1. Meningitis
Dr. Kalpana Malla
MD Pediatrics
Manipal Teaching Hospital
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2. Definitions
• Meningitis : inflammation of the lepto-meninges
covering the brain and the spinal cord
• Encephalitis : inflammation of brain parenchyma, with
cerebral dysfunction.
• Encephalopathy : cerebral dysfunction , due to
toxins, metabolites, poisons etc , affecting neurons
without inflammatory response.

3. Classification:
1) Viral
2) Bacterial
3) Tubercular
4) Others:
Parasitic: malarial, amebic, toxoplamosis
Fungal: candiadiasis, cryptococcal,
histoplasmosis

4. Bacterial Meningitis
• Causes:
• 0-2months: - Group B & D streptococcus
- Gram neg enteric bacilli - E.coli,
Klebsiella pneumoniae
- L. monocytogenes
- Sometimes H influenza
2mo-5years: - H. influenzae typeb
- Strep. Pneumoniae
- N. meningitidis
>5 years: - S. pnemoniae
- N. meningitidis

5. May spread to the meninges either
Hematogenously, or by contiguous spread
Predisposing factors include:
1) Septicemia
2) Septic foci in skin, lungs, bones
3) Trauma ie. Fracture base of the skull
4) Neural tube defects
5) Suppurative ear, mastoid infec

6. Etiology
• N meningitis – epidemics
• S. Pneumoniae – epidemics
• H influenza – uncommon after 3 years,
incidence decreased after Hib vaccine.
• Less common – staph – seen in vp shunt
• Less common – E. coli, pseudo, proteus –
neonates, immuno compromised.

7. PATHOGENESIS
Host :
• Young age , close contact with bacteria , altered
immunoglobulin response, defect of complement
system – C5-8 – recurrent meningococcal inf.,
• Defect of properdin system : meningococcal inf.,
• Splenic dysfunction : pnemococcal and H influenza
• T lymphocyte defect : L monocytogens
• Altered mucocutaneous barrier : cribiform plate
damage, middle ear inf. – pneumococcal
• Lumbosacral myelocele : staph and gram neg. enteric
bacilli

8. BACTERIAL COLONISATION OF NASOPHARYNX with pathogenic bacteria
(eg N meningitis and H influenza attach to mucosal surface by pilli
and enter circulation)
DIRECT INVASION Blood stream BLOOD CYTOKININE
Invasion / Bacteremia RELEASE
THROUGH choroid plexus
Intravascular
Lat ventricle, meninges
CNS PENETRATION Volume decreases
Bacteria rapidly multiply ↓CSF flow
As CSF conc. Of complement
And antibody LOW
Endothelial
Complement system activation CSF cytokine Leukocyte activation
release
Release of
PMN STIMULATION BBB disturbed ↓CSF flow Secondary mediators
FREE RADICAL RELEASE Meningeal inflammation
Brain damage
Brain edema

9. Clinical features:
• Constitutional symptoms :
Lethargy, irritability , anorexia, vomiting,
fever – mild, high, hypothermia in infants, Poor
feeding, Arthralgia, myalgia
Meningeal features:
Neck rigidity, kernig’s, brudzinski’s sign.
These may be absent in infants, Neck pain,

10. Clinical features:
• Features of raised ICP:
- HTN with bradycardia,
- Apnea or hyperventilation,
- Head ache , photophobia,
- Vomiting- projectile
- Buldging AF if open, 6th nerve palsy
- Hypertonia, extensor plantars
- Decorticate/decerebrate posturing
- Papilledema

11. Raised ICP due to:
1) Cell death (cytotoxic cerebral edema)
2) Cytokine induced increased vascular
permeability(vasogenic cerebral edema)
3) Increased hydrostatic pressure after
obstructed reabsorption of CSF in the villus
or obstruction of the flow of fluid from the
ventricle
4) SIADH

12. Clinical features:
Features of parenchymal involvement:
Altered sensorium, seizures, Coma and focal
neurological signs
• Cutaneous features: erythamatous macular
rashes, petechiae

13. Clinical features:
• Extra CNS manifestations:
Rashes, petechiae, athralgia, shock, DIC,
depending on etiology
In very young, immunocompromised, severely
malnourished child signs of overt meningitis
may be absent

14. Meningitis in neonates and infants
• Vacant stare, persistent vomiting, refusal to
suck, poor tone, poor cry, shock, circulatory
collapse, hypothermia/fever, convulsions, neur
ological signs.
• More risk if – premature, LBW, coplicated
labour, PROM, maternal sepsis……

15. Signs:
• Neck rigidity
• Kernig’s sign
• Brudzinski’s sign
• Bulged fontanelle
• Sutural diastasis
• Cranial n. palsies (oculomotor, abducens,
facial, auditory)
• photophobia

16. Tubercular Meningitis
• Most serious complication & fatal without Rx
• Commonly affects children from 6mo- 4years
of age
• Rapid progression occur in infants & young
children

17. TBM
• Pathogenesis:
1) Rupture of subependymal tubercles – TB
bacilli in subarachnoid space
2) Lymphohematogenous dissemination of
primary infection

18. First stage
• Over 1-2 weeks – 2-8 weeks
• Stage of invasion/prodromal stage
• Nonspecific and vague
Fever Headache
Irritability Drowsiness
Malaise Shrill cry
100% cure

19. Second stage - Stage of meningitis
• Over 1-2 wks
• More abrupt
• Lethargy - Projectile vomiting
• Nuchal rigidity - Bulging frontanelle
• Seizures - Cranial nerve palsies
• Kernig/brudzinisky’s sign +
• 25% mortality, 25 % sequelae

20. • Hypertonia
• Cranil N palsies 3rd-7th
• Ocular paralysis
• Strabismus, nystagmus
• Hemiplegia/quadriplegia
• Semicoma/coma

21. Third stage - Stage of coma
• Unconscious- Coma
• Repeated convulsions
• High fever: “terminal fever”
• Severe neurological involvements –
- Hemiplegia/paraplegia
- Quadriplegia/ decerebrate rigidity
- Decerebrate posturing
- Opsithotonus
- Deteriorating mental status
• Deteroration of vital signs- Hypertension
• 50% mortality
• 50% cure but almost all have sequelae

22. Disabilities of TBM
• Blindness deafness
paraplegia /hemiplegia
squint MR
epilepsy CP
CN palsies
Endocrine disturbances

23. INVESTIGATIONS
1)Lumbar puncture: should be done before any
antibiotics started
precautions: C/I for an immediate LP :
- EVIDENCE OF increased ICT ( other than
bulging fontanels). - Fundoscopy, to rule
out papilloedema -
-infections overlying the site of puncture
-Relative C/I - Thrombocytopenia
-Cardiopulmonary compromise & shock

24. LP
• DO RBS 30 min before LP.
• CHILD IN LATERAL POSITION with knee, hip, head
flexed.
• Clean site L4-5, L3-4.
• LP stilleted needle, with direction towards umblicus
, perpendicular to spine.
• Collect CSF – TUBE 1 – cell count, type
• Tube 2 – C/S.
• TUBE 3 – glucose, protein
• Tube 4 – latex fixation tests
• 0.5 to 1 ml each tube.

25. Investigations
2) Blood Culture:
3) Chest Roentogram
4) S. electrolytes
5) CBC, CRP
6) Skin scraping for C/S
7) Mantoux Test
7) Serology: Latex agglutination, counter
current immunoelectrophoresis
8) CT,MRI- for detection of hydrocephalus,
abcess, effusion, exudates, edema

26. Normal PYOGENIC VIRAL MYCOBACT FUNGAL
ERIAL
GROSS TURBID CLEAR COBWEB CLEAR-
CLEAR TURBID
Pressure 100-300 80-150 >80 >80
Mm H20
50-80

27. PYOGENIC VIRAL MYCOBA FUNGAL
CTERIAL
SUGAR <40(<50% N ( < 40 <50 <50
MG/DL OF RBS) IN
>50(75% MUMPS
OF RBS )
PROTEI 100-500 50-200 100-3000 25-500
N
MG/DL
20-45

28. PYOGENIC VIRAL MYCOBA FUNGAL
CTERIAL
TOTAL 100-10,000 100 10-500 5-500
CELL
<5
PREDO PMN lympho Lympho Monnucl
MINAT cytes ear
TYPE
,>75%
Lympho

29. PARTIALLY TREATED MENINGITIS
• Culture : sterile in 48 hrs
• Sugar normalize by 48 hrs
• Cells may increase initially, persistence of
neutrophil indicates poor response.
• Protein : take longer time to normalize, thus
not good parameter for adequacy of
treatment.

30. RAPID DIAGNOSTIC TESTS
• PCR – for diagnosis of infections ( herpes, TB,
meningococci)
• Latex agglutination and ELISA- antigen
antibody detection
• CSF C-RP, LDH, lactic acid – to differentiate
pyogenic from non pyogenic.

31. ORGANISM ANTIBIOTIC DOSE DURATION
UNKNOW EMPERIC 10 DAYS
1)CEFTRIAXONE 100-150
N MG/KGDAY
2)CEFOTAXIME
4 LAC
3)AMPI/PENCILLIN
U/KG/DAY
G + CHRAMPHENi
100
MG/KGDAY
MENINGOC Pencillin G 3-4 lac 7DAYS
OCCUs U/KG/DAY

32. ORGANISM ANTIBIOTIC DOSE DURATION
Pneumococcu Pencillin G or if 40 10DAYS
s resistance – MG/KG/D
Ceftriaxone plus
Vancomycin
Gram neg. Ceftriaxone/cefo 21DAYS
taxime plus
aminoglycogide

33. ORGANISM ANTIBIOTIC DOSE DURATION
Pseudomonas Ceftazidime 150 14-21DAYS
MG/KG/D
Staphyloco Vancomycin 40 28DAYS
cci MG/KGD
AY
H influenza Ceftriaxone 10-14
DAYS
Cefotaxime

34. 2) Anti inflammatory therapy
Dexamethasone: 0.15mg/kg/dose 6hrly for 2
days
First dose should be given prior to starting
antibiotics
In case of TBM: prednisolone;4-6wks

35. STEROID THERAPY
• Rationale : to decrease cytokine related damage ,
esp . To 8th nerve .
• Decrease ICT
• ESP. useful for children older than 6 weeks with
suspected H influenza.
• Current recommendation :
• Dexamethasone : 1-2 hr before first antibiotic dose
• 0.15mg/kg/dose every 6 hrly for 2 days.

36. General Care
- Fluid and electrolytes homeostasis -Check for shock –
fluid bolus NS
• NPO
• Oral feeds if sensorium –ok
• Care of oral cavity, eyes, bladder,bowel and skin
• IF suspecting SIADH – give 2/3rd maintenance
• Symptomatic Management:
Paracetamol
Diazepam, Phenytoin, Phenobarbitone

37. Supportive care
Seizures
• No role for prophylactic use of AED
• For immediate control : lorazepam/diazepam,
• Load on phenytion to reduce recurrence.
• Phenytoin preferred than pheno as produces less
CNS depression and permits assessment of levels
of consciousness.

38. Treatment of raised intracranial pressure
• Head end elevation to 30 degree
• Fluid – 2/3 rd maintaiance
• Do not use hypotonic fluids
• 20% mannitol
• Frusemide
• Acetazolamide
• Glycerol

39. 4) Treatment of complications:
Shock: Volume expander, FFP,
Dopamine
Subdural effusion: Aspiration
Hydrocephalus: Shunt Operation (VP)

40. Complications - immediate
• Seizure • Ventriculitis
• Raised ICP • Brain abscess
• Stroke • Hydrocephalus
• Cerebral or • DIC
Cerebellar • Cranial Nerve Palsy
herniation • Thrombosis of dural
• Sub Dural Effusion sinuses
• SIADH • Shock

41. CHRONIC –late
• Permanent brain damage with
- CP,Mental retardation,
- Epilepsy
- Deafness
- Blindness
- Hemiplegia
- Hydrocephalus
• EHAVIOUR PROBLEMS

42. POOR PROGNOSIS
• SEIZURES THAT PERSIST after 4 days of illness
and are difficult to treat
• Coma
• CSF pleocytosis may be absent in
overwhelming meningitis and sepsis.
• < 6 months
• Focal deficit at presentation
• Pnemococcal organism

43. PREVENTION
• Immuno prophylaxis :
- Hib vaccine - routine
- Meningococcal vaccine -
epidemics

44. PREVENTION
• Chemo prophylaxis: ( for house hold contacts)
1. H influenza : Rifampicin : 20 mg/kg/day,
single dose/day for 4 days
2.Meningococcus : Rifampicin : 20 mg/kg/day, in
2 divided doses for 2 days
Or
Ciprofloxacin- single dose 500mg

45. Thank you
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