MBEYA ZONAL CONSULTANT HOSPITAL.

Meningoencephalitis in pediatric. Presented by : Dr John Romanus Nyeho, MD.

Dr. Michael Haule, MD.

Outlines:• Definitions.• Routes for organisms to reach the CNS• Types of Meningitis and their organisms: - Acute Pyogenic Meningitis. Pathophysiology & Complications. - Other types of Meningitis: (Viral,fungal,protozoan,parasitic,malignant & inflammatory).• Diagnosis & CSF analysis.• Treatment.• Complications.

Definitions:

Meningitis Encephalitis

CerebritisCerebral abscess

Causes of meningitis:

Infectious causes.Non infectious causes: - Malignant. - Autoimmune. - Chemical.

Types of Meningitis.

Meningitis

Acute Pyogenic Meningitis.

Aseptic Meningitis.

Chronic Meningitis.

Acute pyogenic Meningitis.

This is classified according to a group of age and their etiologies are differ from one group to another.• Neonates (BEL)• Infants (B,E,L, + H.influenza,S.pneumonia, N.Meninitides)

• Children & Young Adult (H.influenza, S.pneumonia, N.Meninitides)

• Old adults

Others:• Pregnant woman: - L. monocygotenes• Alcoholic patients:

- S. Pneumoniae. - L. monocygotenes.

• Inmunocomprised Patient. - S. Pneumoniae. - L. monocygotenes - Pseudomona Aeuriginosa - Mycobacterium Tuberculosis. - Mycobacterium Avum.

PATHOPHYSIOLOGY OF ACUTE PYOGENIC MENINGITIS.

Bacterial entry & colonization

(invasion)

Migration & proliferation

Initiation of the immune

response(meningitis)

Risks factors.

• Immunosuppression.• Otitis media.• Sinusitis.• Age extremes (neonates & elderly).• Parameningeal infections (osteomyelitis of

the skull).• Neurological procedure.• Infections (Systemic).

Clinical Presentation. Fever

Neck stiffness Mental status (Meningismus) changes

In neonates and infants this conditions does not presents with the classic features of meningitis. The child might presents with:- Fever or hypothermia.- Irritability or lethargy.- Poor feeding.- Vomiting.- Convulsions.- Toxic aspect.- Bulging fontanela- Paralysis of the cranial nerves (III & IV).

Physical Examinations:• Brudzinski’s sign.

• Kerning sign.

• Meningococcal Skin rashes.

From the 1st to the 3rd day, at least one-third of patients with meningococcal meningitis develop petechiae, most prominently in areas subjected to pressure; for example, Axillary folds and the belt line.

Diagnosis• History & physical examination.• Investigation: - CBC - Blood cultures & gram staining. - PCR (for viral meningitis). - Latex Agglutination Test for antigen detection. - India ink stain (Cryptococcus detection in CSF). - CSF analysis. - Electrolytes - CT or MRI (for toxoplasmosis,HSV or to exclude any space occupying lesions)

CSF Findings.

DIFFERENTIAL DIAGNOSIS.• Bacterial meningitis.• Tubercular Meningitis.• Fungal Meningitis.• Parasitic Meningitis.• Viral Meningitis.• Subarachnoid hemorrhage. (RBC in CSF)• Meningioma (x ray for tumor presence).• Brain Abscess.• Tetanus (trismus & clean mentation)

MANAGEMENT.General management:- Admit the patient- IV line access- Vital signs- Fowler position - Input & output documentation.If the patient has the signs of cerebral edema & increased intracranial pressure:- Fowler position- Osmotic diuretics (manitol 20%) 0.25mg /kg/dose 4

hourly.- Steroids (dexamethasone) 0.15 mg/kg/dose 6 hourly in

the 1st 4 days to decrease the edema & intracranial pressure.

Specific management:Bacterial meningitis.Start the empirical treatment enough to cover the suspected organisms according to each group.• Children < 3 months old (BEL organisms) .The management is similar to that of neonatal sepsis . ampicillin iv + gentamycin iv or ampicillin iv + cefotaxime / ceftriaxone ivIf the CSF revealed the presence of- Listeria monocygotene ( Rx for 21 days) & ampicillin only or in association with gentamycin can be used.- GBS (Rx for 14 days)

• Children > 3 months old .Empirical treatment it consists of 3rd generation cephalosporin + vancomycin .After getting the culture results & sensitivities you have to adjust the Mgx ORGANISM ANTIBIOTICS

S.PNEUMONIAECEFTRIAXONE (100mg/k/day) or CEFOTAXIME (200mg/kg/day) + VANCOMYCIN IV (45-60 mg/kg/) TID

L.MONOCYGOTENE AMPICILLIN IV(50mg/kg/dose) 6

hourly H. INFLUENZAE CEFTRIAXONE / CEFOTAXIME IV

N. MENINGITIDIS CEFTTRIAXONE / CEFOTAXIME + PENICILLIN IV

Management of Other meningitis:Tb meningitis : ant tuberculosis therapyViral meningitis: supportive measures- Herpes simplex & Herpes zoster: Acyclovir

30mg/kg/day 8 hourly for 21 days ( neonates dose 60mg/k/day).

- Cytomegalovirus:Gancyclovir 6mg/kg/dose BID for 3 -4 weeks.

Fungal Meningitis: anti fungal drugs

COMPLICATIONS:• Hearing loss.• Cerebral abscess.• Hydrocephalus.• Increased ICP.• Cranial nerves palsy.• Focal seizure & epilepsy.

END