Presentasi Kasus

MENINGITIS
Pembimbing :
dr. Ajuar Arif, Sp.A
dr. Charles Hutasoit, Sp.A
Oleh :
Edward Indra Go (2009-061-314)
Febry Loudryan (2009-061-328)

Identitas

Nama
: an. A.Y
Jenis kelamin
: laki-laki
Umur
: 13 tahun
Berat badan
: 35 kg
Masuk RS tanggal : 12 Mei 2011

Anamnesis
Dilakukan secara alloanamnesis
terhadap ibu & ayah pasien
Keluhan utama : penurunan
kesadaran
Keluhan tambahan : demam, sakit
kepala, muntah2, batuk

Riwayat penyakit sekarang

1 bulan SMRS, pasien mengalami demam.
Menurut keluarga pasien, demam muncul
tiba2, suhu pada saat itu tidak diukur.
Terdapat batuk tidak berdahak. Dan batuk
hanya kadang2. pasien sudah diberikan
obat penurun panas. Jika diberi obat
penurun panas, demam turun, tapi
setelah itu naik lagi.
1 minggu SMRS pasien merasakan sakit
kepala yang sangat hebat dan terdapat
muntah2.

Riwayat Penyakit Sekarang

Tidak ada riwayat trauma kepala.
Riwayat batuk lama disangkal, riwayat
penurunan berat badan & keringat
malam disangkal.
Riwayat kontak (+), ayah pasien
pernah didiagnosa menderita TBC
dengan riwayat pengobatan tidak
tuntas, sekarang ayah pasien
mengaku masih batuk2

 Pasien lalu dirawat inap di RS Sanggau.

Di RS Sanggau pasien mendapat terapi :

Cefotaxime 3 x 1,5 gr
Dexametasone 3x5 mg
Ranitidin 3 x 40 mg
Drip quinin 3x350 mg
Bufect forte 3 x 1 cth
OAT :
Rifampisin 1x1 tab
Pyrazinamid 1x1,5 tab
INH 1x2 tab

2 hari SMRS pasien mengalami

penurunan kesadaran, lalu pasien
dirujuk ke RSSA dengan diagnosa kerja :
meningitis susp.bakterialis DD/SOL
intrakranial + TB paru + malaria + ISK

Pemeriksaan Fisik
Keadaan umum : tampak sakit berat
Kesadaran : somnolen (GCS = E4 M5
V1 = 10)
Tekanan darah :130/80 mmHg
Laju denyut jantung : 55x/menit
Laju napas : 20x/menit
Suhu : 37,8 oC

Pemeriksaan Fisik
Kepala : normocephali, deformitas
Mata : konjungtiva tidak anemis, sklera
tidak ikterik, pupil anisokor, diameter
pupil 4mm/3mm, refleks cahaya -/ Hidung : septum nasi di tengah, sekret
-/ Mulut : sulit dinilai
Telinga : sekret -/-

 Thoraks paru

I : simetris dalam keadaan statis dan dinamis

P : pengembangan paru kanan-kiri simetris
P: sonor pada kedua lapangan paru
A : suara napas bronchovesikular, wheezing -/-,
ronki -/-

Jantung

I : ictus cordis tidak terlihat

P : ictus cordis tidak teraba
P : batas jantung dalam batas normal
A : bunyi jantung I & II reguler, gallop -, murmur -

Abdomen

I : datar, venektasi (-)

P: hepar lien tidak teraba, ballotement (-)
P : timpani pada semua lapangan abdomen
A : bising usus +, 4x/menit

Pemeriksaan Neurologis
Pemeriksaan kaku kuduk +,
brudzinski I, II, kernig +
Refleks babinski +/+
Refleks patela kanan - kiri : +/+,
hiperrefleks.

Pemeriksaan penunjang
Di RS Sanggau
WBC : 10,6
Hb : 12,2
Ht : 35,2
PLT : 325
SGOT : 30,2
SGPT : 49,3
Gamma GT : 60,9
Ureum : 49,45
Kretinin : 0,980
LED : 36 mm/jam

Di RS St.Antonius
WBC : 14,88
Hb : 13,1
PLT : 394
LED : 23 mm/1 jam
41 mm/2 jam

CT scan
Tampak gambaran hipodens
Ventrikel agak melebar
Tidak ada midline shift
Kesimpulan : curiga meningitis
dengan hidrosefalus ringan
Saran : CT scan dengan kontras

Diagnosa kerja
Meningitis e.c susp TBC
DD/ meningitis e.c susp bakteralis

Tatalaksana

Rawat dalam ICU

IVFD D5 40cc/jam
Diet 1500 kkal + 59 gr protein
Manitol 3x100 cc
Merobat 3 x 0,5 gr
Neurotam 2x1 gr
Depachen syrp 2x1 cth

Follow Up (12/5/11)

Kesadaran : somnolen
Kaku kuduk : +
TD : 130-140 / 80-100 mmHg
N : 51-70x/menit
RR : 17-22x/menit
S : 36,3 36,8 oC

Follow Up (13/5/11)
Hasil rontgen : cor pulmo tidak tampak kelainan
Terapi :

Infus RL 30 cc/jam
Merobat 3x0,5 gr
Manitol 3x100 cc
Neurotam 2x1 gr
Streptomycin 1x750 mg
Farmadol infus 50 cc
Syrp depaken 2x1 cth
Cap camp 1x1 (Rif 300 + INH 300 + etambutol
300)
Cap camp 2x1 (pyrazinamid 300 + prednison 100 )

Follow Up (14/5/11)
Kaku kuduk (+), pupil anisokor
Suhu
: 37,5 38 oC
TD
: 110 140 / 70 100
mmHg
N
: 76 96 x/menit
RR
: 20 34 x/menit

Follow up (15/5/11)
Demam (-) (36,1 37,4 oC)
Hasil lab :
WBC
Hb
Ht
PLT

:
:
:
:

16,09
13,8
40
368

Follow up (16/6/11)
Keadaan umum
: tampak sakit
berat
Kesadaran
: somnolen & gelisah
Suhu
: 36 36,5 oC
N
: 86 92 x/menit
Pasien pindah ke ruangan (Lidwina)

Follow up (17/6/11)
R.Lidwina
Keadaan umum
: tampak sakit
berat
Kesadaran
: somnolen & gelisah
Suhu
: 36,7 37 oC
N
: 86 92 x/menit

Follow up (18/6/11)
R.Lidwina
Keadaan umum
: tampak sakit
berat
Kesadaran
: somnolen & gelisah
Suhu
: 36,7 37,4 oC
N
: 86 92 x/menit

MENINGITIS
Definition
Meningitis is inflammation of the membranes
surrounding the brain and spinal cord
including the dura, pia mater, and the
arachnoid, due to a variety of causes.
Bacterial meningitis results most commonly
from seeding of the leptomeninges from a
distant focus (hematogenous/bacteremic
spread). Uncommonly, it can also result from
a direct extension from a contiguous focus
(e.g., sinusitis, otitis media, mastoiditis) or by
direct invasion (e.g., head trauma,
meningomyelocele).

ETIOLOGI
Neonatal period
a. Group B streptococci
(GBS)
b. Gram-negative enteric
bacilli (Escherichia coli,
Enterobacter spp.)
c. Listeria monocytogenes
Age 1 to 3 months
a. Streptococcus
pneumoniae
b. Neisseria meningitidis
(for meningococcemia
c. Haemophilus influenzae
type b
d. Listeria monocytogenes

Age over 3 months

a. S. pneumoniae
b. N. meningitidis (see
Meningococcemia)
c. H. influenzae type b
(unvaccinated children)
Neurosurgical patients
(e.g., patients with
ventriculoperitoneal
shunts)
a. Coagulase negative
Staphylococcus
epidermidis
b. Staphylococcus aureus

CLINICAL FEATURES
The incidence of meningitis caused by H. influenzae
has declined dramatically since the introduction of the
conjugate vaccine.
S. pneumoniae is now the most common etiology
during infancy (1 to 23 months), and N. meningitidis is
the most common etiology between 2 and 18 years of
age.
The gold standard for diagnosing meningitis is
cerebrospinal examination (CSF) by performing a
lumbar puncture (LP)
Only contraindication for an LP is increased intracranial
pressure (ICP)
If the patient has focal neurologic signs or papilledema,
treat the patient with antibiotics first, followed by a CT
scan prior to performing LP.
Antigen detection tests (e.g., latex agglutination,
countercurrent immunoelectrophoresis) may help in
partially treated meningitis.
India ink stain is recommended for immunocompromised

 Examination of the CSF shows pleocytosis with a

polymorphonuclear predominance, elevated protein, and
decreased glucose in bacterial meningitis. Gram's stain
may be positive for the presence of bacteria and
subsequent CSF culture would be positive (unless the
patient has received prior antibiotic therapy)
Examination of the CSF shows pleocytosis with
lymphocytes, slightly elevated or normal protein, and
normal glucose in aseptic meningitis. Neutrophils may
predominate early in the course of even viral meningitis.
Decreased CSF glucose may also occur in mumps and
herpes meningoencephalitis.
Tuberculous meningitis may present with a gradual onset
over several weeks (1 to 3 weeks). Low-grade fever,
weight loss, adenopathy, vomiting, lethargy, cranial nerve
palsies, and coma are common presentations.
Other laboratory tests should include CBC with platelet
count, blood culture, serum electrolytes (monitoring for
syndrome of inappropriate secretion of antidiuretic
hormone [SIADH]), glucose, and coagulation profile
(monitoring for disseminated intravascular coagulation).
Place a 5 TU PPD tuberculin test on the forearm of all
patients with meningitis in areas where tuberculosis is
endemic.

 Radiographic tests
Head CT scan need not be routinely performed
in patients with a clinical diagnosis of
uncomplicated meningitis (e.g., absence of
focal neurological signs) prior to performing an
LP.
A head CT scan should be obtained prior to LP if
elevated ICP or mass lesion is suspected (e.g.,
to exclude abscess, subdural empyema, brain
tumor, or intracranial hemorrhage).
A head CT scan or MRI is performed in patients
with meningitis with focal neurological findings
(e.g., suspected focal complications such as
subdural effusion or empyema), prolonged
obtundation or irritability, seizures, worsening
ICP, persistent fever, persistently abnormal CSF
indices, and neonates (who are prone to
abscess formation).
Complications of meningitis include seizures,
subdural effusion, hydrocephalus, cerebral
infarction, hearing loss, and developmental delay

Signs and symptoms of

meningitis
Older child
Neonate (signs and
symptoms are often
subtle and nonspecific)
Fever or hypothermia
Poor suck/poor feeding
Lethargy or irritability
Weak or high-pitched cry
Seizures
Apnea or respiratory distress
Septic shock
Infants
Fever
Lethargy or irritability
Vomiting
Bulging anterior fontanelle
Seizures
Coma
Septic
shock

Fever
Lethargy/mental status
changes (confusion/coma)
Petechiae or purpura
(especially meningococcal
infections
Headache
Photophobia
Seizures
Septic shock
Focal neurological findings
Ataxia (labyrinthine
dysfunction or vestibular
neuronitis)

Differential diagnosis
Bacterial meningitis of
various etiologies
Aseptic meningitis or
meningoencephalitis
Tuberculous meningitis
Fungal meningitis (e.g.,
Cryptococcus neoformans,
Coccidioides immitis)
Brain abscess,
tuberculoma
Parameningeal/paraspinal
infection (e.g., subdural or
epidural abscess)
Sepsis Seizures from other
etiologies and postitcal
state
Retropharyngeal abscess
Cervical adenitis

Trauma
Subarachnoid hemorrhage
(ruptured AVM/aneurysm)
Focal intracranial mass
lesions (e.g., intracranial
or brainstem tumor)
Rickettsia
Spirochetes
Metabolic disturbances
Bacterial endocarditis with
embolism
Toxic ingestions
phenothiazines
Collagen vascular
diseases
Malaria
Typhoid fever

Treatment
Empiric treatment of bacterial meningitis in
patients <4 weeks of age:
Provide coverage for GBS, E. coli, and Listeria.
Ampicillin (100-200 mg/kg per day divided every 6
hours) andcefotaxime (300 mg/kg per day divided
every 8 hours) or ampicillin and an aminoglycoside
(e.g., gentamicin)
Consider antiviral therapy if herpes is suspected
(while awaiting confirmation of bacterial meningitis).

Empiric treatment of bacterial meningitis in

patients 4 weeks to 12 weeks of age:
Provide coverage for H. influenzae, pneumococci,
and meningococci.
Vancomycin (60 mg/kg per day divided every 6
hours) andcefotaxime (225 to 300 mg/kg per day
divided every 8 hours) orceftriaxone (100 mg/kg per
day divided every 12 to 24 hours)

 Empiric treatment of bacterial

meningitis in patients > 12 weeks of
age:
Provide coverage for pneumococci and
meningococci.
Vancomycinandcefotaxime orceftriaxone

Hospitalize all patients with a clinical

diagnosis of meningitis.
Patients presenting with septic shock
requiring resuscitation (e.g.,
meningococcemia) will need ICU monitoring.
Patients also need standard and droplet
precautions for the first 24 hours after
institution of appropriate antibiotics.