Management of meningeal signs in children
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Transcript of Management of meningeal signs in children
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Fariba shirvani MD
Management of meningeal signs in children
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Definition:
•Signs and symptoms of meningitis in children•The 3 classic symptoms (less likely in younger children): Fever Headache Meningeal signs
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What are meningeal signs
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Meningeal signs
• Neck pain • Meningeal irritation :Brudzinski sign ,
Kernig sign, tripod phenomenon, or neck stiffness in children older than 1 year.
• In children 1 year or younger: bulging fontanel
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Clinical signs of meningeal irritation
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Disorders accompanied with meningeal signs in children:
Trauma
Paravertebral abscess
Retropharyngeal abscessMuscle spasm
Right upper lobe pneumonia
Meningitis
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Scoring for bacterial meningitis:
• Total Score = [1 × Duration of Main Problem (1 Point for Each Day)] + [2 × Vomiting in History (Yes = 1; No = 0)] + [7.5 × Meningeal Irritation (Yes = 1; No = 0)] + [6.5 × Cyanosis (Yes = 1; No = 0)] + [4 × Petechiae (Yes = 1; No = 0)] + [8 × Disturbed Consciousness (Yes = 1; No = 0)] + [0.1 × Serum C-reactive Protein (CRP) (per 10 mg/L)].
Oostenbrink RMoons KGMDonders ARTGrobbee DEMoll HA Prediction of bacterial meningitis in children with meningeal signs: reduction of lumbar punctures. Acta Paediatr. 2001;90611- 617
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Scoring for bacterial meningitis:
• . In those with a risk score of less than 9.5 points (approximately 35% of the patients), bacterial meningitis seemed always to be absent. In the remaining patients with(score, ≥9.5), the risk of bacterial meningitis was 44%.
Oostenbrink RMoons KGMDonders ARTGrobbee DEMoll HA Prediction of bacterial meningitis in children with meningeal signs: reduction of lumbar punctures. Acta Paediatr. 2001;90611- 617
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Bacterial meningitis score
• Components of the bacterial meningitis score are as follows:
• Positive CSF Gram stain• CSF absolute neutrophil count 1000/µL or higher• CSF protein level 80 mg/dL or higher• Peripheral blood absolute neutrophil count 10,000/µL
or higher• History of seizure before or at the time of presentation
Meta-analysis of bacterial meningitis score validation studies.Arch Dis Child. 2012; 97(9):799-805 (ISSN: 1468-2044)Nigrovic LE; Malley R; Kuppermann N
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What are the predictors of bacterial meningitis
• CSF indices:• identified the absolute PMN cell count • CSF–blood glucose ratio
– independent determinants of presence of bacterial meningitis.
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What are the predictors of bacterial meningitis
• patient characteristics:• duration of the main problem, vomiting, meningeal irritation, cyanosis, petechiae, disturbed consciousness, and serum CRP, can discriminate well between the absence or presence of bacterial meningitis
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Contraindication of LP
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(1) a short period of antibiotic therapy prior to LP does not change cerebrospinal fluid (CSF) white blood cell count, protein, or glucose; (2) the yield of CSF gram stain and culture may be somewhat reduced by a short period of antibiotic therapy, but these tests often remain positive; and (3) adjunctive tests, including blood cultures and CSF antigen tests, can often independently identify the bacterial meningopathogen. The available evidence suggests that if bacterial meningitis is suspected and LP must be delayed, intravenous antibiotics are warranted before CSF is obtained.
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Treatment
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• < 30 days, ampicillin and an aminoglycoside or a cephalosporin
• 30-60 days, ampicillin and a cephalosporin; because Streptococcus pneumoniae may occur in this age range, consider vancomycin instead of ampicillin
• In older children, a cephalosporin or ampicillin plus chloramphenicol with vancomycin (needs to be added secondary to the possibility of S pneumoniae)
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Duration of Treatment
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Neisseria meningitidis - 7 days
Haemophilus influenzae - 7 days
Streptococcus pneumoniae - 10-14 days
S agalactiae (GBS) - 14-21 days
Aerobic gram-negative bacilli - 21 days or 2 weeks beyond the first sterile culture (whichever
is longer)
Listeria monocytogenes - 21 days or longer