pyomeningitis in pediatric population .pptx

pyomeningitis

1. PYOMENINGITIS By Dr Sehar Afzal House officer Arif memorial teaching hospital

2. Meningitis Meningitis is the inflammation of meninges ( the membrane surrounding the brain and spinal cord ) due to infection. Meningoencephalitis is the inflammation of meninges and brain cortex. Types of meningitis : Meningitis can be caused by Viral, Bacterial, Fungal. Viral meningitis is the Most common Type It is less severe than bacterial meningitis. Bacterial meningitis is severe and deadly type of meningitis It progresses to permanent brain damage, neurological problems and death. Fungal meningitis and is very rare and cause chronic meningitis.

3. Pyomeningitis and its Pathogenesis Bacterial meningitis is also called Pyomeningitis . Incidence : Bacterial meningitis is commonest in infancy. It may resin death within hours of onset if not treated. Responsible for 3% of hospital admissions. Greater risk during 6-12 months and 95% cases occur between 1month and 5years Pathogenesis : The causative agent enter CNS via blood or direct invasion . Anatomic or congenital defects can also cause invasion. Inflammation of meninges is initiated when cell elements of organisms disrupt the blood brain barrier followed by outpouring of polymorphs and fibrin. It causes release of cytokines and chemokines in CNS stimulated by bacteria Meninges become swollen and inflamed and covered in exudate .

4. Causative agents for different ages

5. Clinical signs and symptoms Clinical symptoms in infants High grade fever( > 100.7 F ) Stiffness in body and neck Inactivity and sluggishness Sleepiness or irritability Hypothermia Ill looking and Poor feeding Constant high pitch cry Bulging of fontanelles Convulsions and seizures Vomiting and rapid breathing Clinical symptoms in older children High grade fever and headache Neck stiffness (+ve kernig and brudzinki sign) Drowsiness and confusion Upper respiratory or GI symptoms Projectile vomiting Cranial nerve palsies and papilledema Seizures, hemiplegia and ataxia Otitis media and mastoiditis Waterhouse friderichsen syndrome (meningococcal meningitis)

6. Brudzinski’s sign is one of the physically demonstrable sign of meningitis.It is demonstrated by flexing the neck. Severe neck stiffness where the forwards Flexion of the neck causes involuntary flexion of the knee and hip . Kernig's sign is one of the physically demonstrable sign of meningitis. It is demonstrated by placing the patient in Supine position then flexing the hip to 90 degrees. Severe stiffness of the hamstrings causes resistance to straighten the leg when flexed to 90 degrees.

7. Investigations Lumbar puncture CSF pressure should be noted, gross visual turbidity, cell count (WBC’s, RBC’s). Xanthochromia due to jaundice, bilirubin from haemorrhage increased protein. CSF glucose should be compared with blood glucose ( CSF glucose is 2/3 of blood glucose). Gram stain and culture to recognise causative agent.

8. Other investigations CBC ( leucocytosis with predominant polymorphs ) Blood culture ( 90 % H. Infuenzae, 80% S. Pneumoniae ) Inflammatory markers ESR , CRP Electrolytes ( for hyponatremia ) Chest Xray ( to rule out TB and pneumonia) PCR ( H. Influenza, N. Meningitides, S. pneumoniae ) Rapid diagnostic tests Concurrent immuno electrophoresis Latex particle agglutination ELISA to detect bacteria antigen in CSF CSF lactate level Enzyme radioisotope to detect activity of B lactamase in CSF

9. Management of meningitis Supportive measures :  Vitals recorded every 15 - 30 minutes until patient is stable Neurologic examinations and seizure evaluation Measure head circumference in children <18 months Intake and output record Body weight, serum electrolytes monitored 12 hourly For fever sponge and give antipyretics Feeding continued and give tube feeding if necessary Fluid restricted to 60%, not indicated in hypotension Care of comatose patient IV diazepam for seizures, phenobarbitone for recurrent seizures

10. Specific treatment Antibiotics  Appropriate antibiotic given by culture report Term infants in 1st month given combination of ampicillin with gentamicin or cefotaxime . Low birth weight preterm infants presenting late should be given vancomycin and an aminoglycoside . 1 - 2 month infants given ampicillin and ceftriaxone . Resistant strains treated with vancomycin alternatively meropenem . Duration of therapy is 7 - 10 days. Steroids  Dexamethasone for 2 - 4 days. Given before antibiotic is started for good results.

11. Complications of meningitis Bacterial meningitis may result in : Cranial nerve palsies Subdural empyema Brain abscess Hearing loss Obstructive hydrocephalus Brain parenchymal damage : learning disability, CP, seizures, Mental retardation Septic shock/ DIC Stroke and ataxia