Shake…Shake….Shake Neurology Module PEDIATRICS II.
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Transcript of Shake…Shake….Shake Neurology Module PEDIATRICS II.
Shake…Shake….ShakeShake…Shake….Shake
Neurology ModuleNeurology ModulePEDIATRICS II
ES, 16 months old, admitted because of convulsionsFive days PTA cough and feverTwo days later grand mal seizures for 10 minutes Birth, neonatal, developmental history unremarkable First attack of febrile seizures at 6 months of age Father and cousins with febrile seizures
Salient Points:Salient Points:
Pertinent Physical Examination Findings:
Febrile, awake, with mild dehydrationCongested pharyngeal wall, no exudates, (+) crackles on both lungs
Neurological Examination Findings:
Essentially normalNo meningeal signs
Salient Points:Salient Points:
Is there a neurologic Is there a neurologic disease?disease?
The description of event appears to be a seizure.
Seizures refer to excessive neuronal
discharge with change in motor activity or behavior.
Is there a neurologic Is there a neurologic disease?disease?
Non-neurologicMetabolic disordersElectrolyte imbalanceHypoglycemiaHypoxiaFeverSystemic infectionsToxinsDrug-related
NeurologicTumorsCNS malformationVascular disordersIdiopathic epilepsy
Causes of seizure:
In this patient, the seizures are ushered in by feverand respiratory infection.
Benign Febrile SeizuresBenign Febrile Seizures should be ruled out.The typical benign FS is characterized by: 1. Grand mal lasting for <15 min 2. Occurring once in the same illness 3. Age incidence: 3 months to 5 years 4. Occurs at temperature 380 C and above 5. Normal neurological examination 6. Family history (+) for FS 7. CNS infection absent
What is the What is the neurologic disease?neurologic disease?
Atypical - May occur more than once in an illness, focal seizure,
more than15 minutes May need investigation to rule out
epilepsyWith focal manifestations
Complex Febrile Complex Febrile SeizureSeizure
Benign febrile seizuresIn the presence of fever, pneumonia and seizure, a CNS infection should be considered.An infant may not show any meningeal signs even in the presence of meningitis.
Diagnostic Diagnostic possibilities:possibilities:
Search for cause of feverNo anticonvulsants neededAntipyretics Education of parentsOral diazepam at onset of febrile
episode (1 mg/kg/24 hrs) for 2-3
days
Management of BFC:Management of BFC:
Not necessary if clear-cut BFC Tests mainly to determine cause of fever and rule out meningitisIf done, CSF examination is normalEEG - Normal and not useful in BFCNeuroimaging - No roleBlood tests / chest X-ray, etc are done to diagnose the cause of fever, not the BFC
Laboratory Tests:Laboratory Tests:
Tests are usually directed towards ruling out meningitis especially in infants where meningeal signs are often lacking.
Do lumbar puncture and CSF examination
Diagnosis:Diagnosis:
While in the hospital, he developed another seizure. Fever persisted. On examination, he was ill-looking, irritable, with some resistance on neck flexion.
Patient E.S.Patient E.S.
CNS Infections
Differential Diagnosis:Differential Diagnosis:Fever with SeizuresFever with Seizures
Forms:MeningitisEncephalitisBrain Abscess
Etiology Viral Bacterial (Acute
Suppurative)TuberculousFungal
CNS InfectionsCNS Infections
Acute Meningitis-Acute Meningitis-Causes:Causes:
Bacterial 0 - 2 months: Grp B and D strep gram-negative
enteric bacilli Listeria 2 mo – 2 yrs: S. pneumoniae N. meningitis H. influenza B Older children: S. pneumoniae N. meningitides
Acute Route of Infection
HematogenousContiguous focus of infectionCSF leak (trauma, congenital defect)Neurosurgical procedure
Bacterial MeningitisBacterial Meningitis
Signs and Signs and symptomssymptoms
NeonatesNeonates Older infants and childrenOlder infants and children
NonspecificNonspecific Fever or hypothermia, abnormally sleepy or lethargic, disinterest in feeding, poor feeding, cyanosis, grunting, apneic episodes, vomiting
Fever, anorexia, confusion, irritability, photophobia, nausea, vomiting, headache, seizure
Meningeal Meningeal inflammationinflammation
+/- Neck rigidity Neck rigidity, Kernig and Brudzinski sign
Increased Increased intracranial intracranial pressurepressure
Bulging fontanel, diastasis of sutures, convulsions, opisthotonus
Headache, bulging fontanel, diastasis of sutures in infants, papilledema, mental confusion, altered state of consciousness
Focal Focal neurologic neurologic signssigns
Hemiparesis, ptosis, facial nerve palsy
Hemiparesis, ptosis, deafness, facial nerve palsy, optic neuritis
Clinical Features:Clinical Features:
1.Lumbar PunctureContraindications
Skin infection over siteIncreased ICP with papilledemaFocal neurologic deficitsSuspected mass lesionHematologic problemsSignificant cardiopulmonary compromise and shock
Laboratory Diagnosis:Laboratory Diagnosis:
CSF Findings
Pressure (mm H20)
Cell Count (white blood cells/mm3)
Glucose (mg/100 ml)
Protein (mg/100 ml)
Normal values 90-180 0-5 lymphocytes 50-75 (at least 50% of simultaneous serum glucose)
15-40
Bacterial meningitis 200-300 100-5,000; neutrophils usually >80%
Reduced, < 40 100-1,000
Tuberculous meningitis 180-300 Usually < 500 lymphocytes
Reduced, < 40 100-200, but up to 1,000 if CSF block is present
Cryptococcal meningitis 180-300 10-200 lymphocytes Reduced, <40 50-200
Viral meningitis 90-200 10-300 lymphocytes; may be >1,000 in echoviral and mumps meningitis and in lymphocytic choriomeningitis; early echoviral meningitis may show up to 80% neutrophilic predominance
Normal; occasionally slightly reduced in mumps meningitis and LCM
50-100
Viral encephalitis 180-300 0-500 lymphocytes Normal 50-100
Contrast enhanced CT image of a 3-month-old baby brain
show brain edema and subdural empyema
Subdural effusion, cerebritis and developing abscess
formation in a patient with bacterial meningitis
2. Neuroimaging
Laboratory Diagnosis:Laboratory Diagnosis:
CSF Analysis: Clear, colorless fluid
OP 130 WBC = 320/cumm, all neutrophils RBC = 0 Protein = 90
Sugar = 40% of blood sugarGram stain = (+) gram-negative coccobacilli
Culture (-)
CBC: Hgb 11, RBC 4.3, WBC 12,000 with lymphocytic
predominance
Patient’s laboratory Patient’s laboratory results:results:
Acute Bacterial Meningitis (Hemophilus)Pneumonia
Diagnosis:Diagnosis:
Bacterial meningitis is a medical emergency; delay in treatment may lead to increased sequelae or deathDrug of choice must be bactericidal for pathogen involvedMust achieve adequate levels in the CSFInitial regimen should cover most likely pathogens for specific age groups, and reach bactericidal levels in the CSF
Treatment:Treatment:
Knowledge of local susceptibility patterns is essential Antibiotics should be guided by the bacteriologic resultsDuration of treatment: 10 -14 days
Treatment:Treatment:
Patient group
Likely etiology
Antimicrobial choicePrimary Alternative
0-2 mos E. coliGram (-) bacilliS. pneumoniae
Ampicillin or Penicillin + Aminoglycoside
Ampicillin + Cefotaxime or Ceftriaxone
2mos – 5 yrs
H. influenzaeS. pneumoniaeN. meningitidis
Ampicillin or Chloramphenicol
Cefotaxime or Ceftriaxone
>5 yrs S. pneumoniaeN. meningitidis
Penicillin G Chloramphenicol
Task Force on Meningitis
Philippine Society of Microbiology and Infectious Diseases
Empiric Therapy for Empiric Therapy for Bacterial Meningitis:Bacterial Meningitis:
Subacute to chronicStaging of symptoms
Stage I: early nonspecificStage II: altered consciousness, minor focal
signs, meningism, abnormal involuntary movements
Stage III: stupor or coma, seizures, severe neurologic deficits and/or abnormal movements
Prognosis is related directly to the clinical stage of diagnosis
Tuberculous Tuberculous MeningitisMeningitis
CSF Findings
Pressure (mm H20)
Cell Count (white blood cells/mm3)
Glucose (mg/100 ml)
Protein (mg/100 ml)
Normal values 90-180 0-5 lymphocytes 50-75 (at least 50% of simultaneous serum glucose)
15-40
Bacterial meningitis 200-300 100-5,000; neutrophils usually >80%
Reduced, < 40 100-1,000
Tuberculous meningitis 180-300 Usually < 500 lymphocytes
Reduced, < 40 100-200, but up to 1,000 if CSF block is present
Cryptococcal meningitis
180-300 10-200 lymphocytes Reduced, <40 50-200
Viral meningitis 90-200 10-300 lymphocytes; may be >1,000 in echoviral and mumps meningitis and in lymphocytic choriomeningitis; early echoviral meningitis may show up to 80% neutrophilic predominance
Normal; occasionally slightly reduced in mumps meningitis and LCM
50-100
Viral encephalitis 180-300 0-500 lymphocytes Normal 50-100
Visual impairmentStrabismus Hearing loss or impairment Locomotion/neuromotor deficitsEpilepsyMental or psychomotor retardationHydrocephalusMicrocephaly
Late Neurologic Late Neurologic Sequelae:Sequelae:
HydrocephaluHydrocephaluss
Cerebral Atrophy
Microcephaly
Majority due to enterovirusesHigher incidence during summer to fall monthsOther viruses associated with meningitis in children:
HSV types 1 and 2MumpsAdenovirusesPoliovirusesLymphocytic choriomeningitis virusEpstein-Barr virusHIVSt. Louis encephalitis virusTick-borne encephalitis virus
Viral MeningitisViral Meningitis
CSF Findings
Pressure (mm H20)
Cell Count (white blood cells/mm3)
Glucose (mg/100 ml)
Protein (mg/100 ml)
Normal values 90-180 0-5 lymphocytes 50-75 (at least 50% of simultaneous serum glucose)
15-40
Bacterial meningitis 200-300 100-5,000; neutrophils usually >80%
Reduced, < 40 100-1,000
Tuberculous meningitis 180-300 Usually < 500 lymphocytes
Reduced, < 40 100-200, but up to 1,000 if CSF block is present
Cryptococcal meningitis 180-300 10-200 lymphocytes Reduced, <40 50-200
Viral meningitis 90-200 10-300 lymphocytes; may be >1,000 in echoviral and mumps meningitis and in lymphocytic choriomeningitis; early echoviral meningitis may show up to 80% neutrophilic predominance
Normal; occasionally slightly reduced in mumps meningitis and LCM
50-100
Viral encephalitis 180-300 0-500 lymphocytes Normal 50-100
Management:1. No specific antiviral therapy
necessary2. Treatment is supportive with IV
fluids3. Outcome is usually a full recovery
Viral MeningitisViral Meningitis
Distinguished from viral meningitis by the extent and severity of cerebral dysfunctionTwo clinical presentations:
Fever and malaise without meningeal signsWith meningeal signs plus cerebral dysfunction (altered consciousness, personality changes, seizures, and paresis) and cranial nerve abnormalities
Viral EncephalitisViral Encephalitis
Causes:Epidemic
ArbovirusPoliovirusEchovirusCoxsakie virus
SporadicHerpes simplexVaricella-ZosterMumps
Viral EncephalitisViral Encephalitis
CSF Findings
Pressure (mm H20)
Cell Count (white blood cells/mm3)
Glucose (mg/100 ml)
Protein (mg/100 ml)
Normal values 90-180 0-5 lymphocytes 50-75 (at least 50% of simultaneous serum glucose)
15-40
Bacterial meningitis 200-300 100-5,000; neutrophils usually >80%
Reduced, < 40 100-1,000
Tuberculous meningitis 180-300 Usually < 500 lymphocytes
Reduced, < 40 100-200, but up to 1,000 if CSF block is present
Cryptococcal meningitis 180-300 10-200 lymphocytes Reduced, <40 50-200
Viral meningitis 90-200 10-300 lymphocytes; may be >1,000 in echoviral and mumps meningitis and in lymphocytic choriomeningitis; early echoviral meningitis may show up to 80% neutrophilic predominance
Normal; occasionally slightly reduced in mumps meningitis and LCM
50-100
Viral encephalitis 180-300 0-500 lymphocytes Normal 50-100
Treatment:Acyclovir 10 mg/kg IV infusion every 8
hours for at least 10 daysSupportive therapy
Prognosis:Mortality rate varies with etiologyPermanent cerebral sequelae more
likely in infants
Viral EncephalitisViral Encephalitis
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