Diseases » Meningococcal disease

Meningitis

Meningitis: Excerpt from The 5-Minute Pediatric Consult

Jason Newland, MD

Louis Bell, Jr., MD

Meningitis - BASICS

Meningitis - description

Inflammation of the membranes of the brain or spinal cord, usually caused by bacteria, viruses, fungi, and rarely parasites.

Meningitis - general prevention

• Haemophilus influenzae type b (HIB) vaccine has significantly reduced the incidence of meningitis and other invasive HIB infections.
• A 7-valent Streptococcus pneumoniae protein conjugate vaccine (PCV 7) has shown >90% efficacy in preventing invasive diagnosis and is recommended for use in all infants given at 2, 4, 6, and 12–15 months of age.

Meningitis - epidemiology

• Bacterial meningitis:
  • Most (80%) occurs in patients <24 months old.
  • S. pneumoniae isolates are becoming more resistant to penicillin. ~25% of isolates causing invasive disease are resistant to penicillin.
• Viral meningitis:
  • 85% are due to enteroviruses that tend to occur in outbreaks in summer and early fall.
• Fungal meningitis
  • Cryptococcus neoformans is a budding encapsulated yeastlike organism found in soil and avian excreta. Although associated with meningitis in immunocompromised adults (especially those with AIDS), this is rare in children with AIDS. 30% of patients with cryptococcal meningitis have no underlying immunodeficiency.
  • Meningitis caused by Candida species occurs in ill premature infants and other immunocompromised individuals.
• Tuberculous meningitis
  • The incidence of disease due to Mycobacteria tuberculosis (TB) is on the rise throughout the world.
  • TB meningitis occurs in 1 of 300 untreated primary TB infections.
  • Most common in children aged 6 months to 6 years
  • Meningitis will accompany miliary TB in ~50% of cases.
  • Increasing number of patients suffer from multidrug-resistant TB

Meningitis - pathophysiology

Usually a result of hematogenous spread

Meningitis - etiology

• Bacterial:
  • Cause differs depending on age:
    • <1 month old: Group B streptococcus, Escherichia coli, other enteric, Listeria monocytogenes, Streptococcus pneumoniae
    • 1–3 months old: Group B streptococcus, E. coli, S. pneumoniae, HIB (almost disappearing secondary to immunization)
    • 3 months to 5 years old: S. pneumoniae, Neisseria meningitides, HIB
    • >5 years old: S. pneumoniae, N. meningitis
• Viral:
  • Enteroviruses: ~70 different strains that include polioviruses, Coxsackie A, Coxsackie B, and echoviruses. Recently discovered enteroviruses are not placed in these 4 groups, but are numbered (e.g., enterovirus 68)
  • Other, less common: Arboviruses (e.g., West Nile virus), mumps, herpes simplex virus
• Fungal:
  • Fungi most commonly isolated include Candida species, Coccidioides immitis, Cryptococcus neoformans, Aspergillus species
• Aseptic meningitis:
  • Agents not easily cultured in the viral or microbiology laboratory can cause meningitis and include Borrelia burgdorferi (Lyme disease), Treponema pallidum (syphilis)
  • Tuberculous meningitis

Meningitis - DIAGNOSIS

Meningitis - signs & symptoms

• Pain
• Fever
• Nausea and/or vomiting

Meningitis - history

• Bacterial meningitis:
  • Children >12 months old will often complain of neck pain, headache, or back pain.
  • Nausea and vomiting are common.
  • In children <12 months old, symptoms are often nonspecific. Common chief complaints by the infants’ caregivers include the following:
    • Irritable or “sleeping all the time”
    • “Won’t take to bottle”
    • ”Not acting right”
    • ”Cries when moved or picked up”
    • ”Won’t stop crying”
    • ”Soft spot bulging out”
  • Unusual pathogen more likely in immunocompromised patients.
• Recurrent meningitis:
  • Recurrent meningitis with S. pneumoniae or Enterococcus may indicate a skull fracture or cribriform plate fracture with contamination of the CSF by nasopharyngeal secretions.
• Viral meningitis:
  • Headache and fever may precede signs of meningitis such as stiff neck, vomiting, photophobia.
  • Duration 2–6 days.
• Fungal meningitis:
  • Cryptococcal meningitis is often indolent, with complaints of worsening headaches and vomiting for days to weeks.
  • Exposure to pigeon droppings or other bird droppings can be a valuable clue to etiology if present.
• Tuberculous meningitis:
  • Symptoms often are nonspecific initially, with personality changes, fever, nausea, and vomiting progressing to anorexia, irritability, and lethargy (stage I disease).
  • Stage II disease is characterized by focal neurologic signs (most often involving the cranial nerves III, VI, and VII).
  • Stage III disease is characterized by coma and papilledema.

Meningitis - physical exam

• Stiff neck in older children but not infants with poor neck muscle tone
• Brudzinski and Kernig signs may be present.
  • Brudzinski sign: Flexion of the neck elicits involuntary flexion of the hips.
  • Kernig sign: While legs are flexed 90° at the hip, extensions of the lower legs are unable to be accomplished beyond 135°.
• Children <12 months old may not have nuchal rigidity, Kernig, and/or Brudzinski signs.
• Classically, there may be “paradoxical” crying—crying that increases when child is picked up.
• Tache cerebri: Flaring of skin when stroked

Meningitis - tests

Meningitis - lab

• CBC, platelet count, prothrombin time, partial thromboplastin time, electrolytes, BUNn, creatinine, glucose, liver function tests, arterial blood gas
• Blood culture

Meningitis - diag proced-surgery

Lumbar puncture with analysis of the CSF:

• If no etiology is discovered after the first lumbar puncture and the child is not responding to therapy, repeated lumbar puncture at 36–48 hours.
• Opening pressure: Normal is <200 mm H
• Depending on the presentation, age, history, and physical exam findings, some or all of the following tests should be requested for CSF analysis.
  • Glucose: Compare with serum glucose; normal is >40 mg/dL or 1/2–2/3 of the serum glucose.
  • Protein: Normal 5–40 mg/dL except in newborns, who may have protein levels of 150–200 mg/dL.
  • Cultures for bacteria, fungi, viruses, and mycobacteria. ~80% of blood cultures are positive in children with bacterial meningitis.
  • Polymerase chain reaction (PCR) analysis for TB, herpes simplex virus (HSV), Epstein barr virus, Borrelia burgdorferi
  • Antibody studies for Lyme disease

Meningitis - differencial diagnosis

• Encephalitis
• Toxic encephalopathy
• Epidural abscess
• Cerebral abscess

Meningitis - TREATMENT

Meningitis - general measures

• Assure adequate ventilation and cardiac function.
  • Airway, breathing, circulation (ABCs)
• Initiate hemodynamic monitoring and support by achieving venous access and treat shock syndrome, if present.
• Monitor serum sodium concentrations because syndrome of inappropriate ADH secretion (SIADH) is a frequent complication during the 1st 3 days of treatment.
• Glucose should be given IV if <50 mg/dL at a dose of 0.25–1 g/kg.
• If pH is <7.2, acidosis should be corrected with 1–2 mEq/kg of sodium bicarbonate.
• Coagulopathy should be treated with platelet concentrates (0.2 U/kg) if platelets are <50,000/mm³ and with fresh frozen plasma (10 mL/kg) if PT/PTT is prolonged.
• Steroids should be used in the initial therapy of TB meningitis along with antituberculosis medication. Use in children with bacterial meningitis is controversial.
• Steroids indicated for HIB meningitis, but is controversial in S. pneumoniae meningitis. Consult ID expert for use.
  • If giving steroids should give before or with first dose of antibiotic.

Meningitis - medication

• Antimicrobial agents:
  • <1 month of age: Ampicillin IV 200 mg/kg/d divided q12h if <7 days of age or 300 mg/kg/d divided q8h if >7 days of age, and cefotaxime IV 180 mg/kg/d divided q6h
  • >1 month of age: Vancomycin IV 60 mg/kg/d divided q6h; and cefotaxime IV 300 mg/kg/d divided q6h or ceftriaxone 100 mg/kg/d divided q12h (should not be used in infants <2 months of age)
• Note: In children <1 month of age, if Gram stain or culture reveals Gram-positive cocci, ampicillin should be changed to vancomycin for possible resistant S. pneumoniae.
• Fungal meningitis:
  • Amphotericin B with or without 5-flucytosine, depending on the type of fungi isolated.
• Tuberculous meningitis
  • Treatment is generally with 4 drugs for 2 months followed by 2 drugs for 10 months.
  • Initially, treat with isoniazid, rifampin, pyrazinamide, and streptomycin.
• Viral meningitis:
  • Enterovirus: No specific therapy other than supportive
  • HSV: Acyclovir 60 mg/kg/d divided q8h

• Remember that in tuberculous meningitis, up to 50% of children will not react to the 5-tuberculin unit Mantoux tests. Therapy should be started if suspicious; do not rely on the skin testing.
• Be aware that the isolation of resistant strains of S. pneumoniae is increasing; therefore, antibiotics such as vancomycin and cefotaxime or ceftriaxone should be used until antibiotic sensitivity data are available.

Meningitis - FOLLOW UP

• Prophylaxis in HIB:
  • Rifampin (20 mg/kg/dose, maximum 600 mg daily for 4 days) should be given to all household contacts if one member is <4 years of age and is unvaccinated.
• Prophylaxis in N. meningitidis
• Rifampin (10 mg/kg/dose, maximum 600 mg b.i.d. for 2 days) for all household contacts, day care contacts, and other persons with close contact 7 days prior to onset of illness.
• Note: If cefotaxime or ceftriaxone was used for treatment, the patient with N. meningitidis or HIB meningitis does not need to receive prophylaxis.

Meningitis - prognosis

• Bacterial meningitis
  • ~500–1,000 deaths each year
  • Hearing deficits and neurologic damage may occur in up to 25% of children.
• Viral meningitis:
  • Prognosis for enteroviral meningitis is quite good.
• Aseptic meningitis:
  • Lyme disease: Prognosis with diagnosis and treatment is quite good (see “Lyme Disease”).
• Tuberculous meningitis
  • The long-term prognosis in children with tuberculous meningitis depends on the stage of disease in which treatment is begun.
  • Complete recovery occurs in 94% of those whose treatment was started in stage 1, but only 51% and 18% for those whose treatment began in stage II or stage III, respectively.

Meningitis - complications

• Bacterial meningitis:
  • Acute complications: SIADH, seizures occur in up to 1/3 of patients, focal neurologic signs occur in 10–15%.
  • Long-term complications: Mental retardation, hearing defects
• Viral meningitis
  • Acute complication: SIADH in 10%
  • Long-term complications: Complications from viral meningitis are rare. However, neonates (<1 month of age) may develop severe EV disease and older agammaglobulinemic children may develop chronic EV meningoencephalitis.
• Tuberculous meningitis
  • Acute complications: Most common are cranial nerve findings, especially 6th cranial nerve palsy affecting the eyes; hydrocephalus
  • Long-term complications: Many, including blindness, deafness, and mental retardation

Meningitis - patient monitoring

• Most children with bacterial meningitis become afebrile by 7–10 days after starting therapy, with gradual improvement in activity with less irritability.
• Evaluation for neurologic sequelae, such as hearing and vision testing, is essential.

Meningitis - bibliography

1. Agarwal R, Emmerson AJ. Should repeat lumbar punctures be routinely done in neonates with bacterial meningitis? Results of a survey into clinical practice. Arch Dis Child. 2001;84:451–452.
2. Arditi M, Mason EO, Bradley JS, et al. Three-year multicenter surveillance of pneumococcal meningitis in children: Clinical characteristics, and outcome related to penicillin susceptibility and dexamethasone use. Pediatrics. 1998;102:1087–1097.
3. El Bashir H, Laundy M, Booy R. Diagnosis and treatment of bacterial meningitis. Arch Dis Child. 2003;88:615–620.
4. Hoffman JA, Mason EO, Schutze GE, et al. Streptococcus pneumoniae infections in the neonate. Pediatrics. 2003;112:1095–1102.
5. Lebel MH, Freij BJ, Syrogiannopoulos GA, et al. Dexamethasone therapy for bacterial meningitis: Results of two double-blind, placebo-controlled trials. N Engl J Med. 1988;319:964–971.
6. Saez-Llorens X, McCracken GH. Bacterial meningitis in children. Lancet. 2003;361:2139–2148.
Stark JR, Smith KC. Tuberculosis. In: Feigin RD, Cherry JD, Demmler GJ, et al., eds. Textbook of Pediatric Infectious Diseases, 4th ed. Philadelphia: WB Saunders; 2004:1337–1370.
7. van de Beek D, de Gans J, McIntyre P, et al. Corticosteroids in acute bacterial meningitis. Cochrane Database Syst Rev. 2003;3:CD004305.

Meningitis - CODES

Meningitis - icd9

322.9 Meningitis

Meningitis - FAQ

• Q: Is a lumbar puncture required before starting antibiotics in the patient with suspected meningitis with unstable vital signs requiring resuscitation?
• A: No. In the unstable patient, it is contraindicated to perform a lumbar puncture. Appropriate IV antibiotic should be started. When resuscitated, a lumbar puncture should be performed.

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Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

More About Meningococcal disease

• Back to disease: Meningococcal disease: Introduction
• Next Book Extract About Meningococcal disease: Meningitis (Pediatric Infectious Disease)
• More Book Extracts: All Online Books for Meningococcal disease

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

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More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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