• POST NEONATAL POST NEONATAL MENENGITIS MENENGITIS

BY DR. AYESHA AHMED ALIBY DR. AYESHA AHMED ALI

• MENENGITIS:-MENENGITIS:-It is an inflammation of the menengies, the membrane that It is an inflammation of the menengies, the membrane that

line the brain and the Spinal Cord.line the brain and the Spinal Cord.

• Types of MenengitisTypes of Menengitis:-:-

• Common:- Common:- • 1. Bacterial (Pyogenic)1. Bacterial (Pyogenic)

• 2. Viral Menegitis2. Viral Menegitis

• 3. Aseptic Menegitis3. Aseptic Menegitis

• Un Common:-Un Common:-• 1. T.B Menegitis 1. T.B Menegitis

• 2. Fungal Menegitis2. Fungal Menegitis

• 3. Syphillis (Acute) Leptospirosis3. Syphillis (Acute) Leptospirosis

• 4. Amebic 4. Amebic

• Etiology:-Etiology:-• 1. 1. Bacterial MenengitisBacterial Menengitis:-:-

• (i) (i) S.Pneumoniae:-S.Pneumoniae:- (Otitismedia, sinusits, Pneumoniae, CSF Otorhea).(Otitismedia, sinusits, Pneumoniae, CSF Otorhea).

• (ii) (ii) N.MenengitidisN.Menengitidis:- :- It may be Sporadic or Epidemic .It may be Sporadic or Epidemic .

• Peak age younger thanPeak age younger than five year.five year.

• (iii) (iii) H.Influniza Type BH.Influniza Type B:- :- 50% in Ist year of life.50% in Ist year of life.

• 2. 2. Viral MeningoencephlitisViral Meningoencephlitis:- :- • (i) Entro Virus(i) Entro Virus• (ii) Arbo Virus(ii) Arbo Virus• (iii) Herpes Simplex-1(iii) Herpes Simplex-1• (iv) Vericella Zooster Virus(iv) Vericella Zooster Virus• (vi) EBV(vi) EBV• (vii) Mumps (vii) Mumps • (viii) Adeno Virus, influnza, Para influnza Virus, Rubella or (viii) Adeno Virus, influnza, Para influnza Virus, Rubella or

RabiesRabies

• 3. 3. Aseptic MenengitisAseptic Menengitis:-:-• VirusVirus

• Common:- Common:- • Antro Virus Antro Virus • Arbo VirusArbo Virus• HSV- 2HSV- 2• Human Harpes Virus 6Human Harpes Virus 6

• Un Common:-Un Common:-• HIV-1 HIV-1 • Epstenbarr Virus Epstenbarr Virus • Mumps Mumps

• Rare:-Rare:-• Adenovirus Adenovirus • Vericella Zooster VirusVericella Zooster Virus• CMV CMV • MeaslesMeasles• RubellaRubella• Influnza A & vInflunza A & v

• BacteriaBacteria

• Common:- Common:-

• Pyogenic ( Partially Treated )Pyogenic ( Partially Treated )

• Mycobactrium T.BMycobactrium T.B

• Mycoplasma Pneuomonia Mycoplasma Pneuomonia

• Leptospria SpeciesLeptospria Species

• Un CommonUn Common:-:-

• Treponema Pallidum Treponema Pallidum

• Borrelia SpeicesBorrelia Speices

• Rickettesia Rickettisii Rickettesia Rickettisii

• Rare:-Rare:-• Coxilla BurnettiCoxilla Burnetti

• Brucella Abortus Brucella Abortus

• Streptobacillus Moniliformis Streptobacillus Moniliformis

• Mums and PolioMums and Polio

• Systemic:-Systemic:-• Bacterial endocarditisBacterial endocarditis

• Kawasaki Disease Kawasaki Disease

• SLESLE

• Sjoggron SyndromSjoggron Syndrom

• Rehumatoid ArthritisRehumatoid Arthritis

• SarcoidosisSarcoidosis

• Melignency:-Melignency:-• LeukemiaLeukemia

• LymphomaLymphoma

• Metastatic Ca:Metastatic Ca:

• CNS TumorCNS Tumor

• Drugs:-Drugs:-• Intrathecal Injunction Intrathecal Injunction

• Contrast MediaContrast Media

• NSAIDNSAID

• Carbamezepine Carbamezepine

• AzathioprineAzathioprine

• IV ImmunoglobulinIV Immunoglobulin

• Antibiotics ( Isoniazid, Ciprofloxacin )Antibiotics ( Isoniazid, Ciprofloxacin )

• MiscelleniusMiscellenius:-:-• Heavy Meatal (Lead, ArsenicHeavy Meatal (Lead, Arsenic

• F. B ( Shunt, Reservior )F. B ( Shunt, Reservior )

• Post MigrainPost Migrain

• Post Neoro Surgery Post Neoro Surgery

EsinophillicEsinophillicFungusFungusParasites ( Esinophillic )Parasites ( Esinophillic )Parasites ( Non Parasites ( Non Esinophillic )Esinophillic )Post InfectiousPost InfectiousVaccine, Rabies, Measels, PolioVaccine, Rabies, Measels, Polio

• EpidimiologyEpidimiology:-:-• B.Menengitis B.Menengitis • Major risk factor for B.M is lack of immunity to specific Pathogen Major risk factor for B.M is lack of immunity to specific Pathogen

specially in young age.specially in young age.• Risk factor include recent pathogenic Bacteria close contact (House Risk factor include recent pathogenic Bacteria close contact (House

hold, day care centre, College, Military Barracks) crowding, poverty, hold, day care centre, College, Military Barracks) crowding, poverty, black race and male gender.black race and male gender.

• Mode of transmission is person to person contact through respiratory Mode of transmission is person to person contact through respiratory Sec: or droplet.Sec: or droplet.

• Risk of Menengitis in infant and young children meningococcus 85 time Risk of Menengitis in infant and young children meningococcus 85 time HIB 12 time in relation to that of Pneumococcus.HIB 12 time in relation to that of Pneumococcus.

• Defect in compliment system (C5-C8) associated with recurrent Defect in compliment system (C5-C8) associated with recurrent meningococcus infection.meningococcus infection.

• Splenic disfuction (Sickle cell Anemia)Splenic disfuction (Sickle cell Anemia)• Asplenia (due to troma or cong: defects)Asplenia (due to troma or cong: defects)• T-lymphocyte defect T-lymphocyte defect • Risk of B.M with Chochlear implant or treatment of hearing loss Risk of B.M with Chochlear implant or treatment of hearing loss • Lumbosacral Dermal sinus and meningomiclocele with staphylococcal Lumbosacral Dermal sinus and meningomiclocele with staphylococcal

and gram negative Bacteria and gram negative Bacteria

• Viral EncephalitisViral Encephalitis• The epidiomologic pattern of viral meningo encephalitis is primarily The epidiomologic pattern of viral meningo encephalitis is primarily

determine by the presence of entro virus the most common etiology determine by the presence of entro virus the most common etiology

• Infection with entro virus is spread directly person to person with Infection with entro virus is spread directly person to person with incubation period 4-6 days.incubation period 4-6 days.

• Epidiomologic consideration in Aseptic menenigitis include season, Epidiomologic consideration in Aseptic menenigitis include season, Geography, climatic condition, animal exposure and specific pathogen Geography, climatic condition, animal exposure and specific pathogen

• Esinophillic MenengitisEsinophillic Menengitis:-:-

• A.cantonensis is found in South East Asia, Japan, Taiwan, Egypt and A.cantonensis is found in South East Asia, Japan, Taiwan, Egypt and CubaCuba

• Infection is acquired by eating raw or under cooked fresh water snail, Infection is acquired by eating raw or under cooked fresh water snail, Prawn or Crabs containing infectious larvae.Prawn or Crabs containing infectious larvae.

• Gnathostoma Infection found in Japan, China, India, Bangladesh and Gnathostoma Infection found in Japan, China, India, Bangladesh and South East Asia.South East Asia.

• This infection is acquired by eating under Cooked or raw Fish, Frog, This infection is acquired by eating under Cooked or raw Fish, Frog, Birds or Snake meat.Birds or Snake meat.

• Sign & SymptomSign & Symptom:-:-• Acute Menengitis represent two patterns Acute Menengitis represent two patterns • 1. The dramatic but less common presentation are rapidly progressive menifestation 1. The dramatic but less common presentation are rapidly progressive menifestation • ShockShock• PurpuraPurpura• DICDIC• Reduced level of consciousnessReduced level of consciousness• resulting Comma and death with in 24 hoursresulting Comma and death with in 24 hours• 2.2. Menengitis is preceded by saveral days of fever Menengitis is preceded by saveral days of fever • Acampained by upper RTI & GIT symptom, followed by non specific sign of CNS infection.Acampained by upper RTI & GIT symptom, followed by non specific sign of CNS infection.

• Non Specific Sign:-Non Specific Sign:-• FeverFever• Anorexia Anorexia • HeadacheHeadache• Mylgia Mylgia • AthralgiaAthralgia• TachycardiaTachycardia• Hypotension Hypotension • NauseaNausea• VomitingVomiting• PhotophobiaPhotophobia• PetechiePetechie• PurpuraPurpura• Erythmatous Macular rashErythmatous Macular rash

• Specific SignSpecific Sign:-:-• Sign & Symptom of menengial irritationSign & Symptom of menengial irritation:-:-• Neck Stiffness 40%Neck Stiffness 40% • Kerning SignKerning Sign ( Flexion of the Hip 90 degree with subsequent pain with ( Flexion of the Hip 90 degree with subsequent pain with

extension of the leg )extension of the leg )• Brudzinski signBrudzinski sign ( Involuntarily Flexion of the knees and Hips after passive ( Involuntarily Flexion of the knees and Hips after passive

flexion of the Neck while supine )flexion of the Neck while supine )

• Sign of ICP:- Sign of ICP:- • Headache Bulging Fontanel or Widening of SutureHeadache Bulging Fontanel or Widening of Suture (Diastases) (Diastases)• Cranial Nerve Involvement with B.M it can be permanent Cranial Nerve Involvement with B.M it can be permanent • Paralysis of extra occular or facial NerveParalysis of extra occular or facial Nerve• Eight ( Auditary ) Nerve often affected Eight ( Auditary ) Nerve often affected • Deafness Deafness • Blindness is rare Blindness is rare • Papilleedema un commonPapilleedema un common• Decree of CNS derangement observed of B.M range from irritability to coma Decree of CNS derangement observed of B.M range from irritability to coma • 50% of Children with B.M have subdural effusion occur50% of Children with B.M have subdural effusion occur• 20-30 % of Children have Seizure (Focal or Generalize) 20-30 % of Children have Seizure (Focal or Generalize) • 20% of Children with B.M have focal Neurological Sign 20% of Children with B.M have focal Neurological Sign • 15% of Children with B.M are Comatos or Semi Comatos15% of Children with B.M are Comatos or Semi Comatos• Peticae and Purpura if present considered danger of developing septic shockPeticae and Purpura if present considered danger of developing septic shock• Decereberate or decorticate posture Decereberate or decorticate posture •

• S/S OF VIRAL MENINGOENCEPHLITISS/S OF VIRAL MENINGOENCEPHLITIS:-:-

• Progress of dieasease are determind by relative degree of menengial Progress of dieasease are determind by relative degree of menengial and parenchymal involvement and specefic etiology . and parenchymal involvement and specefic etiology .

• The onset of illness are generaly acute .The onset of illness are generaly acute .• Headach(generalized,frontal,reterobulbar pain)Headach(generalized,frontal,reterobulbar pain)• HyperasthesiaHyperasthesia• LethargyLethargy• IrritabilityIrritability• FeverFever• NauseaNausea• VomittingVomitting• PhotophobiaPhotophobia• Pain in legPain in leg• Pain in neckPain in neck• Mental dullnessMental dullness• ConvulsionConvulsion• Flacid paralysisFlacid paralysis• Loss of blader and bowel controlLoss of blader and bowel control

• S/S OF ASEPTIC MENENGITISS/S OF ASEPTIC MENENGITIS• S/S Of of aseptic menengitis are same but less severeS/S Of of aseptic menengitis are same but less severe

• Esionophillic MenengitisEsionophillic Menengitis• Illness start 1-3 wk after exposure Illness start 1-3 wk after exposure

• FeverFever

• Periphral esinophilliaPeriphral esinophillia

• VomittingVomitting

• Abdominal painAbdominal pain

• Creeping skin infectionCreeping skin infection

• PleurisyPleurisy

• HeadachHeadach

• C.N palsiesC.N palsies

• ParasthesiaParasthesia

• T.B Menengitis:-T.B Menengitis:-

• DiagnosisDiagnosis• Base lineBase line• CBCCBC• RBSRBS• S.Electrolite(esp;NA)S.Electrolite(esp;NA)• Urea/CreatinineUrea/Creatinine• S.CaS.Ca• P.TP.T• APTTAPTT• FibrinogenFibrinogen

• Specific Specific L.PL.P Gram stainGram stain

• Bacterial cultureBacterial culture• Cell count Cell count • CSF conc: of protein and glucoseCSF conc: of protein and glucose• Specific stain for isolation of organismSpecific stain for isolation of organism

• Blood cultureBlood culture• SerologySerology• Brain biopsyBrain biopsy

• Blood cultureBlood culture• SerologySerology• Brain biopsyBrain biopsy

• Imaging:-Imaging:-• C.T scaneC.T scane• MRIMRI• Imaging help in complicated casesImaging help in complicated cases• If herniation of brain is presentIf herniation of brain is present• If significant increase in ICPIf significant increase in ICP• Children with history of Immunosupression,Hydrocephalus;V.P Children with history of Immunosupression,Hydrocephalus;V.P

Shunt, head trauma; etcShunt, head trauma; etc• May be help full for decision on management during course of May be help full for decision on management during course of

therapytherapy• Imaging not be routinely done as result of prologed or Imaging not be routinely done as result of prologed or

sec;feversec;fever

• PCR(Sesitive method of diagnosis in PCR(Sesitive method of diagnosis in menengitis caused by Enterovirus; menengitis caused by Enterovirus; Herpesvirus ; or other virus)Herpesvirus ; or other virus)

• CSF FINDING IN CNS DISORDERCSF FINDING IN CNS DISORDER• ConditionCondition Pressure Pressure (MM H2 O)(MM H2 O) Leukocytes Leukocytes (MM3)(MM3) Protein Protein (MG/DL)(MG/DL) Glucose Glucose (MG/DL)(MG/DL)

• Normal Normal 50-80 <5,>75% LYM 20-45 >50 (75%)S.G 50-80 <5,>75% LYM 20-45 >50 (75%)S.G

• Aqute B.MAqute B.M Elevated Elevated (100-300) 100-1000 or more 100-500 <40 OR <50% (100-300) 100-1000 or more 100-500 <40 OR <50%

• PMNS Serum GlucosePMNS Serum Glucose

• Viral M.NViral M.N Normal or slightly Rarely >1000 pmns 50-200 Normal or dec: Normal or slightly Rarely >1000 pmns 50-200 Normal or dec:

• ElevatedElevated b/t mononuclear b/t mononuclear

• T.B, M.NT.B, M.N Elevated Elevated 10-500 PMNS early 10-500 PMNS early 100-3000 <50 100-3000 <50

• b/t Lymphocytes may be highb/t Lymphocytes may be high

• Fungal M.NFungal M.N Elevated 5-500 PMNS early 25-500 <50 Elevated 5-500 PMNS early 25-500 <50

• b/t mononuclear late b/t mononuclear late

• SphilisSphilis Elevated 50-500 lymphosytes 50-200 Normal Elevated 50-500 lymphosytes 50-200 Normal

• Amebic M.NAmebic M.N Elevated 1000-10000 PMNS 50-500 Normal or Dec Elevated 1000-10000 PMNS 50-500 Normal or Dec

• Plan of TreatmentPlan of Treatment• Bacterial Menengitis Bacterial Menengitis • Acute menengitis is always medical emergency and should dictete Acute menengitis is always medical emergency and should dictete

immediate management. All children with altered state of consciousness should immediate management. All children with altered state of consciousness should observe closelyobserve closely

• Assessment of child who is vitaly stable frequently first 72 hour consist ofAssessment of child who is vitaly stable frequently first 72 hour consist of Early sign of CNSEarly sign of CNS• (level of consciousness, pupilary reflex, motor strength, cranial nerve sign, (level of consciousness, pupilary reflex, motor strength, cranial nerve sign,

development of seizure etc)development of seizure etc)• CVSCVS• Metabolic complication Metabolic complication • Changes in vital sign (pulse, B.P, R.rate)Changes in vital sign (pulse, B.P, R.rate)• Development of SIADHDevelopment of SIADH• Assessment of child with rapidly progressive diseases of less than 24 hour patient is in Assessment of child with rapidly progressive diseases of less than 24 hour patient is in

profound coma or whose detoriate level of consciousness should evaluated for profound coma or whose detoriate level of consciousness should evaluated for complication complication

• cerebral abcesscerebral abcess• Multiple organ failureMultiple organ failure• Shock Shock • ICPICP• ARDSARDS• Obstructive hydrocephalusObstructive hydrocephalus

Therapy that are crucial for all patient with B.M Therapy that are crucial for all patient with B.M

Initial managementInitial management Maintain IV lineMaintain IV line pass NG tubepass NG tube NPO NPO

Specific treatmentSpecific treatment1.Fluid management1.Fluid management2.Anti microbial therapy2.Anti microbial therapy3.Anti inflammatory therapy3.Anti inflammatory therapy4.Anti convulsant therapy 4.Anti convulsant therapy

11.11. Fluid ManagementFluid Management If pt is half to two normovolumic normal BP IV fluid should be restricted If pt is half to two normovolumic normal BP IV fluid should be restricted

to one third of maintenenceor 800,1000ml/m2/24hrto one third of maintenenceor 800,1000ml/m2/24hr

--To minimize brain edema and prevent SIADH with has been reported in To minimize brain edema and prevent SIADH with has been reported in 29 to 88% of B.m29 to 88% of B.m

2. Fluid restriction is not appropriate in the presence of systemic 2. Fluid restriction is not appropriate in the presence of systemic hypotension b/c reduce BP may result in reduced cerebral perfusion hypotension b/c reduce BP may result in reduced cerebral perfusion pressure and CNS ischemia. Therefore shock must be treated pressure and CNS ischemia. Therefore shock must be treated aggressively to prevent Brain and other Organ dis-function (ATN, aggressively to prevent Brain and other Organ dis-function (ATN, Acute respiratory distress syndrome.Acute respiratory distress syndrome.

• 3. Fluid Administration may be returned to normal 1500 – 1700 ml/ m2/24 3. Fluid Administration may be returned to normal 1500 – 1700 ml/ m2/24 hours, When S.NA level are normal.hours, When S.NA level are normal.

4. Patient with septic shock may required fluid resuscitation and with Vaso 4. Patient with septic shock may required fluid resuscitation and with Vaso constrictive agent such as Dopamine and Epinephrine.constrictive agent such as Dopamine and Epinephrine.

5. Patient with shock and Markedly Elevated ICP, coma and refractory Seizure 5. Patient with shock and Markedly Elevated ICP, coma and refractory Seizure require central Arterials monitoring and Venous acess and Pediatric ICU care.require central Arterials monitoring and Venous acess and Pediatric ICU care.

• 6. S.NA concentration should be closely monitor every 4-6 hours during ist 24 6. S.NA concentration should be closely monitor every 4-6 hours during ist 24 hours of Therapy –hours of Therapy –

• - If S.NA level decrees to <125 mEq/L this should repeat as soon as possible - If S.NA level decrees to <125 mEq/L this should repeat as soon as possible • -If S.NA level is still <125 mEq/L fluid should be restricted to keep Vein open -If S.NA level is still <125 mEq/L fluid should be restricted to keep Vein open

until S.Electrolyte concentration have been corrected.until S.Electrolyte concentration have been corrected.• - For B.M providing routine maintenance fluid at approximately 80% of - For B.M providing routine maintenance fluid at approximately 80% of

maintenance rate after fluid repletion and advancing to full maintenance rate as maintenance rate after fluid repletion and advancing to full maintenance rate as S.NA increased >135 mEq/L seem to be appropriate.S.NA increased >135 mEq/L seem to be appropriate.

• 7. The period of fluid restriction may only need to be <1 day.7. The period of fluid restriction may only need to be <1 day.

• Anti Microbial Therapy:-Anti Microbial Therapy:-• Initial TherapyInitial Therapy• Initial (empirical) choice of therapy based on age B/C of causative agent is Initial (empirical) choice of therapy based on age B/C of causative agent is

present at the time of diagnoses.present at the time of diagnoses.

• Adjustment of therapy can be made as Vaccination history and result of Adjustment of therapy can be made as Vaccination history and result of CSF culture are confirmed.CSF culture are confirmed.