Meningitis (Case 19)

Chapter 49 Meningitis (Case 19)



Rebecca Tenney-Soeiro, MD




Case


A 2-year-old boy with fever, vomiting, and irritability is found to have meningitis.




Differential Diagnosis








Bacterial meningitis Aseptic meningitis


Speaking Intelligently


When I suspect a child has meningitis, I quickly assess clinical status to determine if antibiotics are urgently needed. Does the child need resuscitation? Is a head computed tomography (CT) scan needed before a lumbar puncture (LP)? After this assessment, I perform an LP, and the cerebrospinal fluid (CSF) is evaluated for cell count, glucose, protein, and Gram stain and culture. For suspected bacterial meningitis, empirical antibiotic therapy is begun. Beyond the neonatal period, treatment includes vancomycin and a third-generation cephalosporin such as cefotaxime. The child’s age, immunization status, season, and recent illness or sick contacts are important considerations. Distinguishing between viral and bacterial meningitis at presentation, and hence the need for hospitalization and treatment, can sometimes be difficult. The Bacterial Meningitis Score may help to differentiate aseptic from bacterial meningitis in patients over the age of 2 months. Patients have a low risk for bacterial meningitis if they demonstrate all of the following: (1) negative CSF Gram stain, (2) CSF absolute neutrophil count (ANC) less than 1000 cells/µL, (3) CSF protein less than 80 mg/dL, (4) peripheral blood ANC less than 10,000 cells/µL, and (5) no history of seizure before or at the time of presentation.



Patient Care



Clinical Thinking



• Support the airway, breathing, and circulation (ABCs).

• Is the intensive care unit needed?

• Begin empirical treatment with broad-spectrum antibiotics and narrow coverage once the organism and sensitivities are known.

• Monitor for complications of bacterial meningitis: change in level of consciousness, increased intracranial pressure (ICP), seizures, acidosis, coagulopathy, syndrome of inappropriate antidiuretic hormone (SIADH), abscess, or subdural empyema.


History



• Was onset sudden, or have symptoms developed gradually?

• Have there been seizures (an important prognostic indicator)? Early generalized seizures may be due to cortical inflammation or SIADH. Focal or later-onset generalized seizures are suggestive of a suppurative complication or permanent brain damage (see Chapter 47, Seizure).

• Review immunization status; specifically Streptococcus pneumoniae and Haemophilus influenzae vaccines, and in adolescents, Neisseria meningitidis.

• A recent upper respiratory infection (URI) or gastroenteritis may suggest aseptic meningitis.

• Has there been recent treatment with antibiotics? If so, consider a partially treated meningitis and limited reliability of culture results.

• Any ill contacts?


Physical Examination



• Assess ABCs.

• Vital signs: Fever in most cases, but can have temperature instability in young infants. Tachycardia will occur if febrile, dehydrated, or in shock. Note hypotension if in shock. Cushing triad of hypertension, bradycardia, and respiratory depression indicates increased intracranial pressure.

• What is the general appearance? Is the child alert and talking? Lethargic? Irritable? Unconscious or disoriented?

• Head, eyes, ears, nose, throat (HEENT): In infants, assess fontanelle size. Measure head circumference under 24 months of age. Any photophobia? Any signs of URI? Is there otitis media?

• Neck: Is there nuchal rigidity? Are Kernig or Brudzinski signs present? These may be unreliable in young infants.

• Skin: Infants may be jaundiced. Is there a rash, particularly petechial or purpuric? Vesicles?

• Neurologic: Any mental status changes? Any cranial nerve palsies to suggest increased ICP?


Tests for Consideration



• Complete blood count (CBC) with differential $116

• Blood culture $152

• Electrolytes, blood urea nitrogen (BUN), and creatinine: To evaluate hydration status, SIADH $174
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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Meningitis (Case 19)

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