOR APPETITE DYSPNEA IRRITABILITY ANOREXIA VOMITING DIARRHEA REFUSAL TO FEEDS

7. SYMPTOMS ANTERIOR FONTANELLE BULGING SEIZURE JITTERINESS ABDOMMINAL DISTENTION NECK RIGIDITY CYANOSIS JAUNDICE SUNSET EYES ABNORMAL BODY TEMPRATURE(HYPO OR HYPERTHERMIA) CHANGE OF ACTIVITY (LETHARGY OR IRRITABILITY).

8. SYMPTOMS IN OLDER CHILD Aforementioned symptoms HEADACHE IRRATIONAL SPEECH MYALGIA Other symptoms include those specific for causative organism eg Petechiae , Purpura, Intravascular coagulopathy in Meningococcal meningitis

9. SIGNS AND SYMPTOMS Symptoms seen with neonatal meningitis are often non specific that may point to several conditions, such as sepsis. These can include fever, irritability, and dyspnea. The only method to determine if meningitis is the cause of these symptoms is lumbar puncture ( LP ; an examination of cerebrospinal fluid).

10. PATHOGENESIS The progression of neonatal meningitis starts with bacteria colonizing the gastrointestinal tract. The bacteria then invades through the intestinal mucosa layer into the blood, causing bacteremia followed by invasion of the cerebrospinal fluid. The neonate’s less efficient immune system lessens their defence against invading bacteria. Colonization of the mother plays an important role in transmission to the neonate, causing early onset meningitis.

11. DIFFERIENTIAL DIAGNOSIS Base of cranium fracture (2) Spinal bifida in neonates (3) Otitis media (4) Immunnodepression (HIV)

12. EXAMINATION Make a general statement about the patient Assess level of consciousness (Glasgow coma score, AVPU, Blantyre coma score) If conscious, comment about degree of alertness Thorough CNS examination Note the patient posture Decorticate or Decerebrate posture in severe cases

13. SIGNS OF MENINGEAL IRRITATIONS NUCHAL RIGIDITY POSITIVE KERNING’S SIGN ;Usually absent in less than 18 months because of short neck POSITIVE BRUDZINKI’S SIGN ; Usually absent in less than 18 months because of short neck. TRIPOD SIGN in older child INCREASED ICP; Bulging tense anterior fontanelle if still patent,sutural diathesis

14. EXAMINATION Examine all the cranial nerves especially optic, occulomotor , facial, abducens and vestibulochochear nerves. Tone and Reflexes may be increased, ankle clonus may be present. Examine associated pathologies, ear in otitis media, spinal bifida. Examine other systems

15. INVESTIGATIONS Diagnosis of neonatal meningitis is based on both; (a) CLINICAL MANIFESTATION and (b ) CSF EXAMINATION VIA LUMBAR PUNCTURE . CSF Should be cultured. CSF analysis; WBCS count. glucose. protein. PCR EEG CT US CBC AND DIFFERENTIALS ,PCV--ANEMIA BLOOD CULTURE MRI

16. EARLY COMPLICATION Increased ICP Cerebellar or cerebral herniation Cranial nerve palsy Transverse myelitis Subdural effusion or Empyema (collection of pus in the brain) Ventriculitis (H Influezae ) DIC Hemiplegia,Coma Transcient deafness Cortical blindness Brain abscess Cerebral oedema Hemorrhage and cerebral infarction

17. LATE COMPLICATION Hydrocephalus Seizure Disorder Sensorineural deafness Cortical blindness Mental retardation Learning disorders Speech impairment

18. TREATMENT AND MANAGEMENT It is important to start treatment as soon as possible! Delayed treatment of neonatal meningitis may cause cerebral palsy, blindness, deafness Fluids. Antimicrobial agents: medications that work against bacteria causing meningitis.

19. TREATMENT AND MANAGEMENT A mix of : Ampicillin with an aminoglycoside Gentamicin , and 3 rd generation cephalosporin Cefotaxime is used for early onset meningitis before identification of infection if it’s bacterial or viral. A regimen of antistaphylococcal antibiotic, such as nafcillin or vancomycin , plus ceftriaxone or ceftazidime with or without an aminoglycoside is recommended for late onset neonatal meningitis . In cases of herpes simplex virus derived meningitis , antiviral therapy Acyclovir or vidarabine .

20. TREATMENT AND MANAGEMENT The aim for these treatments is to sterilize the CSF of any meningitis causing pathogens. A repeated LP 24 -48 hours after initial treatment should be used to declare sterilization. Depending on the severity of the illness, the infant may require other supportive therapies, such as; Anticonvulsant medicine, if the baby is having seizures. Monitoring with an intracranial pressure monitoring device placed. Dexamethasone given before or simultaneously with antibiotics. This reduces the risk of deafness in H influenzae meningits Evaluation for cerebral abscess. Evaluation for hydrocephalus.

21. PREVENTION There are vaccines for three types of bacteria that can cause meningitis: (1) Neisseria meningitides. (2) Streptococcus pneumoniae. (3) Hib (haemophilus influenzae type B). Like with any vaccine, the vaccines that protect against these bacteria are not 100% effective , The vaccines also do not protect against all the types (strains) of each bacteria. For these reasons, there is still a chance you can develop bacterial meningitis even if you were vaccinated.

22. PREVENTION Pregnant women should talk to their clinicians, or midwife about getting tested for group B streptococcus. Women receive the test when they are 35 to 37 weeks pregnant. Doctors give antibiotics ( during labor ) to women who test positive in order to prevent passing group B strep to their newborns.

23. PREVENTION You can also help protect yourself and others from bacterial meningitis by maintaining healthy habits: (1) Don’t smoke and avoid cigarette smoke. (2) Get plenty of rest. (3) Avoid close contact with people who are sick. This is especially important for people at increased risk for disease, including: (a) Young babies. (b) Older adults. (c) People with weak immune systems.

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