Fariba shirvani MD

Management of meningeal signs in children

Definition:

•Signs and symptoms of meningitis in children•The 3 classic symptoms (less likely in younger children): Fever Headache Meningeal signs

What are meningeal signs

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

Clinical signs of meningeal irritation

Disorders accompanied with meningeal signs in children:

Trauma

Paravertebral abscess

Retropharyngeal abscessMuscle spasm

Right upper lobe pneumonia

Meningitis

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

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

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

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.

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

Contraindication of LP

(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.

Treatment

• < 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)

Duration of Treatment

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