MENINGITIS

AND
MARASMUS

Presented By :

Clarisa Monica
Widya Margaret
INTRODUCTION
 BACKGROUND
Meningitis
An inflammation of the meninges
Can be caused by bacterial, viral,
rickettsial, or protozoa
The 17th position as the cause of
death in all age groups and the 3rd
position leading cause of infant
mortality in Indonesia.
Marasmus
One of severe acute malnutrition
(SAM) condition
Primarily caused by a deficiency in
calories and energy
The common symptoms : old man
face, prominnent ribs, baggy pants
 OBJECTIVES

The objective of this paper is to report a case of a 3

years girl with diagnosis of meningitis + marasmus. This
paper provides a knowledge about meninglitis +
marasmus that can be use for clinical practice. This
paper is alsoone of the requirement to complete the
clinical assistant program in Child Health Department
of Haji Adam Malik General Hospital,University of
Sumatera Utara.
LITERATURE REVIEW
MENINGITIS
 DEFINITION

An inflammation of the
meninges
 ETIOLOGY

Virus Bacteria

Parasites Fungi
 DIAGNOSIS

History Physical Other

Taking Examination Examination
 MANAGEMENT

Convulsion Anticonvulsion

Increase of Mannitol
intracranial
pressure Corticosteroid

Antibiotics Broad spectrum

 Duration

Germ causes Management

Age PROGNOSIS Predisposes

MARASMUS
Definition

A condition primarily
caused by a deficiency
in calories and energy
DIAGNOSTIC
 TYPICAL CHARACTERISTICS OF A WASTED (MARASMIC)
CHILD INCLUDE:

Skin and
bones Old man face Front view
apperance

Active and
Back view may appear to
be alert
 LISTS THAT MUST BE PAID
ATTENTION

Complete Growth
history measurements

Complete
physical
examination
 MANAGEMENT

Initial Rehabilitation Follow-up

 PROGNOSIS

Good if treatment and

follow-up care are correctly
applied
CASE
Patient FA, 3years Loss of
4 months consciousness
 History of Illness

Intermittent cough
with a white
phlegm

Intermittent fever and

lost 5 kgs

Persistent cough
with greenish
phlegm

Hospitalized
in Mitra
medika
Loss of
consciousness

2 month ago 1 month ago 10 days ago A week ago 5 days ago Now
History of IVFD NaCl 0.9%,
medication Inj.Meropenem,Inj.Phenytoin,Paracetamol
drips,Anti-Tuberculosis Drugs (H4), Prednison.

History of There was no history of the same

family
disease in family
History of
parents
medication None
The age of mother was 31 years
History of old during pregnancy, Gestation
Pregnancy
weeks was 38 weeks.
 History of assisted by a midwife, born pervagina, cried
Birth immediately, Body weight 3500 gram, body length
51 cm but the head circumference was unclear.

Breast milk from birth to 2 months, formulated

History of milk from 2 months until now. Porridge strain
feeding from 6 months to 12 months and family meals
since the age of 1 year until now.

History of
immunization
Not Complete.

History of
growth and The patients mother reported that FA grew
development normally. FA had developed talking, crawling, and
walking skills on time
 Physical Examination

Level of consciousness: Sopor (E=4 V=1 M=3)

Present Body temperature: 38,8 C
Status BW: 8 kg, BH: 85 cm.
BW/A: Z-Score < -3 SD BL/A: Z-Score < -3 SD
anemic (+/+), ikteric (-/-), dyspnea (-), cyanosis(-), edema (-)

Old mans face (+)

Eye: light reflex +/+, isochoric pupil, conjunctiva
Head palpebra inferior pale (-/-)
Ear: within normal range
Nose: NGT and Oxygen via nasal canule
Mouth: within normal range
 Physical Examination

Jugular Vein Pressure: (R+2) cmH2O

Stiff Neck: (+)
Neck
Enlarged Lymph Nodes:(+)Multiple, : 0.5 cm colli dextra et
sinistra

Symetrical fusiformis, Retractions (-), RR: 40x/minute,

Thorax regular, respiratory sound: vesicular,ronchi (+/+), HR: 128
x/minute, regular, murmur (-).

Abdomen Soepel, Peristaltic (+) N, Hepar and Lien: unpalpable

 Physical Examination

Pulse: 124x/minute, regular, tension/volume: enough,

warm acral, CRT < 3, edema pretibial (-), Plantar
Extremities
palmar et pedis pales (+/+) blood pressure: 90/60
mmHg, Spastic (+).

Neurologist Examination
Physiologic reflex: Pathologic reflex:
APR/KPR : +/+ Babinski : +/+
Oppenheim: +/+
Chaddock: +/+
Gordon: +/+
Meningeal Reflex:
Kernig: +/+
Brudzinski I : -
Brudzinski II: +
 Laboratory Findings

Test Results Test Results

Hemoglobin 12.8 Lymphocyte absolute 1.30

Erythrocyte 5.04 Monocyte absolute 0.71

Leucocyte 15.9 Basophyl absolute 0.01
Thrombocyte 495 MCV 77
Hematocrite 39 MCH 25.4
Eosinophil 0.00 MCHC 33.1
Basophil 0.10 Blood Glucose 9.70
Neutrophil 87.20 Sodium 132
Lymphocyte 8.20 Kalium 4.3
Monocyte 4.50 Chloride 96
Neutrophil absolute 13.88
 1. Meningitis + Marasmus
Differential
Diagnosis
2. Encephalitis + Marasmus
3. Meningoencephalitis + Marasmus

Meningitis + Marasmus
Diagnosis
 Head elevation 300 and midline position
O2 via nasal canule 1 L/minute
IVFD NaCl 0.9% 20cc/ hour
IVFD NaCl 3% 0.1 cc/kg/hr -> 0.8 cc/ hour
Inj. Ceftriaxone 50mg/kg/ 24 hrs divided into 2
dose = 200mg/ 12hr
Therapy Inj. Phenytoin loading dose 10 mg/ kg -> 80 mg
in 20 cc NaCl 0.9% for 20 minutes then 12 hrs
later maintenance dose 25 mg in 20 cc NaCl/ 12
hrs
Inj. Dexamethasone 0.6 mg/ kg/ 24 hrs divided
into 3 dose = 1.6 mg/ 8hr
Inj. Furosemide 8mg/ 24hrs

X-ray
Planning Head CT-Scan
Lumbal Punction and CSF culture
 Follow up
3rd February 2017

S Seizure (-), Fever (+), loss of consciousness (+)

Sensorium: GCS : 8 ( E4V1M3), T: 38.4 oC, BW: 8 kg, BH: 85 cm. BP :

100/60 mmHg, HR:130x/min, regular RR: 36x/min, regular, respiratory
O sound: vesicular,stridor (+/+) , Extremities : Rigid.
Neurologist Examination :
Physiologic, Pathologic, Meningeal reflex : Positive

-Head elevation 300 and midline position -O2 via nasal canule 1 L/minute
-IVFD NaCl 0.9% 20cc/ hour -IVFD NaCl 3% 0.8 cc/ hour
-Inj. Ceftriaxone 50mg/kg/24 hrs -Inj. Phenytoin maintenance dose
P divided into 2 dose = 200mg/ 12hr -Inj. Dexamethason 1.6 mg/ 8hr
-Inj. Furosemide 8mg/ 24hrs -Diamox 3 x 70 mg
-Eritromycin syr. 3xI cth -F75 150cc/ 3hrs with 3cc mineral mix
-Vit.A 1x200.00 IU -Vit.C 1x100 mg
-Vit. Bcomp 1x1 tab -Folic Acid 1x5mg
 Follow up
4th-5th February 2017

S Seizure (-), Fever (+), loss of consciousness (+)

Sensorium:
4th Feb 2017 : GCS : 8 ( E4V1M3), T: 37.7 oC , BW: 8kg, BH: 85 cm, RR:
30x/min, HR: 116 x/min , Extremities :Rigid, BP: 100/60 mmHg.
O 5th Feb 2017 : GCS : 8 ( E4V1M3), T: 37.7 oC , BW: 8 kg, BH: 85 cm. RR;
36 x/min, HR:120x/min, Extremities :Rigid, BP: 110/60 mmHg.
Neurologist Examination :
Physiologic, Pathologic, Meningeal reflex : Positive
-Head elevation 300 and midline position-O2 via nasal canule 1 L/minute
-IVFD NaCl 0.9% 20cc/ hour -IVFD NaCl 3% 0.8 cc/ hour
-Inj. Ceftriaxone 50mg/kg/ 24 hrs -Inj. Phenytoin maintenance dose
divided into 2 dose = 200mg/ 12hr -Inj. Dexamethason 1.6 mg/ 8hr
P aff 5/2/2017
-Inj. Furosemide 8mg/ 24hrs -Diamox 3 x 70 mg
-Eritromycin syr. 3xI cth -Diet F75 150cc/ 3hrs with 3cc mineral mix
-Vit.C 1x100 mg -Vit. Bcomp 1x1 tab
-Folic Acid 1x1mg
 Follow up
6th February 2017

S Seizure (-), Fever (+), loss of consciousness (+)

Sensorium: GCS : 8 ( E4V1M3), T: 38.1 oC, BW: 8 kg, BH: 85 cm

HR: 112 x/min , RR: 32x/min, regular, respiratory sound: vesicular,stridor
O (+/+) , Extremities : Rigid.
Neurologist Examination :
Physiologic (+), Pathologic, Meningeal reflex (K/BI/BII) : (+/-/+)

-Head elevation 300 and midline position -O2 via nasal canule 1 L/minute
-IVFD NaCl 0.9% 20cc/ hour -IVFD NaCl 3% 0.8 cc/ hour
-Inj. Ceftriaxone 50mg/kg/ 24 hrs -Inj. Phenytoin maintenance dose
P divided into 2 dose = 200mg/ 12hr -Inj. Furosemide 8mg/ 24hrs
-Diamox 3 x 70 mg -Eritromycin syr. 3xI cth
-F75 150cc/ 3hrs with 3cc mineral mix -Vit.C 1x100 mg
-Vit. Bcomp 1x1 tab -Folic Acid 1x1mg
-NaCl 0.9% nebule/8hrs
 Follow up
7th-8th February 2017

S Seizure (-), Fever (+), loss of consciousness (+)

Sensorium:
7th Feb 2017
GCS : 10 ( E4V3M3), T: 38 oC , BW: 8.1 kg, BH: 85 cm, RR: 30x/min, HR: 116
x/min,BP: 100/60 mmHg
O
8th Feb 2017
GCS : 10 ( E4V3M3), T: 37.7 oC , BW: 8.1 kg, BH: 85 cm, RR: 32x/min, HR:
128 x/min, BP: 100/60mmHg
Neurologist Examination : Physiologic, Pathologic, Meningeal reflex : Positive

-Head elevation 300 and midline position -O2 via nasal canule 1 L/minute
-IVFD NaCl 0.9% 20cc/ hour -IVFD NaCl 3% 0.1 cc/ hour
-Inj. Ceftriaxone 50mg/kg/ 24 hrs -Inj. Phenytoin maintenance dose
divided into 2 dose = 200mg/ 12hr -Inj. Furosemide 8mg/ 24hrs
P -Diamox 3 x 70 mg -Eritromycin syr. 3xI cth
-Diet F100 150cc/ 3hrs with 3cc mineral mix
-Vit.C 1x100 mg -Vit. Bcomp 1x1 tab
-Folic Acid 1x1mg
DISCUSSION
According with the previous epidemiological study, the meningitis is one of the most
dangerous infection disease in children. In Indonesia, meningitis is in the 17th
position as the cause of death in all age groups (0.8%) after malaria. The proportion
of meningitis as the causes of death at the age of 1-4 year about 8.8 %

The patient in this case report is a 3 years old and 4 months old girl
Findings on physical examination varies based on the age and the infecting organism. As the
child grows older, physical examination to more easily searchable such as
Meningeal signs easier to observe , focal neurological signs, seizures occur in 30% of children
with bacterial meningitis.

Patient presented with loss of conciousness which experienced since 5 days before
entering Adam Malik hospital. Before the patient experienced loss of
consciousness, she had convulsion. The patient also had fever. The patient also had
coughs for 10 days and happened intermittent for 2 months. The coughs comes
with phlegm The history of body weight loss was found. The patient lost 5
kilograms in a month. The patient had pathologic reflex such as Babinski,
Oppenheim, Chaddock, Gordon and meningeal reflex such as Kernigs sign and
Bruzinski II.
Management for meningoencephalitis:
Convulsion, treated with Anti-convulsion
The increase of intracranial pressure
Antibiotics

Management for this patient:

Head elevation 300 and midline position
O2 via nasal canule 1 L/minute
IVFD NaCl 0.9% 20cc/ hour
IVFD NaCl 3% 0.8 cc/ hour
Inj. Phenytoin loading dose 10 mg/ kg -> 80 mg into 20 cc NaCl 0.9% for 20
minutes then 12 hrs later maintenance dose 25 mg in 20 cc NaCl/ 12 hrs
Inj. Dexamethasone 0.6 mg/ kg/ 24 hrs divided into 3 dose = 1.6 mg/ 8hr
Inj. Furosemide 8mg/ 24hrs
Diamox 3 x 70 mg
SUMMARY
A 3 years and 4 months years old girl, BW 8.5 kg and a BH 85 cm, admitted to
emergency room in Haji Adam Malik General Hospital medan on 2nd February
2017 with the main complain of loss of consciousness since 5 days ago.
Symptoms such as seizures, fever, history of chronic cough were also found.
Sign of old mans face, stiff neck, lymph nodes enlargement, rigid extremities,
pathologic neurologic examination, meningeal reflex were positive.
Leukocytosis and Thrombocytosis were also found. The patient was decided
to be hospitalized and further follow up suggested meningitis with marasmus
as diagnosis. The patient was monitored throughly the hospitalization and was
in theraphy with anticonvulsion, antibiotic, diuretic, and corticosteroid. After
7 days hospitalization, the patient showed obvious clinical improvement and
still on treatment in hospital.