Narong Auervitchayapat,MD MD., Assist Prof Department of Pediatrics Faculty of Medicine KKU
5 common diseases:- 1. Bacterial meningitis 2. Tuberculous meningitis 3. Aseptic meningitis 4. Viral encephalitis 5. Brain abscess
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
efinitions * Encephalitis: Inflammation of the brain * Meningoencephalitis: Inflammation of the brain accompanied by meningitis
Bacterial Meningitis
Introduction 1. Common 2. High morbidity & mortality rates 3. Emergency condition
Epidemiology The causative organism depends on *Age * Place * Underlying disease
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 37 8 0 0 0 rep group B (GBS) 13 8 0 0 0 lmonella 3 35 6 0 0.influenzae 2 87 47 26 0 pneumoniae 2 43 19 28 16.meningitidis 0 9 2 2 5
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
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)
athology
Clinical manifestations - Brudzinski s sign * Fever + Acute onset * Headache Signs of increased intracranial pressure + * Meningeal signs - Stiffneck - Kernig s sign
Clinical manifestations - Consciousness - Seizures - Nausea, vomiting - Diarrhea - Poor feeding
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 70-100% -Protein: > 40 mg/dl, most > 150mg/dl - Sugar: < 50% of blood sugar, < 40 mg/dl - Gram stain, culture/sensitivity
Bacterial Antigen: 1. Latex agglutination 2. CIE ( Counter-Immuno-Electrophoresis )
Treatment Specific treatment * Emergency antibiotics * Empiric antibiotics - Newborn: Ampicillin + gentamicin Ampicillin + cefotaxime - Beyond the neonatal period: Ampicillin + chloramphenicol Cefotaxime or ceftriaxone + vancomycin?
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
uration of antibiotics H.Influenzae S.pneumoniae Group B streptococci 10-14 days 10-14 days 14-21 days Gram negative enteric bacilli N.meningitidis Salmonella 21 days 7-10 days 42 days
*Adjunctive Dexamethasone Therapy*
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.
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
Odio C et al N Eng J Med 1991 101 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%)
Wald E, Pediatrics 1995 143children,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%)
Bonadio WA, Pediatrics 1996 Rate of neurologic and audiologic sequalae in children received dexa was significantly lower
Supportive treatment *Critical peroid: first 3-4 days* Monitor: Vital signs Neurological signs Intake-output Electrolytes SIADH Body weight
Bacterial meningitis with subdural effusion Brudzinski s sign positive
GBS meningitis
Meningococcemia
Aseptic meningitis Etiology - Viral: Enteroviruses - Postviral: Mumps, measles, chickenpox - Bacterial: Partially treated bacterial meningitis - Rickettsiae: Scrub typhus - Spirochetes: Leptospirosis - Mycoplasma: M.pneumoniae
Clinical manifestations As same as that of bacterial meningitis
SF findings As same as that of viral encephalitis
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
uberculous Meningitis Introduction - Common in tropical countries -HIV - The result of treatment depended on the stage of disease
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
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
SF findings of TB meningitis Pressure: high Appearance: Turbid, xanthochromia WBCs: 50-500cells/mm 3, lymphocytes predominate ( >50% ) Protein: 200-500 mg/dl, may be 1-2 gram or slightly increase Sugar: < 50% of blood sugar, or < 40mg/dl AFB stain Culture
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
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
4. Good supportive treatments 4.1 Nutrition 4.2 Aspiration 4.3 Bed sore 4.4 Fever 4.5 Seizures 4.6 rehabilitation
ncephalitis Etiology:- -Viral: Japanese B encephalitis - 50% CMV, HSV, EBV, Poliovirus, rabies - Postviral: Measles, mumps, chickenpox, rubella - Postvaccinal: Rabies vaccine
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
Global distribution of major neurotropic flaviviruses
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
Diagnosis Fever + conscious change + seizures
CSF findings Pressure: 300-400 mmh 2 O WBCs: 10-1,000 cells/mm 3, lymphocytes predominate Protein: normal or slightly increased (50-80 mg/dl) Sugar: normal
reatment No specific treatment Supportive treatment directed to brain edema 1. Airway and breathing 2. Fever 3. Seizures
Treatment 4. Brain edema: 20%manitol 0.5-1 gm/kg/dose Steroids - no benefit 5. Complications: Pneumonia, bed sore, SIADH, UTI 6. Nutrition 7. Rehabilitation
Brain abscess - Common in Thailand - High morbidity and mortality rates - Often delayed diagnosis and treatment - Usually recur
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
Diagnosis Fever + headache + neurodeficit Underlying disease CT or MRI brain
Treatment. Antibiotics -Empiric: cefotaxime + metronidazole -Depended on underlying diseases:- COM: aminoglycosides or 3rd gen cephalosporins Compound fracture: cloxacillin
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