The document discusses pyogenic meningitis, including the pathophysiology of convulsions which can result from meningitis due to imbalances in excitatory and inhibitory neurotransmitters. It also outlines the clinical features, investigations, treatment including antibiotics and dexamethasone, and complications of acute bacterial meningitis, with a focus on different age groups. Prevention methods like vaccination and prophylactic antibiotics for contacts are also covered.

1. Pyogenic Meningitis
ACUTE BACTERIAL
MENINGITIS
Asso. Prof. Dr.Khin Htwe

2. Pathophysiology of convulsions
• Seizures are paroxysmal manifestations of
the electrical properties of the cerebral
cortex
• A seizure results when a sudden
imbalance occurs between the excitatory
and inhibitory forces within the network of
cortical neurons in favour of a sudden-
onset net excitation

3. • Impairment of the γ-aminobutyric acid
(GABA)–ergic inhibitory system
• Excitatory glutamatergic synapses
(excitatory amino acid neurotransmitters
glutamate, aspartate)
• Seizures may arise from areas of neuronal
death, and these regions of the brain may
promote development of novel hyperexcitable
synapses that can cause seizures eg
temporal lobe lesions can cause seizures

4. Brain injury –
• One suggests that inhibitory neurons are
selectively damaged and remaining
principal excitatory neurons become
hyperexcitable
• The other hypothesis suggests that
aberrant excitatory circuits are formed as
part of reorganization after injury

5. Seizures more common in
chhildren
• Underdeveloped brain is more susceptible to
specific seizures than is the brain of an older
child or adult (age specific – infantile spasm)
• Immature brain is more excitable than the
mature brain, reflecting the greater influence
of excitatory glutamate-containing circuits
• Actions of GABA, the major inhibitory
neurotransmitter, are often paradoxically
excitatory in the immature brain

6. Differential diagnoses of acute
onset of fever and fits
• Febrile convulsion
• Acute bacterial meningitis
• Cerebral malaria
• Encephalitis

7. Meningitis
• Inflammation of leptomeninges
• Viral infection – commonest, self-
resolving in most cases
• Bacterial meningitis – may have
severe consequences

8. Clinical features
Newborn - 2 months
- Signs and symptoms are not typical as in
older children.
• Poor sucking Poor tone
• Staring eyes Poor cry
• Irritability Drowsiness
• Convulsion
• There may be history of
• Prematurity LBW
• Complicated labour PROM
• Maternal sepsis.

9. Clinical features
Infants and older children
• Preceding history of
• Ear discharge
• Head injury
• Sinusitis may be present

10. Signs and Symptoms
• Less common - Dramatic onset -
Meningococcal infection may progress
rapidly leading to shock, purpura, DIC
and reduced level of conciousness and
died within 24 hours
• Commonly – several days of fever with
URT or GI symptoms followed by non-
specific CNS symptoms

11. • Infants and young children – fever, poor
feeding, vomiting, irritability, lethargy,
drowsiness, seizures or reduced
consciousness
• Older children – fever, Vomiting,
headache, photophobia, neck stiffness,
drowsiness, convulsion, coma

12. Signs and Symptoms
• Bulging and tense fontanelle.
• Signs of meningeal irritation
• Neck stiffness
• Kernig’s sign
• Brudzinski’s Sign.

13. Increased ICP suggested by
• Head ache, vomiting, bulging fontanelle or
diastasis (widening ) of sutures
• Ocular or abducens nerve paralysis
• Hypertension with bradycardia
• Apnea or hyperventilation
• Decorticate or decerebrate posture
• Stupor or coma.
• Pappilloedema is uncommon (chronic process).

18. Meningococcal meningitis
Meningococcemia
• Petaechiae, and/or purpura, or maculopapular
rashes
• Signs of shock may be present.

19. Organisms causing bacterial
meningitis
Neonatal to 3 months - Group B streptococcus
E.coli and other coliforms
Listeria monocytogenes
1 month – 6 year - Nisseria meningitidis
Streptococcus pneumoniae
Haemophilus influenzae
>6 years - Nisseria meningitidis
Streptococcus pneumoniae

20. Acute bacterial meningitis
(Causal organisms) (M Protocol)
• 0-1 month - GBS
E. coli
• 1-3 m – GBS, E.coli,
Strep.pneumoniae
H.influenzae type b
• >3 mo - N. meningitidis
S. pneumoniae
H. influenzae type b

21. Investigations for Diagnosis
- CSF examination including Gram stain & culture
• CSF Examination
• Raised CSF pressure
• Appearance - Turbid or opalescent
• Raised protein
• Increased cell count, may be numerous, mainly
neutrophils
• Reduced sugar

23. Infection Pressure Leucocyte Leucoc Protein Glucose
mm Hg s ytes g/l Mmol/l
Total/cum (Differ)
m
Normal 50-80 <5 lympho 0.2-0.4 2.8 - 4.4
cytes
Bacterial 100-300 100- PMN 1.0 – 5.0 0.5 – 1.5
meningiti >50,000
s
TB increased 10 - 500 Lymphoc 1 - 5 0-2
meningiti ytes
s

24. CSF Gram Stain
• Results within hours
• Gram (+) cocci, Gram (-) cocci, Gram (-)
coccobacilli or bacilli
CSF Culture & Sensitivity
• 3 to 7 days to get the results
• Organisms identified
CSF Antigen – Latex agglutination test
CSF PCR - organism

25. Blood
• Culture may identify organisms dose
• FBC – Neutrophil leucocytosis
• Latex agglutination test of blood for antigen
• PCR – organism
• Glucose

26. Investigations for complications
• BUSE
SIADH - urea level normal
: serum Na level low, high urine Na
• Coagulation screen (DIC)
• CT/MRI brain scan and EEG
- for hydrocephalus, subdural effusion, brain
abscess, cerebral infarct
• Ultrasound for infants - confirm with CT/MRI
brain scan

27. Contraindications to LP
• Cardiorespiratory instability
• Focal neurologic signs
• Signs of increased ICP
Glasgow coma scale <8
Abnormal dolls’ eye reflex, Unequal pupils
Papilloedema, High BP low HR
• Coagulopathy, thrombocytopenia
• Local infection at the site of LP
• Immediately after recent seizure

28. Fever and S&S of
bacterial meningitis
LP contraindicated
No(carry out Yes (withhold LP)
LP)
• do blood,urine
• Start antibiotic
dexamethasone
Abnormal CSF Normal CSF,wait for CSF culture and Latex agglutination
Continue antibiotic positive negative
improvement No improvement Re-evaluate, consider discontinu
antibiotic
Complete course of treatment Change antibiotic No response- consider TB,fungus or
encephalitis

29. Treatment
• Antibiotics
• Dexamethasone
• Supportive treatment
• Fluid balance, Fluid restriction
• Monitor vital signs and signs of raised ICP, Input and
output
• Fit chart
• Daily neurological assessment
• Measure OFC daily
• Follow up
• Prevention

31. Dexamethasone
• Use of steroids – Antiinflammatory to
prevent cytokine release
- Best given before or with first
antibiotic dose
- Dose: dexamethasone 0.15mg/kg
6hly for 4 days or 0.4mg/kg 12hly for
2 days

32. Fluid
• Maintanence
• Fluid restriction (2/3 of maintenance)
• Fluid replacement if shock is present
in cases of meningococcal meningitis.

33. Cerebral monitoring
(Neuro-observation Chart)
Cerebral oedema
• IV 20 % mannitol 7 to 10 ml/kg/20 mins, can be
repeated 8 hourly
Seizure – anticonvulsants
Apnoea – mechanical ventilation
Care of unconscious patient – Nursing,
bladder, bowel, skin.

34. Complications
• Immediate
• Seizures
• Cerebral or cerebellar herniation
• Increase Intracranial pressure
• Cranial nerve palsies
• Subdural effusion
• SIADH
• Hydrocephalus
• Waterhouse Friderichsen syndrome

35. Complications
• Remote
• Neurological deficit
• eg. hemiplegia, aphasia, ocular palsies
• Deafness
• Blindness
• Learning difficulty
• Brain abscess
• Hydrocephalus
• Epilepsy

36. Follow up
Follow Up (long term FU is important)
• Developmental assessment
• Measurement head circumference
• Ask about any occurrence of fits or any
beh. abnormalities (for epilepsy and
behavioural problems)
• Assess vision, hearing and speech
• Neurological assessment

39. Prevention
1. Antibiotic prophylaxis
• Meningococcal infection (all contacts)
• Rifampicin 10 mg/kg OD for 2 days
• H. influenzae infection (only if <5yr child at home)
• Rifampicin 20 mg/kg OD for 4 days
• Alternative – Ciprofloxacin (for adult
contacts)

40. Prevention
• 2. Vaccination
• HiB vaccine
• Meningococcal vaccine
• Pneumococcal vaccine
• 3. Adequate treatment of pyogenic
infection elsewhere in the body

41. Lumbar Puncture

42. Lumbar Puncture
• Informed consent from the parents are needed.
• Parents should be told on why the test is needed
• How the procedure are going to be carried out
• The complications that can occur & its risk

43. To seek verbal consent for LP
• Introduce yourself
• Check knowledge about condition of the
child and need for LP
• Clearly explain about LP - why is it
necessary and what is involved (a
technique to sample the fluid surrounding
the brain and spinal cord, put a needle on
the back and take few mls of fluid)

44. Why LP is necessary
• Meningitis is potentially serious
• The most serious forms of meningitis can be
effectively treated with antibiotics
• Delay in making the diagnosis and starting
treatment worsens the outlook
• LP is the only way of excluding meningitis
• While it is possible to give an antibiotic
without performing a LP, there is less chance
of making an accurate diagnosis

45. • Explain about analgesia, antiseptic
• Explain what to expect afterwards – the fluid sample
will be sent to the laboratory for analysis to see any
evidence of infection
• Explain risks – infection, leak, headache, technically
unsuccessful
• Explain benefits – confirm diagnosis and
management, selection of treatment, length of
treatment, follow-up arrangements
• Invite patient any further questions, check
understanding
• Ask permission, using and open-ended, non-
diirective question

46. References
• Illustrated Paediatrics 4th edition
• Nelson Textbook of Paediatrics 19th
edition
• Paediatric Protocols for Malaysia Hospitals
2nd edition 2010

47. • A 12 year-old boy was in his normal state of health until
5 days ago, when he developed a fever of 105.8 F
(41C). Over the next 2 days, he developed stiff neck and
began vomiting. He was brought to the emergency
department (ED) when he developed altered mental
status. In the ED, his heart rate is 135 bpm, blood
pressure 120/70 mm Hg, respiratory rate 25 breaths/min,
and temperature 104F (40C). He is combative, unaware
of his surroundings,
• and does not follow instructions. Kernig and Brudzinski
signs are present.
• ➤ What is the most likely diagnosis?
• ➤ How would you confirm the diagnosis?
• ➤ What treatment is indicated?
• ➤ What are possible complications?

48. Investigation findings
• FBC –
WBC – 16,000/cmm
N 80%, L 15%
• LP
CSF – turbid
cell – 1000/cmm, N 80%
Protein – 1 G/L
Sugar – 1.3 mmol/l

49. CASE STUDY

50. A one year 6 months old malay boy, came to
A&E accompanied by his mother, with
chief complaint of fits and fever.
Questions
• State the immediate management
• State the differential dx
• Mention information you would like to
know.
• Physical signs you would look for

51. Case study
• Fever – started in the morning, 39.5°C, not
relieved by paracetamol
• Fits – started around 1.20pm, around 4 hrs
after the onset of fever. Generalized tonic-
clonic, uprolling of eyes, drooling of saliva
and urinary incontinence. It lasted for 5
minutes.
• Postictal – crying, No drowsiness, no
weakness of limbs and the baby did not
sleep.

52. • Not drowsy, not irritable, no weaknesses, still
feeding well during fever. No fast breathing, no
cyanosis, no ear discharge, no rashes.
• No hx of head injury, no recent travelling to other
country
• He had similar episode 2 mths ago. The fever
was 38°C and fits 5 hrs after onset of fever.
Similar generalized tonic-clonic with uprolling of
eyes, drooling of saliva and incontinence. No
post-ictal drowsiness or weakness and the fits
lasted for 10 minutes. The baby was admitted in
hospital for 1 day. No medication given.

53. Case study
• Antenatal history – GDM with insulin
injection. C-sec, birthweight 4.03kg. After
birth, baby was having respiratory distress
and was given O2 via headbox, not
intubated
• Developmental – normal
• Family hx – youngest of 4, no similar
presentations in family or afebrile
convulsion in family

54. • Physical examination?

55. Physical examination
• Anthropometry - normal
• Neurologic examination – power and
sensory intact. No signs of cranial nerves
palsy
• Anterior fontanelle not bulging
• Neck stiffness absent
• Eyeground (fundoscope): no abnormalities
detected
• Liver and spleen not palpable

56. • Provisional diagnosis?
• Recurrent Simple Febrile seizure
• Differential Diagnosis
• Cerebral malaria
• Meningitis
• Encephalitis

57. • Investigation?

58. Investigation
• FBC – for presence of Infections
• RBS
• BUSE with creatinine, Ca, Mg
• Infection screen
• Blood culture
• Urine culture
• Lumbar puncture (indication?)

59. Investigation
• Unnecessary in this case
• EEG
• Neuroimaging (MRI, CT)
• Toxicology screening if suspicious of drug
exposure

60. Management