This document presents a case study of meningitis in a 9-month old infant and discusses the approach to diagnosis and treatment. Key points include: common causative pathogens in infants include E. coli, group B streptococcus, and Listeria; clinical findings may include fever, vomiting, seizures, and rash; lumbar puncture is important for CSF analysis; treatment involves intravenous antibiotics such as cefotaxime or ceftriaxone for bacterial causes. Prognosis can be serious even with treatment, with potential long term sequelae.

1. Approach to
A case of meningitis
Presented by
DR MOHAMED ABDELAZIZ
march 2012

2. MENINGES

3. MENINGES

4. MENINGITIS
Meningitis is an inflammatory response
to infections of the meninges and
CSF,caused by bacteria, viruses, fungi,
CSF,
and other organisms such as protozoa
and rickettsia.

5. Types of Meningitis
Pyogenic Bacterial meningitis
Aseptic (viral) meningitis
Tubercular meningitis

6. Case study
an infant, a 9 month old girl,presents to casuality
with history of fever,vomiting and loose stool over the
last 3 days. She had a brief convulsion j before
ust
arrival at the hospital in the form of a generalized
colonic siezure with uprolling of the eyes, which
settled spontanously. Mum fells that the child has not
been herself for the last few days and seems irritable
most of the time.
O n examination the infant is febrile at 39C, drowzy
and irritable but had apprpriate reactions on being
handled,is midly dehydrated and has cool
peripheries. H er throat is slightly inflamed.

7. What are the most important differntial
diagnosis?
This infant appear s acutly unwell with fever but
no obvious source of infection is d iscribed .
You m ust concern about bacterial infection
causing septic shock and m eningitis.

8. M EN IN GITIS-D IFFEREN TIAL D IAGN O SIS
Brain abscess
Encephalitis
Epid ural abscess
Bacterial end ocard itis with septic em bolism
Subarachnoid hem orrhage
Tum or

9. What are the most common
causing pathogen?
N eonates
E. C oli
Proteus
Group B Streptococci
L isteria m onocytogenes
Enterococcus, Enterobacter,
K lebsiella, Salm onella,

10. Pre School C hild ren
– H em ophilus influenzae
– N eisseria m eningitid is
– Streptococcus pneum oniae
– M ycobacterium tuberculosis

11. O ld er C hild ren and Ad ults
– N eisseria m eningitid is (M eningococcus)
– Streptococcus pneum oniae
– M ycobacterium tuberculosis
– L isteria m onocytogenes
– H em ophilus influenzae
– Staphylococcus aureus

12. What exam ination find ings and observations
would you like to establish im m ed iately?
L ook for focus
Ears:otitis m ed ia,m astoid itis.
Throat:tonsilitis,epiglottitis,gland ular
fever,quinzy.
Skin:im ptigo,cellulitis,abscess.
C hest:bronchiolitis,upper respiratory tract
infection,pneum onia.
Abd om en:append icitis,perforations,abscess.
Bone and joint:osteom ylitis,septic arthritis.

13. L ook for focus
blood :septecaem ia,toxic shock,acute viraem ia.
renal:urinary tract infection,pyelonephritis.
gastrointestinal tract:viral or bacterial GE.
C N S:encephalitis or brain abscess

14. What are the clinical picture?
Bacterial m eningitis usually presents in two
patterns
– Acute - com m on with S. pneum oniae and N .
m eningitid es
– Subacute - preced ing U RI like sym ptom s,
m ore com m on with H . influenza and other
pathogens

15. C L IN IC AL PRESEN TATIO N
H ead ache
Fever
D rowsiness Most common
N eck stiffness
N ausea and vom iting
Irritability
Aversion to light
Restlessness
Altered m ental status (Stupor,C om a)
Seizure
M enngococcal m eningits - Purpural rashes(70% )

16. Skin rashes
Is d ue to sm all skin bleed
All parts of the bod y are affeced
The rashes d o not fad e und er pressure
Pathogenesis:
a. Septicem ia
b. wid e spread end othelial d am age
c. activation of coagulation
d . throm bosis and platelets aggregation
e. red uction of platelets

18. What are the signs and find ings in physical
exam inations?
Bulging fontanel
Focal neurological signs
N eck rigid ity
Ptosis, papilloed em a,
C ushing’s triad (Brad ycard ia, H ypertension,
Altered respirations)
Positive K ernig’s and Brud zinski’s sign

19. KERNIG’S SIGN
Patient placed supine with hips flexed 90
d egrees. Exam iner attem pts to extend the leg
at the knee
Positive test elicited when there is resistance to
knee extension, or pain in the lower back or
thigh with knee extension d ue to m eningeal
irritation

21. BRU D ZIN SK I’S SIGN
Patient placed in supine position and neck is
passively flexed toward s the chest
Positive test is elicited when flexion of neck
causes flexion at knees and / hips of the
or
patient

23. What are the investigations requied for this
infant
C T or M RI are ind icated if there are focal
neurological signs,raised IC P or prolonged
fever. These are helpful in d etection of C N S
com plication of bacterial infections such as
hyd rocephalus,cereberal infract,brain abscess
and venous sinus throm bosis.
L um ber puncture :

24. MENINGITIS-DIAGNOSIS

25. CSF Patterns in Meningitis
Condition Appearance WBC/mm3 Glucose Total
Predominant Protein
type
Normal Clear 0-5 50-75 15-40
lymphocytes >60% of
Blood
Bacterial Turbid 100-10,000 glucose
<45 100-1000
PMN
Viral Clear 10- 2000 Normal 50-100
lymphocytes
Fungal Cloudy <300 <45 40-300
lymphocytes
TB Cloudy <500 <45 100-1000
lymphocytes

26. O TH ER IN VESTIGATIO N S
C BC
– N orm al WBC d oes not rule out m eningitis
Blood cultures
Electrolytes
Renal function
Serum glucose
- U seful to com pare with C SF glucose
O ther relevant investigations

27. What is the treat m ent of this case?
Bacterial M eningitis
Quick initiation of antibiotics is a must
Typical Meningococcal rash
Benzyle Penicillin 2.4 G IV 6th hrly
A dults without Typical Meningococcal rash
C efotaxim e 2 G IV 6th hrly or
C eftriaxone 2 G IV 1 2th hrly
Pinicillin Resistant pnuemococci
C efotaxim e or C eftriaxone
+ Vancom ycin 1 gm IV 1 2th hrly
A lter antibiotic choices once C SF gram stain results are available .

28. N . meningitidis
Inj Benzyle Penicillin 2.4 G IV 6th hrly * 5-7 d ays
Strep. pneumoniae / H. influenae
Inj C efotaxim e 2 G IV 6th hrly or
Inj C eftriaxone 2 G IV 1 2th hrly * 1 0-1 4 d ays
Pinicillin Resistant pnuemococci
Inj C efotaxim e or C eftriaxone
+ Inj Vancom ycin 1 gm IV 1 2th hrly
L isteria monocytogenes
Inj Am picillin 2G iv 6 hrly
+ Inj Gentam ycin 5g/ iv
kg * 8- 1 0 d ays

29. Supportive C are
Steroid s
– Steroid s thought to blunt effects of host inflam m atory
response
– Theoretical concern of steroid s red ucing perm eability of
blood brain barrier to antibiotics
C onsid er repeat L P 24-36 hours after initiating treatm ent to
assure sterilization of C SF if resistant organism or poor
response to treatm ent
Features of Septicaem ia – IC U C are

30. Why d o we use steroid s?
D ecreases inflam m ation which can lead to d ecreased
intracranial pressure.
M ay interrupt the cytokine m ed iated neurotoxic effects of
bacteriolysis, which are at a m axim um d uring the first few
d ays of antibiotic therapy.
Proven red uction in m orbid ity, such as severe hearing loss, in
child ren with H iB m eningitis and Strep. Pneum o m eningitis.
Proven red uction in m ortality in ad ults and child ren with
tuberculous m eningitis(particularly d ue to a red uction in
hepatitis second ary to treatm ent of TB.)

31. When D o We U se Steroid s?
Therapy should be initiated shortly before or at
the sam e tim e as the first d ose of antibiotics,
(likelihood of unfavorable outcom e was m uch
higher in patients in whom d exam ethasone
was given after antibiotics).
D exam ethasone should not be given to ad ults
who have alread y received antibiotics, because
it has not been shown to im prove patient
outcom es.

32. What is the prognosis of this case
Even with appropriate antibiotics, m ortality
rate is significant
– 8% H .influenza,
– 1 5% N eisseria m eningitid is,
– 25% Pneum ococcal
U p to 35% of survivors have sequelae
includ ing d eafness, seizures, blind ness,
paresis, ataxia, hyd rocephalus

33. thank you

34. VIRUSE S
Enteroviruses (coxsackievirus, echovirus, poliovirus, enterovirus)
Arboviruses: Eastern equine, Western equine, Venezuelan equine, St. L ouis encephalitis,
Powassan and C alifornia encephalitis, West N ile virus, C olorad o tick fever
H erpes sim plex (types 1 ,2)
H um an herpesvirus type 6
Varicella-zoster virus
Epstein-Barr virus
Parvovirus B1 9
C ytom egalovirus
Ad enovirus
Variola (sm allpox)
M easles
M um ps
Rubella
Influenza A and B
Parainfluenza
Rhinovirus
Rabies
L ym phocytic choriom eningitis
Rotaviruses
C oronaviruses
H um an im m unod eficiency virus type 1

35. BA C TE RIA
Mycobacterium tuberculosis
Leptospira species (leptospirosis)
Treponema pallidum (syphilis)
Borrelia species (relapsing fever)
Borrelia burgdorferi (L ym e d isease)
Nocardia species (nocard iosis)
Brucella species
Bartonella species (cat-scratch disease)
Rickettsia rickettsiae (Rocky M ountain spotted fever)
Rickettsia prowazekii (typhus)
E hrlichia canis
Coxiella burnetii
Mycoplasma pneumoniae
Mycoplasma hominis
Chlamydia trachomatis
Chlamydia psittaci
Chlamydia pneumoniae
Partially treated bacterial m eningitis

36. BA C TE RIA L
PA RA ME NING E
A L FOC US
Sinusitis
M astoid itis
Brain abscess
Subd ural-epid ural em pyem a
C ranial osteom yelitis
FUNG I
Coccidioides immitis (coccid ioid om ycosis)
Blastomyces dermatitidis (blastom ycosis)
Cryptococcus neoformans (cryptococcosis)
H istoplasma capsulatum (histoplasm osis)
Candida species

37. PA RA SITE S
(E OSINOPHIL IC )
Angiostrongylus cantonensis
G nathostoma spinigerum
Baylisascaris procyonis
Strongyloides stercoralis
Trichinella spiralis
Toxocara canis
Taenia solium (cysticercosis)
Paragonimus westermani
Schistosoma species
F asciola species
PA RA SITE S
(NONE OSINOPHIL I
C)
Toxoplasma gondii (toxoplasm osis)
Acanthamoeba species
Naegleria fowleri
M alaria

38. POSTINFE C TIOUS
Vaccines:rabies, influenza, m easles, poliovirus
D em yelinating or allergic encephalitis
SYSTE MIC OR
IMMUNOL OGIC A L L Y
ME DIA TE D
Bacterial end ocard itis
K awasaki d isease
System ic lupus erythem atosus
Vasculitis, includ ing polyarteritis nod osa
Sjögren synd rom e
M ixed connective tissue d isease
Rheum atoid arthritis
Beh çet synd rom e
Wegener granulom atosis
L ym phom atoid granulom atosis
Granulom atous arteritis
Sarcoid osis
Fam ilial M ed iterranean fever
Vogt-K oyanagi-H arad a synd rom e

39. MA L IG NA NC Y
L eukem ia
L ym phom a
M etastatic carcinom a
C entral nervous system tum or (e.g., craniopharyngiom a, gliom a,
epend ym om a, astrocytom a, m ed ulloblastom a, teratom a)
DRUG S
Intrathecal infections (contrast m ed ia, serum , antibiotics, antineoplastic
agents)
N onsteroid al anti-inflam m atory agents
O K T3 m onoclonal antibod ies
C arbam azepine
Azathioprine
Intravenous im m une globulins
Antibiotics (trim ethoprim -sulfam ethoxazole, sulfasalazine, ciprofloxacin,
isoniazid )

40. MISC E L L A NE OUS
H eavy m etal poisoning (lead , arsenic)
Foreign bod ies (shunt, reservoir)
Subarachnoid hem orrhage
Postictal state
Postm igraine state
M ollaret synd rom e (recurrent)
Intraventricular hem orrhage (neonate)
Fam ilial hem ophagocytic synd rom e
Post neurosurgery
D erm oid -epid erm oid cyst