meningoencephalitis in pediatric
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MBEYA ZONAL CONSULTANT HOSPITAL.
Meningoencephalitis in pediatric. Presented by : Dr John Romanus Nyeho, MD.
Dr. Michael Haule, MD.
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Outlines:• Definitions.• Routes for organisms to reach the CNS• Types of Meningitis and their organisms: - Acute Pyogenic Meningitis. Pathophysiology & Complications. - Other types of Meningitis: (Viral,fungal,protozoan,parasitic,malignant & inflammatory).• Diagnosis & CSF analysis.• Treatment.• Complications.
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Definitions:
Meningitis Encephalitis
CerebritisCerebral abscess
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Causes of meningitis:
Infectious causes.Non infectious causes: - Malignant. - Autoimmune. - Chemical.
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Types of Meningitis.
Meningitis
Acute Pyogenic Meningitis.
Aseptic Meningitis.
Chronic Meningitis.
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Acute pyogenic Meningitis.
This is classified according to a group of age and their etiologies are differ from one group to another.• Neonates (BEL)• Infants (B,E,L, + H.influenza,S.pneumonia, N.Meninitides)
• Children & Young Adult (H.influenza, S.pneumonia, N.Meninitides)
• Old adults
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Others:• Pregnant woman: - L. monocygotenes• Alcoholic patients:
- S. Pneumoniae. - L. monocygotenes.
• Inmunocomprised Patient. - S. Pneumoniae. - L. monocygotenes - Pseudomona Aeuriginosa - Mycobacterium Tuberculosis. - Mycobacterium Avum.
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PATHOPHYSIOLOGY OF ACUTE PYOGENIC MENINGITIS.
Bacterial entry & colonization
(invasion)
Migration & proliferation
Initiation of the immune
response(meningitis)
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Risks factors.
• Immunosuppression.• Otitis media.• Sinusitis.• Age extremes (neonates & elderly).• Parameningeal infections (osteomyelitis of
the skull).• Neurological procedure.• Infections (Systemic).
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Clinical Presentation. Fever
Neck stiffness Mental status (Meningismus) changes
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In neonates and infants this conditions does not presents with the classic features of meningitis. The child might presents with:- Fever or hypothermia.- Irritability or lethargy.- Poor feeding.- Vomiting.- Convulsions.- Toxic aspect.- Bulging fontanela- Paralysis of the cranial nerves (III & IV).
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Physical Examinations:• Brudzinski’s sign.
• Kerning sign.
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• Meningococcal Skin rashes.
From the 1st to the 3rd day, at least one-third of patients with meningococcal meningitis develop petechiae, most prominently in areas subjected to pressure; for example, Axillary folds and the belt line.
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Diagnosis• History & physical examination.• Investigation: - CBC - Blood cultures & gram staining. - PCR (for viral meningitis). - Latex Agglutination Test for antigen detection. - India ink stain (Cryptococcus detection in CSF). - CSF analysis. - Electrolytes - CT or MRI (for toxoplasmosis,HSV or to exclude any space occupying lesions)
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CSF Findings.
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DIFFERENTIAL DIAGNOSIS.• Bacterial meningitis.• Tubercular Meningitis.• Fungal Meningitis.• Parasitic Meningitis.• Viral Meningitis.• Subarachnoid hemorrhage. (RBC in CSF)• Meningioma (x ray for tumor presence).• Brain Abscess.• Tetanus (trismus & clean mentation)
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MANAGEMENT.General management:- Admit the patient- IV line access- Vital signs- Fowler position - Input & output documentation.If the patient has the signs of cerebral edema & increased intracranial pressure:- Fowler position- Osmotic diuretics (manitol 20%) 0.25mg /kg/dose 4
hourly.- Steroids (dexamethasone) 0.15 mg/kg/dose 6 hourly in
the 1st 4 days to decrease the edema & intracranial pressure.
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Specific management:Bacterial meningitis.Start the empirical treatment enough to cover the suspected organisms according to each group.• Children < 3 months old (BEL organisms) .The management is similar to that of neonatal sepsis . ampicillin iv + gentamycin iv or ampicillin iv + cefotaxime / ceftriaxone ivIf the CSF revealed the presence of- Listeria monocygotene ( Rx for 21 days) & ampicillin only or in association with gentamycin can be used.- GBS (Rx for 14 days)
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• Children > 3 months old .Empirical treatment it consists of 3rd generation cephalosporin + vancomycin .After getting the culture results & sensitivities you have to adjust the Mgx ORGANISM ANTIBIOTICS
S.PNEUMONIAECEFTRIAXONE (100mg/k/day) or CEFOTAXIME (200mg/kg/day) + VANCOMYCIN IV (45-60 mg/kg/) TID
L.MONOCYGOTENE AMPICILLIN IV(50mg/kg/dose) 6
hourly H. INFLUENZAE CEFTRIAXONE / CEFOTAXIME IV
N. MENINGITIDIS CEFTTRIAXONE / CEFOTAXIME + PENICILLIN IV
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Management of Other meningitis:Tb meningitis : ant tuberculosis therapyViral meningitis: supportive measures- Herpes simplex & Herpes zoster: Acyclovir
30mg/kg/day 8 hourly for 21 days ( neonates dose 60mg/k/day).
- Cytomegalovirus:Gancyclovir 6mg/kg/dose BID for 3 -4 weeks.
Fungal Meningitis: anti fungal drugs
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COMPLICATIONS:• Hearing loss.• Cerebral abscess.• Hydrocephalus.• Increased ICP.• Cranial nerves palsy.• Focal seizure & epilepsy.
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