View source for Meningitis (peds)

{{PediatricPage|meningitis}}
==Background==
[[File:Meningitis-Epidemics-World-Map.png|thumb|Epidemic meningitis geographic distribution showing "meningitis belt."]]
*Meningismus is difficult to discern if <6mo, (esp if <2mo)
*<3months old
**1% incidence of bacterial meningitis in the developed world
**[[E. coli]], [[Group B strep]], [[listeria]]
*>3months old
**[[S. pneumo]], [[meningococcus]], [[staph]]
**Lower [[S. pneumo]] rates since Prevnar- if unvaccinated, cover for this
===Risk Factors===
{{Meningitis risk factors}}

==Clinical Features==
[[File:Charlotte Cleverley-Bisman Meningicoccal Disease.jpg|thumb|Severe [[meningococcal]] meningitis with classic petechial rash progressing to gangrene.]]
Following features in the correct clinical context should raise suspicion
*[[Fever (Peds)|Fever]], [[hypothermia]]
*[[headache (peds)|Headache]]
*Meningeal signs
*Poor feeding
*Irritability
*Apnea
*[[Lethargy]]
*[[Seizure (peds)|Seizures]]
*[[Bulging_Fontanelle|Bulging fontanelle]]
*Hypotonia
*Weak cry
*[[Hypoglycemia]]
*Rash

==Differential Diagnosis==
{{Pediatric fever DDX}}

===Drug-induced altered mental status with fever<ref>Source APLS page 182, 5th ed.</ref>===
*[[Sympathomimetic]]/[[cocaine]]
*[[Anticholinergic]]
*[[Arsenic]]
*[[LSD]]
*[[PCP]]
*[[Phenothiazines]]
*[[Salicylates]]
*[[Theophylline]]
*[[Thyroxine]]

{{Peds Rash DDX}}

==Evaluation==
===Work-Up===
#CBC
#Chem
#Blood culture 
#?[[head CT|CT head]]: See [[CT Before Lumbar Puncture]]
#[[CXR]] (50% of patients with [[pneumococcal]] meningitis have evidence of pneumonia on CXR) 
#[[Lumbar Puncture]]

===CSF interpretation by age===
*In general neutrophils are abnormal in pediatric CSF and should increase the suspicion for bacterial meningitis. Meningitis can also occur in children with normal CSF microscopy.
{| {{table}}
|+CSF interpretation by age
| align="center" style="background:#f0f0f0;"|''''''
| align="center" style="background:#f0f0f0;"|'''Neutrophils'''
| align="center" style="background:#f0f0f0;"|'''Lymphocytes'''
| align="center" style="background:#f0f0f0;"|'''Protein'''
| align="center" style="background:#f0f0f0;"|'''Glucose'''
|-
| ||(x 10<sup>6</sup> /L)||(x 10<sup>6</sup>/L)||(g/L)||(CSF:blood ratio)
|-
| Normal<br> (>1 month of age)||0||  ≤ 5||< 0.4||≥ 0.6 (or ≥ 2.5 mmol/L)
|-
| Normal neonate<br> (<1 month of age)||0||  < 20||<1.0||≥ 0.6 (or ≥ 2.5 mmol/L)
|-
|}

===CSF Interpretation by Diagnosis===
*'''If the CSF is abnormal the safest course is to treat as if it is bacterial meningitis until cultures return negative growth.''''<ref>Brouwer MC et al. Dilemmas in the diagnosis of acute community-acquired bacterial meningitis. Lancet. 2012 Nov 10. 380(9854):1684-92.</ref>
*Infants with aseptic meningitis should still be admitted given still at high risk of dehydration and neurologic sequelae
*PCR is available for Neisseria meningitidis, Herpes Simplex and Enterovirus and will with inpatient diagnosis.  PCR is most helpful for patients with encephalitis and has poor sensitivity and specificity for bacterial antigens. 

{| {{table}}
|+Interpretation of abnormal CSF lab values 
| align="center" style="background:#f0f0f0;"|''''''
| align="center" style="background:#f0f0f0;"|'''Neutrophils'''
| align="center" style="background:#f0f0f0;"|'''Lymphocytes'''
| align="center" style="background:#f0f0f0;"|'''Protein'''
| align="center" style="background:#f0f0f0;"|'''Glucose'''
|-
| ||(x 10<sup>6</sup> /L)||(x 10<sup>6</sup>/L)||(g/L)||(CSF:blood ratio)
|-
| Normal (>1 month of age)||0||≤ 5||< 0.4||≥ 0.6 (or ≥ 2.5 mmol/L)
|-
| Normal term neonate||0*|| < 20||< 1.0||≥ 0.6 (or ≥ 2.5 mmol/L)
|-
| Bacterial meningitis||100-10,000 ||Usually < 100||> 1.0||< 0.4
|-
| Viral meningitis||Usually <100||10-1000||0.4-1||Usually normal
|-
| TB meningitis||Usually <100||50-1000||1-5||< 0.3
|}

===Pediatric Bacterial Meningitis Score<ref>Chavanet P, Schaller C, Levy C, et al. Performance of a predictive rule to distinguish bacterial and viral meningitis. J Infect 2007;54: 328–36. </ref>===
{| class="wikitable"
| align="center" style="background:#f0f0f0;"|'''Bacterial Meningitis Score'''
| align="center" style="background:#f0f0f0;"|''''''
|-
| '''Criteria'''||'''Point Score'''
|-
| Positive CSF Gram Stain||2
|-
| CSF protein > 80mg/dL||1
|-
| Blood Absolute neutrophil count > 10,000 cells/mm3||1
|-
| Incidence of seizures with illness||1
|-
| CSF neutrophil count ≥ 1000 cells/mm3||1
|}
*0 points: Aseptic meningitis likely<ref>Nigrovic LE, Kuppermann N, Macias CG, et al. Clinical prediction rule for identifying children with cerebrospinal fluid pleocytosis at very low risk of bacterial meningitis. JAMA 2007;297:52–60. </ref>
*1 point: Aseptic meningitis less likely<ref>Fine AM, Nigrovic LE, Reis BY, Cook EF, Mandl KD. Linking surveillance to action: incorporation of real-time regional data into a medical decision rule. J Am Med Inform Assoc 2007;14: 206–11. </ref>
*≥2 points:  Bacterial Meningitis more likely<ref>Dubos F, Korczowski B, Aygun DA, et al. Distinguishing between bacterial and aseptic meningitis in children: European comparison of two clinical decision rules. Arch Dis Child 2010;95:963–7. </ref>

===Delay in LP===
*CSF cultures are negative '''2 hrs''' after parenteral antibiotics in meningococcal meningitis, and '''6 hrs''' in pneumococcal meningitis<ref>Kanegaye JT, Soliemanzadeh P, Bradley JS. Lumbar puncture in pediatric bacterial meningitis: defining the time interval for recovery of cerebrospinal fluid pathogens after parenteral antibotic pretreatment. Pediatrics2001;108:1169–74</ref><ref>Michael B1, Menezes BF, Cunniffe J, Miller A, Kneen R, Francis G, Beeching NJ, Solomon T. Effect of delayed lumbar punctures on the diagnosis of acute bacterial meningitis in adults. Emerg Med J 2010;27:6 433-438. PMID 20360497</ref>
*12 hrs after antibiotics: CSF glucose levels increase and protein levels decrease. CSF WBC and neutrophils are not affected<ref>Lise E. Nigrovic, Richard Malley, Charles G. Macias, John T. Kanegaye, Donna M. Moro-Sutherland, Robert D. Schremmer, Sandra H. Schwab, Dewesh Agrawal, Karim M. Mansour, Jonathan E. Bennett, Yiannis L. Katsogridakis, Michael M. Mohseni, Blake Bulloch, Dale W. Steele, Ron L. Kaplan, Martin I. Herman, Subhankar Bandyopadhyay, Peter Dayan, Uyen T. Truong, Vince J. Wang, Bema K. Bonsu, Jennifer L. Chapman, Nathan Kuppermann. Effect of Antibiotic Pretreatment on Cerebrospinal Fluid Profiles of Children With Bacterial Meningitis. Pediatrics Oct 2008, 122 (4) 726-730. PMID 18829794</ref>

==Management==
''"Steroids are unlikely to be beneficial for children with bacterial meningitis in the post-PCV7 era"''<ref>Kowalsky RH, Jaffe DM. "Bacterial Meningitis Post-PCV7: Declining Incidence and Treatment" Pediatric Emergency Care. June 2013. 29(6)758-766</ref>
===<1 month old<ref>van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702</ref><ref>Kowalsky RH, Jaffe DM. "Bacterial Meningitis Post-PCV7: Declining Incidence and Treatment" Pediatric Emergency Care. June 2013. 29(6)758-766</ref>===
{{Neonatal meningitis antibiotics}}

===> 1 month old<ref>van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702</ref>===
{{Pediatric meningitis antibiotics}}

===Children with Predisposing Factors<ref>Kowalsky RH, Jaffe DM. "Bacterial Meningitis Post-PCV7: Declining Incidence and Treatment" Pediatric Emergency Care. June 2013. 29(6)758-766</ref>===
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Risk Factor'''
| align="center" style="background:#f0f0f0;"|'''Therapy'''
|-
| [[Basilar skull fracture]]||[[Vancomycin]] + third-generation [[cephalosporin]]
|-
| Penetrating trauma or recent neurosurgery||[[Vancomycin]] + [[cefepime]], [[ceftazidime]], or [[meropenem]]
|-
| [[VP shunt|Ventricular shunt]]||[[Vancomycin]] alone; if Gram stain reveals presence of gram-negative bacilli, then add [[cefepime]], [[ceftazidime]], or [[meropenem]]
|}

==Disposition==
*Admit despite negative meningitis score if:
**Age <2mo with any degree of pleocytosis
**Appear ill
**Infants with aseptic meningitis

==See Also==
*[[Meningitis]]
*[[Neoplastic meningitis]]

==References==
<references/>
[[Category:ID]]
[[Category:Neurology]]
[[Category:Pediatrics]]