Narong Auervitchayapat,MD MD., Assist Prof Department of Pediatrics Faculty of Medicine KKU

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1 Narong Auervitchayapat,MD MD., Assist Prof Department of Pediatrics Faculty of Medicine KKU

2 5 common diseases:- 1. Bacterial meningitis 2. Tuberculous meningitis 3. Aseptic meningitis 4. Viral encephalitis 5. Brain abscess

3 efinitions * Meningitis: Inflammation of meninges Abnormal number of WBCs in CSF * Bacterial meningitis: Meningitis and evidence of a bacterial pathogen in CSF * Aseptic meningitis: Meningitis in the absence of bacterial pathogen in the CSF by usual laboratory techniques

4 efinitions * Encephalitis: Inflammation of the brain * Meningoencephalitis: Inflammation of the brain accompanied by meningitis

5 Bacterial Meningitis

6 Introduction 1. Common 2. High morbidity & mortality rates 3. Emergency condition

7 Epidemiology The causative organism depends on *Age * Place * Underlying disease

8 Sirinavin S et al 420 cases of bacterial meningitis in 14 hospitals Age 0 mo 1-6 mo 7-11 mo 1-5 yr 6-15 yr Pathogens ram negative bacilli rep group B (GBS) lmonella influenzae pneumoniae meningitidis

9 Underlying diseases Splenectomy & asplenia: S.pneumoniae, H.influenzae type b,gram negative enteric Hemoglobinopathies: S.pneumoniae, H.influenzae type b C5-8 deficiency: Meningococcal infection, Salmonella

10 Underlying diseases CSF leak eg. middle ear defect ; base of skull fracture: pneumococcal meningitis Dermal sinus, meningomyelocele: staphylococci, gram- negative enteric CSF shunt: staphylococci ( esp. coagulase -ve)

11 athology

12 Clinical manifestations - Brudzinski s sign * Fever + Acute onset * Headache Signs of increased intracranial pressure + * Meningeal signs - Stiffneck - Kernig s sign

13 Clinical manifestations - Consciousness - Seizures - Nausea, vomiting - Diarrhea - Poor feeding

14 Diagnosis Fever + headache + meningeal signs Beware herniation in:- Lumbar puncture 1. Papilledema 2. Tensed anterior fontanel 3. Localizing signs

CSF findings - Pressure: Normal, > 300 mmh 2 O - Appearance: Turbid, xanthochromia - WBCs: 100-50,000, PMN

15 CSF findings - Pressure: Normal, > 300 mmh 2 O - Appearance: Turbid, xanthochromia - WBCs: ,000, PMN % -Protein: > 40 mg/dl, most > 150mg/dl - Sugar: < 50% of blood sugar, < 40 mg/dl - Gram stain, culture/sensitivity

16 Bacterial Antigen: 1. Latex agglutination 2. CIE ( Counter-Immuno-Electrophoresis )

17 Treatment Specific treatment * Emergency antibiotics * Empiric antibiotics - Newborn: Ampicillin + gentamicin Ampicillin + cefotaxime - Beyond the neonatal period: Ampicillin + chloramphenicol Cefotaxime or ceftriaxone + vancomycin?

18 Dosage of antibiotics for bacterial meningitis Increased from systemic dosage Penicillin group: Cephalosporins: Increase 3-4 folds Increase 2 folds Chloramphenicol: As same as systemic dosage Amonoglycosides: As same as systemic dosage

19 uration of antibiotics H.Influenzae S.pneumoniae Group B streptococci days days days Gram negative enteric bacilli N.meningitidis Salmonella 21 days 7-10 days 42 days

20 *Adjunctive Dexamethasone Therapy*

21 The use of corticosteroids Antibiotics and pediatric intensive care: MR = 5% but 20-30%: long-term sequalae esp. hearing impairment Dexamethasone substantially reduced levels of cytokines IL-1, TNF & PGE 2 within CSF of infected animal: reduction of ICP, brain edema & CSF lactate: decreased MR and sequalae in animals.

22 Bacterial meningitis Antibiotics Rapid lysis of bacteria:- Release of endotoxin (H.influenzae) Lipoteichoic acid (S.pneumoniae) Dexamethasone Release of cytokines: *Interleukin 1β *Tumor necrotic factor-α *Platelet activating factor Prostaglandin E-2 Phospholipase A 2 Neutrophil recruitment Neutrophil induced inflammation Cerebral edema Vasculitis Decreased cerebral perfusion Dead Sequelae

23 Odio C et al N Eng J Med children, 6 weeks- 13 years 79 H. influenzae, 8S. pneumoniae, 2 N. meningitidis Cefotaxime + dexa vs Cefotaxime + placebo Dexamethasone 0.15 mg/kg every 6 hr for 4 days Given 15 min prior to cefotaxime rate of neurologic and audiologic sequalae in children received dexa was significantly lower ( 14%vs 38%)

24 Wald E, Pediatrics children,8wk -12yr 83 H. influenzae, 33S. pneumoniae, 24 N. meningitidis Ceftriaxone + dexa vs Ceftriaxone + placebo Dexamethasone 0.15 mg/kg every 6 hr for 4 days No significant difference in rate of neurologic and audiologic sequalae Bilateral deafness was significantly lower in H. influenzae meningitis receiveing dexa( 0%) vs placebo (7%)

26 Bonadio WA, Pediatrics 1996 Rate of neurologic and audiologic sequalae in children received dexa was significantly lower

28 Supportive treatment *Critical peroid: first 3-4 days* Monitor: Vital signs Neurological signs Intake-output Electrolytes SIADH Body weight

29 Bacterial meningitis with subdural effusion Brudzinski s sign positive

30 GBS meningitis

31 Meningococcemia

32 Aseptic meningitis Etiology - Viral: Enteroviruses - Postviral: Mumps, measles, chickenpox - Bacterial: Partially treated bacterial meningitis - Rickettsiae: Scrub typhus - Spirochetes: Leptospirosis - Mycoplasma: M.pneumoniae

33 Clinical manifestations As same as that of bacterial meningitis

34 SF findings As same as that of viral encephalitis

35 reatments - Viral & postviral: Supportive treatments - Bacterial: Partially treated bacterial meningitis - Continue the most appropriated antibiotics - Rickettsiae: Scrub typhus - doxycycline, chloramphenicol - Spirochetes: Leptospirosis - doxycycline - Mycoplasma: M.pneumoniae - macrolides eg. erythromycin

36 uberculous Meningitis Introduction - Common in tropical countries -HIV - The result of treatment depended on the stage of disease

37 linical manifestations Chronic meningitis: 3 stages 1. Prodromal stage: nonspecific symptoms (low grade fever, anorexia, nausea, vomiting ) 2. Transitional stage: prominent neurological symptoms meningeal signs, CN palsy, fever 3. Terminal stage: coma, fixed and dilated pupil, decreased RR, PR, dead

38 Diagnosis 1. History & physical examination 2. Family history 3. CSF findings 4. Other sources of TB (pulmonary, lymph node, miliary TB 5. Tuberculin test 6. CT brain, ELISA, PCR

39 SF findings of TB meningitis Pressure: high Appearance: Turbid, xanthochromia WBCs: cells/mm 3, lymphocytes predominate ( >50% ) Protein: mg/dl, may be 1-2 gram or slightly increase Sugar: < 50% of blood sugar, or < 40mg/dl AFB stain Culture

42 Treatment Good clinical respond depended on:- 1. Early diagnosis & early treatment 2. Good medications & adequate duration INH + rifampicin + pyrazinamide + streptomycin for 2 months INH + rifampicin for 10 months

43 3. Reduction of the increased intracranial pressure Keep CSF pressure < 200 mmh2o 3.1 Lumbar puncture 3.2 Dexamethasone 3.3 Acetazolamide 3.4 Ventriculostomy or ventriculoperitoneal shunt

44 4. Good supportive treatments 4.1 Nutrition 4.2 Aspiration 4.3 Bed sore 4.4 Fever 4.5 Seizures 4.6 rehabilitation

45 ncephalitis Etiology:- -Viral: Japanese B encephalitis - 50% CMV, HSV, EBV, Poliovirus, rabies - Postviral: Measles, mumps, chickenpox, rubella - Postvaccinal: Rabies vaccine

46 apanese B encephalitis - Most common cause of encephalitis in the world - Common in southeast Asia esp. Thailand - Northeast Thailand is 2 nd common - Severe, morbidity and mortality rates are high - No medication for treatment - Outbreak

47 Global distribution of major neurotropic flaviviruses

48 linical manifestations 1. Prodromal stage (2-3 days): Fever, headache, malaise, nausea, vomiting 2. Acute encephalitic stage (3-4 days): Fever, conscious change, seizures, neurosigns, meningeal signs (meningoencephalitis) 3. Subacute stage (7-10 days): Neurosigns improved, complication eg. Pneumonia, UTI 4. Late stage and sequalae (4-7 weeks): Stable or improved neurosigns, sequale eg. spastic paralysis, atrophy

49 Diagnosis Fever + conscious change + seizures

50 CSF findings Pressure: mmh 2 O WBCs: 10-1,000 cells/mm 3, lymphocytes predominate Protein: normal or slightly increased (50-80 mg/dl) Sugar: normal

51 reatment No specific treatment Supportive treatment directed to brain edema 1. Airway and breathing 2. Fever 3. Seizures

52 Treatment 4. Brain edema: 20%manitol gm/kg/dose Steroids - no benefit 5. Complications: Pneumonia, bed sore, SIADH, UTI 6. Nutrition 7. Rehabilitation

53 Brain abscess - Common in Thailand - High morbidity and mortality rates - Often delayed diagnosis and treatment - Usually recur

54 Clinical manifestations 3 Main groups of signs and symptoms:- 1. Infection: Fever, anorexia, fatigue, increased WBCs and ESR 2. Increased ICP: Most common:- headache, vomiting, diplopia, papilledema 3. Focal neurodeficit: Depend on location of the abscess, silent area - no neurodeficit

55 Diagnosis Fever + headache + neurodeficit Underlying disease CT or MRI brain

62 Treatment. Antibiotics -Empiric: cefotaxime + metronidazole -Depended on underlying diseases:- COM: aminoglycosides or 3rd gen cephalosporins Compound fracture: cloxacillin

63 Treatment 2. Drainage All patients except 2.1 Small abscess diameter < 2 cm 2.2 Multiple abscesses 2.3 Abscess in vital area 3. Supportive treatment 4. Treatment of the underlying disease

CNS Infections in the Pediatric Age Group

CNS Infections in the Pediatric Age Group Introduction CNS infections are frequently life-threatening In the Philippines, bacterial meningitis is one of the top leading causes of mortality in children