Acute Bacterial Meningitis Beyond
the Neonatal Period
Dr. Bersabeh
(Pediatrician)
Case Study
• A 5 months old child presented with high grade fever,
vomiting of ingested matter, irritability of 2 days.
• GTC seizure that lasted for 3minutes
• P/E:
• acutely sick looking
• bulged anterior fontanel
• febrile, tachycardic
• conscious, Rt side hemiparesis
• no CN palsy
Meningitis
• A clinical syndrome characterized by inflammation of the
meninges.
• Can occur at any age but more common in the younger age
groups
Mode of transmission:
• person-to-person contact through respiratory tract secretions
or droplets
Etiology
• S. pneumoniae
• N. meningitidis
• H. influenzae type b
* invasive disease has become much less common since the
introduction of universal immunization
• S. pneumoniae is associated with more severe
disease and sequelae
• When septic material embolizes or extends directly from
ears or sinuses
• more than one type of bacterial flora common to these
sources may be transmitted
• Infections reach the intracranial structures by
• hematogenous spread
• extension from cranial structures
• iatrogenic:
• Cerebral/ spinal surgery
Etiology…
• What determines the most likely invading organism?
• the age of the patient
• the clinical setting of the infection
• community-acquired, postsurgical, or nosocomial
• evidence of systemic and local cranial disease
• the immune status of the patient
• Alterations of host defense (due to anatomic defects or
immune deficits)
• less-common pathogens:
• P. aeruginosa
• S. aureus
• Coagulase-negative staphylococci
• Salmonella spp.
• Anaerobes
• L. monocytogenes
Risk factors
• young age
• recent colonization with pathogenic bacteria
• close contact with individuals having invasive disease
• crowding
• Poverty
• genetic predisposition: eg. Complement deficiency
• male gender
Pathogenesis
• 4 main processes:
• colonization
• invasion into the bloodstream
• occurs either transcellularly or pericellularly
• survival in the bloodstream
• requires evasion of the immune system
• Entry into the subarachnoid space (lack of host
defenses bacteria multiply unhindered.)
Clinical
manifestation
depends on:
•the age of the child
•the duration of illness
•the host response to infection
•the etiology:
Petechial and purpuric skin
eruptions →
meningococcaemia, also
present in Hib meningitis.
Clinical manifestation…
• Fever • Irritability (paradoxical)
• Headache • high –pitched cry
• Neck stiffness • Depression of consciousness,
• Vomiting coma
• Photophobia • Seizure (~1/3 of pts)
• Bulging fontanel
P/E
• G/A
• V/S
• Focal neurologic signs, CN palsies
• Signs of meningeal irritation
• Level of consciousness
• Systemic and extracranial findings
Diagnosis
• LP and CSF analysis :
• Cell count, protein, glucose
• gram stain and culture
• Molecular methods/ rapid Ag detection tests: PCR
• Brain CT/MRI before LP if a focal N. deficit
Contraindication to LP
• Respiratory distress
• Thrombocytopenia
• Increased ICP
• Infection over the site
• Signs of FND
leptomeningeal enhancement
Characteristic CSF findings in meningitis
CSF findings Normal TB Viral Bacterial
Cells 0 10–500 0–500 5–10,000
Differential — polys→monos polys→monos poly
Protein (mg/dL) 15–45 >150 20–50 20–400
Glucose (mg/dL) 50–75 20–50 30–80 <20 20–40
• CSF WBC ranges from 250 to 100,000/mm3,
• usually 1,000 to 10,000/mm3
• WBC >50,000/ mm3
• possibility of a brain abscess having ruptured into
a ventricle
Additional Investigations
• Blood cultures
• Complete blood counts
• Serum electrolytes
• RBS
• RFT, LFT
• urine output and specific gravity
• coagulation studies in the presence of bleeding tendency
Treatment
• Bacterial meningitis is a medical emergency
• Antibiotic treatment
• Choice of antibiotic depend upon
• the age
• most likely organisms
• local resistance patterns
• Steroids/ dexamethasone
Treatment…
• Supportive and adjunctive treatment
• ensure adequate cerebral perfusion
• controlling fever, maintaining arterial BP,
hyperventilation
• adequate oxygenation, and respiratory support if needed
• careful fluid management
• prevention of hypoglycaemia and hyponatraemia
• control of seizures
Empirical therapy of meningitis
• 4-12 wk: 3rd gen. cephalosporin plus ampicillin (plus dexa.)
• 3 mo-18 yr:
- 3rd gen. cephalosporin plus vancomycin (± ampicillin)
• Immununocompromised state:
- Vancomycin plus ampicillin and ceftazidime
• Basilar skull fracture: 3rd gen. cephalosporin plus vancomycin
• Head trauma, neurosurgery, CSF shunt:
- Vancomycin plus ceftazidime
Complications
• Can develop before diagnosis or several days after starting
treatment
• Peripheral circulatory collapse
• DIC
• Gangrene of the distal extremities
• SIADH
– The raised serum [ADH] is an appropriate host
response to unrecognized hypovolemia
1. Focal neurological findings
• 10–15% of patients
• can be associated with cortical necrosis, occlusive
vasculitis, or thrombosis of the cortical veins
• hemiparesis, quadriparesis, etc
• Cranial nerve palsy
• 2nd, 3rd, 6th, 7th, and 8th CNs that course through the
subarachnoid space
2. Subdural effusion
• present in > 1/3 of pts
• mainly in children < 2 yrs of age
• Less frequent with meningococcal than with H influenzae
or pneumococcal meningitis.
• commonly resolve spontaneously
– Indications for needle puncture
• suspicion of empyema
• a rapidly enlarging head circumference in the absence
of hydrocephalus
• focal neurological findings
• evidence of increased ICP
3. Subdural empyema
• prolonged fever
• irritability
• stiff neck coupled with CSF leukocytosis
4. Arthritis
• Early occurrence (suppurative arthritis)
• Usually H influenzae type b
• late (reactive arthritis)
• immune complex– mediated event
• occurs after the 4th day of treatment
• affects several joints
• most frequently seen with N. meningitidis
5. Brain abscess
6. Increased ICP (20-25mmHg)
• cell death (cytotoxic cerebral edema)
• cytokine-induced increased capillary vascular
permeability (vasogenic cerebral edema)
• increased hydrostatic pressure (interstitial cerebral
edema) due to hydrocephalus.
CUSHING’S TRIAD
• SIADH may produce excessive water retention and
potentially increase the risk of elevated ICP
Raised ICP and progression to herniation syndrome
Other Complications
• Cerebritis
• Intracranial hemorrhage
• Ventriculitis
• Vasculitis and cerebral infarction
Prognosis and Sequelae
Prognosis depends on
• age of the patient
• intensity of host’s inflammatory response
• time before effective antibiotic treatment is begun and adequacy
of treatment
• virulence and number of bacteria in the CSF
• Pneumococcal meningitis
• MR: ~ 10% in most studies
• Hearing loss: 20-30%
• Meningococcal meningitis: MR < 5%
Prognosis and Sequelae...
• residual abnormalities ~15% (range 10% to >30%)
• Cognitive impairment/ learning problems
• Behavioral problems
• Hemiplegia, Spastic quadriplegia, Dystonia
• Hearing or visual loss
• Epilepsy
Prevention
• Vaccination
• the most effective means of prevention of bacterial
meningitis in children
• Antibiotic prophylaxis of susceptible at-risk contacts
– a single dose of ceftriaxone, rifampicin or ciprofloxacin is
effective
• to eradicate nasopharyngeal colonization and
transmission
Case Study
• A 5 months old child, vaccinated for his age, presented with
high grade fever, vomiting of ingested matter, irritability of 2
days, and Rt side GTC seizure that lasted for 3minutes and
decreased movement of the Rt upper and lower limbs(UL>LL)
of 6hrs
• P/E:
• acutely sick looking
• bulged anterior fontanel
• febrile, tachycardic
• conscious, Rt side hemiparesis
• no CN palsy
• What other Hx would you like to ask?
• P/E finding?
• Investigation required
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