MENINGITIS

Shashi
Shashi Vaish
Vaish
Paediatric
PaediatricSpR
SpR
AMNCH
AMNCH
Tallaght
Tallaght

CAUSES
Bacterial
Viral
Fungal

N.
N.meningitides
meningitides
G-ve
G-vediplococci
diplococci

E.Coli
E.Coli
G-ve
G-vebacilli
bacilli

Streptococci-GBS
Streptococci-GBS
G+ve
G+vecocci
cocci

Strep.
Strep.pneumoniae
pneumoniae
G+ve
G+vediplococci
diplococci

Bacterial Meningitis Organisms

Birth - 4 wks: GBS, E.coli
4 - 12 wks:

GBS, E.coli, Pneumococcus

Salmonella, Listeria, H. Influenza

3 mths - 3 yrs: Pneumococcus, Meningococcus

H. Influenza
3 yrs+ adult:

Pneumococcus, Meningococcus

Bacterial Meningitis Pathogenesis

Infection of upper respiratory tract
Invasion of blood stream (bacteraemia)
Seeding & inflammation of meninges

Meningitis: Clinical features

Newborn & Infants: non-specific

Fever
Irritability
Lethargy
Poor feeding
High pitched cry, bulging AF
Convulsions, opisthotonus

Kernigs sign

Brudzinskis sign

Meningitis: older children

Acute Meningococcaemia
Neisseria meningitidis: serotype Grp B
commonest
Endotoxin causes vascular damage
vasodilatation, third spacing, severe shock
Severe complication:
Waterhouse-Friderichsen syndrome: massive
haemorrhage of adrenal glands secondary to
sepsis: adrenal crisis-low B.P, shock, DIC,
purpura, adreno-cortical insufficiency

Septicaemia

Purpura fulminans

Clinical features

Clinical features

Clinical features

Clinical features

Tumbler (glass) test

DIAGNOSIS
Hx & PE
Investigations:
FBC
R/L/B
CRP
Coag
Blood gas
Glucose

Blood C/S
Skin scrapings
PCR
CXR+ Mantoux if
TB suspected

Diagnosis

CSF FINDINGS
Bacterial

Cells

Viral

TB

10-100,000

<2,000

250-500

polys

lymphs

lymphs

Glucose

low

normal

very low

Protein

N-INC

N-INC

N-INC

G-Stain

gen +ve

-ve

+ve Zn

Bacterial Meningitis
Management

Medical emergency
Early diagnosis essential
Immediate optimum treatment
Intensive supportive therapy
Rehabilitation
Prophylaxis to family
Notification to GP & Public Health

Bacterial Meningitis/Meningococcaemia
Management

ABC
PICU
Fluid management: aggressive resuscitation
Dexamethasone: only in Pneumococcal and
HiB, given before antibiotics
Inotropes: increasing aortic diastolic
pressure and improving myocardial
contractility

Antibiotics
Less than 2 months of age:
Ampicillin + Cefotaxime+/- Gentamicin
Treat for 3 weeks (neonate)
Over 2 months:
Cefotaxime
Treat for 7-10 days

Prophylaxis
Rifampicin:
Children 5mg/kg bd x 2/7
Adults: 600 mg bd x 2/7
Pregnant contact:
Cefuroxime IM x 1 dose
OR
Just do T/S and await result

Meningitis - Complications

Septic shock - DIC

Cerebral oedema
Seizures
Arteritis/venous thrombosis
Subdural effusions
Hydrocephalus . Abscess . Brain damage
Deafness

Meningococcaemia - poor
prognosis
Onset of Petechiae within 12 hrs
Absence of meningitis
Shock (BP 70 or less)
Normal or low WCC
Normal or low ESR

Subdural Effusion
Failure of temp to show progressive
reduction after 72 hours
Persistent positive spinal cultures after 72 hr
Occurrence of focal/ persistent convulsions
Persistence/recurrence of vomiting
Development of focal neurological signs
Clinical deterioration after 72 hr especially
ICP

Partially treated meningitis

50% cases prior antibiotic - alters the
findings in bacterial meningitis Accurate history vital
CSF mainly lymphocytic [not usual polys]
Can have normal glucose
+ve cultures reduced by 30%
Gram stain reduced by 20%

Viral meningitis
Most common infection of CNS especially in <1yr
Causes: enterovirus (commonest, meningitis
occurring in 50% of children <3mth ) herpes,
influenza, rubella, echo, coxsackie, EBV,
adenovirus
Mononuclear lymphocytes in CSF
Symptomatic treatment. Complications associated
with encephalitis and ICP

TB Meningitis
Usually insidious: difficult to diagnose in early
stages (fever 30%, URTI 20%)
Rare in children in developed countries
If untreated is usually fatal
Meningitis usually occurs 3-6mths after primary
infection
1 stage-lasts 1-2wk, fever malaise, headache
2 stage-+/- suddenly, meningeal signs
3 stage-worsening neurological condition, death

Mortality/Morbidity

Bac meningitis: Overall mortality 5-10%

Neonatal meningitis: 15-20%
Older children: 3-10%
Strep. pneumonia: 26-30%
H. influenza type B: 7-10%
N. meningitidis: 3.5-10%
30% neurological complications
4% Profound b/l hearing loss
(sensorineural) in all bac meningitis

Mortality/Morbidity
Viral meningoencephalitis: Enteroviral
fewer complications
Tuberculous meningitis: related to stage of
disease
Stage I-30% morbidity
Stage II- 56%
Stage III-94%

VACCINATE!