Meningitis (peds): Difference between revisions
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{{Peds top}} [[meningitis]]
==Background==
==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)
*Meningismus is difficult to discern if <6mo, (esp if <2mo)
*<3months old
*<3months old
**1% incidence of bacterial meningitis
**1% incidence of bacterial meningitis in the developed world
**[[E. coli]], [[Group B strep]], [[listeria]]
**[[E. coli]], [[Group B strep]], [[listeria]]
*>3months old
*>3months old
**[[S. pneumo]], [[meningococcus]], [[staph]]
**[[S. pneumo]], [[meningococcus]], [[staph]]
 
**Lower [[S. pneumo]] rates since Prevnar- if unvaccinated, cover for this
===Risk Factors===
===Risk Factors===
{{Meningitis risk factors}}
{{Meningitis risk factors}}


==Clinical Features==
==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
Following features in the correct clinical context should raise suspicion
*Fever
*[[Fever (Peds)|Fever]], [[hypothermia]]
*Headache
*[[headache (peds)|Headache]]
*Meningeal signs
*Meningeal signs
*Poor feeding
*Poor feeding
*Irritability
*Irritability
*Apnea
*Apnea
*Lethargy
*[[Lethargy]]
*Fever
*[[Seizure (peds)|Seizures]]
*Hypothermia
*[[Bulging_Fontanelle|Bulging fontanelle]]
*Seizures
*Bulging fontanelle
*Hypotonia
*Hypotonia
*Weak cry
*Weak cry
*Hypoglycemia
*[[Hypoglycemia]]


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


==Work-Up==
==Evaluation==
===Work-Up===
#CBC
#CBC
#Chem
#Chem
#Blood cx
#Blood culture
#?CT head: See [[CT Before Lumbar Puncture]]
#?[[head CT|CT head]]: See [[CT Before Lumbar Puncture]]
#CXR (50% of pts w/ pneumoccocal meningitis have e/o pna on CXR)  
#[[CXR]] (50% of patients with [[pneumococcal]] meningitis have evidence of pneumonia on CXR)  
#[[Lumbar Puncture]]
#[[Lumbar Puncture]]
==Diagnosis==


===CSF interpretation by age===
===CSF interpretation by age===
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===CSF Interpretation by Diagnosis===
===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>
*'''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.  
*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.  


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*≥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>
*≥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>


==Treatment==
===Delay in LP===
''Treatment guidelines based on van de Beek et al''<ref>van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702</ref>
*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>
===Neonates (up to 1 month of age)===
*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}}
{{Neonatal meningitis antibiotics}}


===> 1 month old ===
===> 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}}
{{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==
==Disposition==
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==See Also==
==See Also==
*[[Meningitis]]
*[[Meningitis]]
*[[Neoplastic meningitis]]


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

Revision as of 10:31, 12 December 2020

This page is for pediatric patients. For adult patients, see: meningitis

Background

Epidemic meningitis geographic distribution showing "meningitis belt."

Risk Factors

Clinical Features

Severe meningococcal meningitis with classic petechial rash progressing to gangrene.

Following features in the correct clinical context should raise suspicion

Differential Diagnosis

Pediatric fever

Drug-induced altered mental status with fever[1]

Pediatric Rash

Evaluation

Work-Up

  1. CBC
  2. Chem
  3. Blood culture
  4. ?CT head: See CT Before Lumbar Puncture
  5. CXR (50% of patients with pneumococcal meningitis have evidence of pneumonia on CXR)
  6. 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.
CSF interpretation by age
' Neutrophils Lymphocytes Protein Glucose
(x 106 /L) (x 106/L) (g/L) (CSF:blood ratio)
Normal
(>1 month of age)		 0 ≤ 5 < 0.4 ≥ 0.6 (or ≥ 2.5 mmol/L)
Normal neonate
(<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.'[2]
  • 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.
Interpretation of abnormal CSF lab values
' Neutrophils Lymphocytes Protein Glucose
(x 106 /L) (x 106/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[3]

Bacterial Meningitis Score '
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[4]
  • 1 point: Aseptic meningitis less likely[5]
  • ≥2 points: Bacterial Meningitis more likely[6]

Delay in LP

  • CSF cultures are negative 2 hrs after parenteral antibiotics in meningococcal meningitis, and 6 hrs in pneumococcal meningitis[7][8]
  • 12 hrs after antibiotics: CSF glucose levels increase and protein levels decrease. CSF WBC and neutrophils are not affected[9]

Management

"Steroids are unlikely to be beneficial for children with bacterial meningitis in the post-PCV7 era"[10]

<1 month old[11][12]

MRSA is uncommon in the neonate

> 1 month old[14]

Children with Predisposing Factors[15]

Risk Factor Therapy
Basilar skull fracture Vancomycin + third-generation cephalosporin
Penetrating trauma or recent neurosurgery Vancomycin + cefepime, ceftazidime, or meropenem
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

References

  1. ↑ Source APLS page 182, 5th ed.
  2. ↑ Brouwer MC et al. Dilemmas in the diagnosis of acute community-acquired bacterial meningitis. Lancet. 2012 Nov 10. 380(9854):1684-92.
  3. ↑ 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.

  4. ↑ 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.

  5. ↑ 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.
  6. ↑ 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.

  7. ↑ 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
  8. ↑ 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
  9. ↑ 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
  10. ↑ Kowalsky RH, Jaffe DM. "Bacterial Meningitis Post-PCV7: Declining Incidence and Treatment" Pediatric Emergency Care. June 2013. 29(6)758-766
  11. ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
  12. ↑ Kowalsky RH, Jaffe DM. "Bacterial Meningitis Post-PCV7: Declining Incidence and Treatment" Pediatric Emergency Care. June 2013. 29(6)758-766
  13. ↑ https://www.aappublications.org/content/early/2015/02/25/aapnews.20150225-1
  14. ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
  15. ↑ Kowalsky RH, Jaffe DM. "Bacterial Meningitis Post-PCV7: Declining Incidence and Treatment" Pediatric Emergency Care. June 2013. 29(6)758-766
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