narong auervitchayapat,md., assist prof department of
TRANSCRIPT
Narong Narong AuervitchayapatAuervitchayapat,,MDMD.,., Assist Assist ProfProfDepartment of PediatricsDepartment of Pediatrics
Faculty of MedicineFaculty of MedicineKKUKKU
1. Bacterial meningitis
2. Tuberculous meningitis
3. Aseptic meningitis
4. Viral encephalitis
5. Brain abscess
5 common diseases:-
Definitions* Meningitis: Inflammation of meninges
Abnormal number of WBCs in CSF* Bacterial meningitis: Meningitis and evidence of a
bacterial pathogen in CSF* Aseptic meningitis: Meningitis in the absence of
bacterial pathogen in the CSF by usual laboratory techniques
Definitions
* Encephalitis: Inflammation of the brain
* Meningoencephalitis: Inflammation of the brain accompanied by meningitis
Bacterial Meningitis
Introduction
1. Common
2. High morbidity & mortality rates
3. Emergency condition
EpidemiologyThe causative organism depends on
* Age
* Place
* Underlying disease
Sirinavin S et al 420 cases of bacterial meningitis in 14 hospitalsAge 0 mo 1-6 mo 7-11 mo 1-5 yr 6-15 yr
PathogensGram negative bacilli 37 8 0 0 0
Strep group B (GBS) 13 8 0 0 0
Salmonella 3 35 6 0 0
H.influenzae 2 87 47 26 0
S.pneumoniae 2 43 19 28 16
N.meningitidis 0 9 2 2 5
Underlying diseasesUnderlying diseasesSplenectomy & asplenia: S.pneumoniae, H.influenzae type b
,gram negative enteric
Hemoglobinopathies: S.pneumoniae, H.influenzae type b
C5-8 deficiency: Meningococcal infection, Salmonella
Underlying diseasesUnderlying diseasesCSF leak eg. middle ear defect ; base of skull fracture:
pneumococcal meningitis
Dermal sinus, meningomyelocele: staphylococci,
gram- negative enteric
CSF shunt: staphylococci ( esp. coagulase -ve)
Pathology
Clinical manifestations* Fever
* Headache
* Meningeal signs
+
+
Acute onset
Signs of increased intracranial pressure
- Stiffneck
- Kernig’s sign
- Brudzinski’s sign
Clinical manifestations- Consciousness
- Seizures
- Nausea, vomiting
- Diarrhea
- Poor feeding
Diagnosis
Lumbar puncture
Beware herniation in:-
1. Papilledema
2. Tensed anterior fontanel
3. Localizing signs
Fever + headache + meningeal signs
CSF findings- Pressure: Normal, > 300 mmH2O- Appearance: Turbid, xanthochromia- WBCs: 100-50,000, PMN 70-100%- Protein: > 40 mg/dl, most > 150mg/dl
- Sugar: < 50% of blood sugar, < 40 mg/dl- Gram stain, culture/sensitivity
Bacterial Antigen:
1. Latex agglutination
2. CIE ( Counter-Immuno-Electrophoresis )
TreatmentSpecific treatment * Emergency antibiotics *
Empiric antibiotics
- Newborn: Ampicillin + gentamicinAmpicillin + cefotaxime
- Beyond the neonatal period:Ampicillin + chloramphenicolCefotaxime or ceftriaxone + vancomycin?
Dosage of antibiotics for bacterial meningitisIncreased from systemic dosage
Penicillin group: Increase 3-4 folds
Cephalosporins: Increase 2 folds
Chloramphenicol: As same as systemic dosage
Amonoglycosides: As same as systemic dosage
Duration of antibioticsH.Influenzae
S.pneumoniae
Group B streptococci
Gram negative enteric bacilli
N.meningitidis
Salmonella
10-14 days10-14 days14-21 days
21 days7-10 days42 days
*Adjunctive Dexamethasone Therapy*
The use of corticosteroidsThe use of corticosteroids
• Antibiotics and pediatric intensive care:
MR = 5% but 20-30%: long-term sequalae esp. hearing
impairment
• Dexamethasone substantially reduced levels of
cytokines IL-1, TNF & PGE2 within CSF of infected
animal: reduction of ICP, brain edema & CSF lactate:
decreased MR and sequalae in animals.
Bacterial meningitis
Rapid lysis of bacteria:-Release of endotoxin (H.influenzae)Lipoteichoic acid (S.pneumoniae)
Release of cytokines:*Interleukin 1β*Tumor necrotic factor-α*Platelet activating factorProstaglandin E-2Phospholipase A2
Neutrophil recruitment
Neutrophil induced inflammation
Cerebral edemaVasculitis
Decreased cerebral perfusion
DeadSequelae
Antibiotics
Dexamethasone
OdioOdio C et al N C et al N EngEng J J MedMed 19911991• 101 children, 6 weeks- 13 years• 79 H. influenzae, 8 S. pneumoniae, 2 N. meningitidis• Cefotaxime + dexa vs Cefotaxime + placebo• Dexamethasone 0.15 mg/kg every 6 hr for 4 days• Given 15 min prior to cefotaxime• rate of neurologic and audiologic sequalae in children
received dexa was significantly lower ( 14%vs 38%)
WaldWald EE,, Pediatrics Pediatrics 19951995• 143 children, 8wk - 12 yr• 83 H. influenzae, 33 S. pneumoniae, 24 N. meningitidis• Ceftriaxone + dexa vs Ceftriaxone + placebo• Dexamethasone 0.15 mg/kg every 6 hr for 4 days• No significant difference in rate of neurologic and audiologic
sequalae• Bilateral deafness was significantly lower in H. influenzae
meningitis receiveing dexa( 0%) vs placebo (7%)
Bonadio WA, Pediatrics 1996
“Rate of neurologic and audiologic sequalae in children received dexa was significantly lower”
Supportive treatment*Critical peroid: first 3-4 days*
Monitor: Vital signs
Neurological signs
Intake-output
Electrolytes
Body weight
Urine specific gravity
SIADH
Bacterial meningitis with subdural effusion
Brudzinski’s sign positive
GBS meningitis
Meningococcemia
Aseptic meningitisEtiology
- Viral: Enteroviruses
- Postviral: Mumps, measles, chickenpox
- Bacterial: Partially treated bacterial meningitis
- Rickettsiae: Scrub typhus
- Spirochetes: Leptospirosis
- Mycoplasma: M.pneumoniae
Clinical manifestations
“ As same as that of bacterial meningitis”
CSF findings
“ As same as that of viral encephalitis”
Treatments- Viral & postviral: Supportive treatments
- Bacterial: Partially treated bacterial meningitis
- Continue the most appropriated antibiotics
- Rickettsiae: Scrub typhus - doxycycline, chloramphenicol
- Spirochetes: Leptospirosis - doxycycline
- Mycoplasma: M.pneumoniae - macrolides eg. erythromycin
Tuberculous MeningitisIntroduction
- Common in tropical countries
- HIV
- The result of treatment depended on
the stage of disease
Clinical manifestationsChronic meningitis: 3 stages
1. Prodromal stage: nonspecific symptoms (low grade
fever, anorexia, nausea, vomiting )2. Transitional stage: prominent neurological symptoms
meningeal signs, CN palsy, fever3. Terminal stage: coma, fixed and dilated pupil,
decreased RR, PR, dead
Diagnosis
1. History & physical examination
2. Family history
3. CSF findings
4. Other sources of TB (pulmonary, lymph node, miliary TB)
5. Tuberculin test
6. CT brain, ELISA, PCR
CSF findings of TB meningitisCSF findings of TB meningitis
• Pressure: high
• Appearance: Turbid, xanthochromia
• WBCs: 50-500 cells/mm3 , lymphocytes predominate
( >50% )
• Protein: 200-500 mg/dl, may be 1-2 gram or slightly increased
• Sugar: < 50% of blood sugar, or < 40 mg/dl
• AFB stain
• Culture
TreatmentGood clinical respond depended on:-
1. Early diagnosis & early treatment
2. Good medications & adequate duration
INH + rifampicin + pyrazinamide + streptomycin for 2 months
INH + rifampicin for 10 months
3. Reduction of the increased intracranial pressure
Keep CSF pressure < 200 mmH2O
3.1 Lumbar puncture
3.2 Dexamethasone
3.3 Acetazolamide
3.4 Ventriculostomy or ventriculoperitoneal shunt
4. Good supportive treatments
4.1 Nutrition
4.2 Aspiration
4.3 Bed sore
4.4 Fever
4.5 Seizures
4.6 rehabilitation
EncephalitisEtiology:-
- Viral: Japanese B encephalitis - 50%
CMV, HSV, EBV, Poliovirus, rabies
- Postviral: Measles, mumps, chickenpox, rubella
- Postvaccinal: Rabies vaccine
Japanese B encephalitis
- Most common cause of encephalitis in the world
- Common in southeast Asia esp. Thailand
- Northeast Thailand is 2nd common
- Severe, morbidity and mortality rates are high
- No medication for treatment
- Outbreak
Global distribution of major Global distribution of major neurotropicneurotropic flavivirusesflaviviruses
Clinical manifestations1. Prodromal stage (2-3 days): Fever, headache, malaise, nausea,
vomiting 2. Acute encephalitic stage (3-4 days): Fever, conscious change,
seizures, neurosigns, meningeal signs (meningoencephalitis)3. Subacute stage (7-10 days): Neurosigns improved, complications
eg. Pneumonia, UTI4. Late stage and sequalae (4-7 weeks): Stable or improved
neurosigns, sequale eg. spastic paralysis, atrophy
Diagnosis
Fever + conscious change + seizures
CSF findings
- Pressure: 300-400 mmH2O
- WBCs: 10-1,000 cells/mm3 , lymphocytes predominate
- Protein: normal or slightly increased (50-80 mg/dl)
- Sugar: normal
Treatment
No specific treatmentSupportive treatment directed to brain edema
1. Airway and breathing
2. Fever
3. Seizures
Treatment
4. Brain edema: 20%manitol 0.5-1 gm/kg/dose
Steroids - no benefit
5. Complications: Pneumonia, bed sore, SIADH, UTI
6. Nutrition
7. Rehabilitation
Brain abscess- Common in Thailand
- High morbidity and mortality rates
- Often delayed diagnosis and treatment
- Usually recur
Clinical manifestations
3 Main groups of signs and symptoms:-1. Infection: Fever, anorexia, fatigue, increased WBCs and
ESR2. Increased ICP: Most common:- headache, vomiting,
diplopia, papilledema3. Focal neurodeficit: Depend on location of the abscess,
silent area - no neurodeficit
Diagnosis
Fever + headache + neurodeficit
Underlying disease
CT or MRI brain
Treatment1. Antibiotics
-Empiric: cefotaxime + metronidazole
-Depended on underlying diseases:-
COM: aminoglycosides or 3rd gen cephalosporins
Compound fracture: cloxacillin
Treatment2. Drainage
All patients except2.1 Small abscess diameter < 2 cm2.2 Multiple abscesses2.3 Abscess in vital area
3. Supportive treatment4. Treatment of the underlying disease