History

Fact Explanation
Fever [1] Bacterial pathogens reach the CNS either by hematogenous spread or by direct extension from a contiguous site.After bacteremia, pathogens penetrate the blood-brain barrier to enter the subarachnoid space.An intense inflammation is elicited by bacterial products which gives rise to fever.(invading bacteria cause the body to reset it's thermostat to a higher level) [1]
Vomiting [2] Intense inflammation is elicited by bacterial products gives rise to oedema.This causes increased intracranial pressure which causes vomiting [2]
Lethargy [2] Cerebral edema in the nonexpendable cranial vault increases intracranial pressure (>300cm of H2O) [2]
Irritable [2] Cerebral edema in the nonexpendable cranial vault increases intracranial pressure (>300cm of H2O) [2]
Refusing food or drink [2] Cerebral edema in the nonexpendable cranial vault increases intracranial pressure [2]
Headache [3] Cerebral edema in the nonexpendable cranial vault increases intracranial pressure (>300cm of H2O) [1]
Chills or shivering [1] Invading bacteria cause the body to reset it's thermostat to a higher level [1]
Skin rash [2] Non blanching petechiae and purpura in meningococcal meningitis [2]
Altered mental state [6] Intense inflammation is elicited by bacterial products gives rise to oedema.Mental state will be altered due to edema and increased intra cranial pressure [2]
Paresis [2] Weakness of the muscles secondary to irritation of the nerve cells that control them [2]
Seizures [1] Intense inflammation is elicited by bacterial products gives rise to oedema.It irritates the nerve cells of the brain which produces the seizure [1]
Focal neurological deficit [1] Cerebral edema irritates the nerve cells of the spinal cord which results in the palsies.Cranial nerves (CN) may also be affected by compressible pressure of brain in general. Abducent (VI) nerves with its longest intra cranial route adjacent to brain stem are more prone to raised intra cranial pressure and exudates (perineuritis) related compression. Other CNs like III, IV, and VII may also be affected. [2]
Photophobia [2] Intense inflammation is elicited by bacterial products gives rise to oedema.Oedema irritates the nerve cells of the optic nerve which produces the visual changes [2]
Age [5] Most cases of viral meningitis occur in children younger than age 5. Bacterial meningitis commonly affects people under 20, especially those living in community settings [1]
Living in a community setting [1] Children in boarding schools and childcare facilities are at increased risk of meningococcal meningitis. This increased risk likely occurs because the bacterium is spread by the respiratory route and tends to spread quickly wherever large groups congregate [1]
Compromised immune system [1] Factors that may compromise the immune system, including AIDS, childhood diabetes and use of immunosuppressant drugs,also make the child more susceptible to meningitis. Removal of the spleen, which is an important part of the immune system, also increase the risk [1]
Skipping vaccinations [4] The routine use of conjugated Hib vaccines in children has been associated with a reduction of more than 99% of invasive disease, including meningitis.If a child has not receive the vaccine, the risk of meningitis is high [1]
References
  1. CHáVEZ-BUENO SUSANA, MCCRACKEN GEORGE H.. Bacterial Meningitis in Children. Pediatric Clinics of North America [online] 2005 June, 52(3):795-810 [viewed 15 July 2014] Available from: doi:10.1016/j.pcl.2005.02.011
  2. HOFFMAN O, WEBER RJ. Pathophysiology and Treatment of Bacterial Meningitis Ther Adv Neurol Disord [online] 2009 Nov, 2(6):1-7 [viewed 15 July 2014] Available from: doi:10.1177/1756285609337975
  3. AZADFAR S, CHERAGHALI F, MORADI A, JAVID N, TABARRAEI A. Herpes simplex virus meningitis in children in South East of caspian sea, iran. Jundishapur J Microbiol [online] 2014 Jan, 7(1):e8599 [viewed 22 September 2014] Available from: doi:10.5812/jjm.8599
  4. NAMANI SA, KOCI RA, QEHAJA-BUçAJ E, AJAZAJ-BERISHA L, MEHMETI M. The epidemiology of bacterial meningitis in Kosovo. J Infect Dev Ctries [online] 2014 Jul 14, 8(7):823-30 [viewed 22 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/25022291
  5. YADHAV ML K. Study of bacterial meningitis in children below 5 years with comparative evaluation of gram staining, culture and bacterial antigen detection. J Clin Diagn Res [online] 2014 Apr, 8(4):DC04-6 [viewed 22 September 2014] Available from: doi:10.7860/JCDR/2014/6767.4215
  6. KARA SS, POLAT M, TAPISIZ A, NAR OTGUN S, TEZER H. [A pediatric case of pneumococcal meningitis due to Streptococcus pneumoniae serotype 35F]. Mikrobiyol Bul [online] 2014 Apr, 48(2):346-50 [viewed 22 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24819273

Examination

Fact Explanation
Febrile [1] Bacteria reach the CNS either by hematogenous spread or by direct extension from a contiguous site.After bacteremia, pathogens penetrate the blood-brain barrier to enter the subarachnoid space.An intense inflammation is elicited by bacterial products which gives rise to fever.(invading bacteria cause the body to reset it's thermostat to a higher level) [1]
Non blanching rash [2] Non blanching petechiae and purpura in meningococcal meningitis [2]
Irritable [2] Cerebral edema in the nonexpendable cranial vault increases intracranial pressure (>300cm of H2O) [2]
Altered mental state (includes confusion, drowsiness, and impaired consciousness) [2] Intense inflammation is elicited by bacterial products gives rise to oedema.Mental state will be altered due to edema and increased intra cranial pressure [2]
Bulging fontanelle (only relevant in children under 2 years) [2] Cerebral edema in the nonexpendable cranial vault increases intracranial pressure (>300cm of H2O) [2]
Kernig’s sign [2] Positive when the thigh is bent at the hip and knee at 90 degree angles, and subsequent extension in the knee is painful.Occurs due to irritation of the meninges [2] Sensitivity of 5% and specificity of 95% [3]
Brudzinski’s sign [2] Forced flexion of the neck elicits a reflex flexion of the hips.Occurs due to irritation of the meninges [2] Sensitivity of 5% and specificity of 95% [3]
Focal neurological deficit including cranial nerve involvement and abnormal pupils [2] Cerebral edema irritates the nerve cells of the spinal cord which results in the palsies.Cranial nerves (CN) may also be affected by compressible pressure of brain in general. Abducent (VI) nerves with its longest intra cranial route adjacent to brain stem are more prone to raised intra cranial pressure and exudates (perineuritis) related compression. Other CNs like III, IV, and VII may also be affected. [2]
Seizures [1] Intense inflammation is elicited by bacterial products gives rise to oedema.It irritates the nerve cells of the brain which produces the seizure [1]
Capillary refill time more than 2 seconds,Hypotension,Cold hands or feet [1] In severe condition, child can go into septicemia and shock [1]
Paresis [2] Weakness of the muscles secondary to irritation of the nerve cells that control them [2]
Papilledema [2] Intense inflammation is elicited by bacterial products gives rise to oedema.Mental state will be altered due to edema and increased intra cranial pressure [2]
References
  1. CHáVEZ-BUENO SUSANA, MCCRACKEN GEORGE H.. Bacterial Meningitis in Children. Pediatric Clinics of North America [online] 2005 June, 52(3):795-810 [viewed 15 July 2014] Available from: doi:10.1016/j.pcl.2005.02.011
  2. HOFFMAN O, WEBER RJ. Pathophysiology and Treatment of Bacterial Meningitis Ther Adv Neurol Disord [online] 2009 Nov, 2(6):1-7 [viewed 15 July 2014] Available from: doi:10.1177/1756285609337975
  3. WARD MA, GREENWOOD TM, KUMAR DR, MAZZA JJ, YALE SH. Josef Brudzinski and Vladimir Mikhailovich Kernig: Signs for Diagnosing Meningitis Clin Med Res [online] 2010 Mar, 8(1):13-17 [viewed 16 July 2014] Available from: doi:10.3121/cmr.2010.862

Differential Diagnoses

Fact Explanation
Brain abscess [1] Brain abscess is defined as a focal infection within the brain parenchyma, which starts as a localized area of cerebritis, which is subsequently converted into a collection of pus within a well-vascularized capsule.Papilledema occurs early in disease, acute or insidious onset. Sterile CSF [2]
Subarachnoid hemorrhage [1] Severe headache with a rapid onset ("thunderclap headache"), vomiting, confusion or a lowered level of consciousness, and sometimes seizures.[3] Red blood cells will be present in CSF [1]
Encephalitis [1] Behavioral changes may be more prominent [1] Neurological examination may reveal focal features such as fronto-temporal signs, aphasia, personality change according to the affected area ( eg: behavioral changes when frontal lobe is involved) [4]
References
  1. CHáVEZ-BUENO SUSANA, MCCRACKEN GEORGE H.. Bacterial Meningitis in Children. Pediatric Clinics of North America [online] 2005 June, 52(3):795-810 [viewed 15 July 2014] Available from: doi:10.1016/j.pcl.2005.02.011
  2. ALVIS MIRANDA H, CASTELLAR-LEONES SM, ELZAIN MA, MOSCOTE-SALAZAR LR. Brain abscess: Current management J Neurosci Rural Pract [online] 2013 Aug, 4(Suppl 1):S67-S81 [viewed 16 July 2014] Available from: doi:10.4103/0976-3147.116472
  3. CONNOLLY ES JR, RABINSTEIN AA, CARHUAPOMA JR, DERDEYN CP, DION J, HIGASHIDA RT, HOH BL, KIRKNESS CJ, NAIDECH AM, OGILVY CS, PATEL AB, THOMPSON BG, VESPA P, AMERICAN HEART ASSOCIATION STROKE COUNCIL, COUNCIL ON CARDIOVASCULAR RADIOLOGY AND INTERVENTION, COUNCIL ON CARDIOVASCULAR NURSING, COUNCIL ON CARDIOVASCULAR SURGERY AND ANESTHESIA, COUNCIL ON CLINICAL CARDIOLOGY. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke [online] 2012 Jun, 43(6):1711-37 [viewed 16 July 2014] Available from: doi:10.1161/STR.0b013e3182587839
  4. KENNEDY P G E. VIRAL ENCEPHALITIS: CAUSES, DIFFERENTIAL DIAGNOSIS, AND MANAGEMENT. Journal of Neurology, Neurosurgery & Psychiatry [online] 2004 March, 75(90001):10i-15 [viewed 16 July 2014] Available from: doi:10.1136/jnnp.2003.034280

Investigations - for Diagnosis

Fact Explanation
Lumbar puncture - bacterial meningitis [1] A lumbar puncture is necessary for the definitive diagnosis of bacterial meningitis.Analysis of CSF should include Gram stain and cultures, white blood cell (WBC) count and differential, and glucose and protein concentrations. Bacterial meningitis Neutrophils: (x 1 000 000/L) 100-10,000 (but may be normal) Lymphocytes: (x 1 000 000/L) Usually < 100 Protein: (g/L) > 1.0 (but may be normal) Glucose: (CSF:blood ratio) < 0.4 (but may be normal) [1]
Lumbar puncture - viral meningitis [1] Neutrophils: (x 1 000 000/L) Usually <100 Lymphocytes: (x 1 000 000/L) 10-1000 (but may be normal) Protein: (g/L) 0.4-1 (but may be normal) Glucose: (CSF:blood ratio) Usually normal [1]
Lumbar puncture - TB meningitis [1] Neutrophils: (x 1 000 000/L) Usually <100 Lymphocytes: (x 1 000 000/L) 50-1000 (but may be normal) Protein: (g/L) 1-5 (but may be normal) Glucose: (CSF:blood ratio) < 0.3 (but may be normal) [1]
Gram stain [3] Commonest organisms causing bacterial meningitis in children over 2 months of age are: Streptococcus pneumoniae Neisseria meningitidis Haemophilus influenzae type B (in unimmunised children) Streptococcus pneumoniae: gram-positive diplococci or gram positive cocci in short chains Neisseria meningitidis : gram-negative diplococci singly and in pairs Haemophilus influenzae type B: gram-negative coccobacilli [1]
PCR [1] PCR is routinely available for Neisseria meningitidis and Enterovirus. As results are not immediately available, they will only help with decisions concerning discontinuing treatment. Also useful to diagnose TB meningitis [1]
Bacterial antigen [4] CSF bacterial antigen tests have low sensitivity and specificity [1]
Blood glucose levels [1] The CSF glucose levels are compared with the blood glucose levels in order to interpret the results of CSF full report [1]
Full blood count [2] Will show high neutrophil counts in bacterial septicemia [2]
References
  1. BAMBERGER DM. Diagnosis, initial management, and prevention of meningitis. Am Fam Physician [online] 2010 Dec 15, 82(12):1491-8 [viewed 15 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21166369
  2. CHáVEZ-BUENO SUSANA, MCCRACKEN GEORGE H.. Bacterial Meningitis in Children. Pediatric Clinics of North America [online] 2005 June, 52(3):795-810 [viewed 15 July 2014] Available from: doi:10.1016/j.pcl.2005.02.011
  3. TAN LE V, THAI LE H, PHU NH, NGHIA HD, CHUONG LV, SINH DX, PHONG ND, MAI NT, MAN DN, HIEN VM, VINH NT, DAY J, CHAU NV, HIEN TT, FARRAR J, DE JONG MD, THWAITES G, VAN DOORN HR, CHAU TT. Viral Aetiology of Central Nervous System Infections in Adults Admitted to a Tertiary Referral Hospital in Southern Vietnam over 12 Years. PLoS Negl Trop Dis [online] 2014 Aug, 8(8):e3127 [viewed 22 September 2014] Available from: doi:10.1371/journal.pntd.0003127
  4. YADHAV ML K. Study of bacterial meningitis in children below 5 years with comparative evaluation of gram staining, culture and bacterial antigen detection. J Clin Diagn Res [online] 2014 Apr, 8(4):DC04-6 [viewed 22 September 2014] Available from: doi:10.7860/JCDR/2014/6767.4215

Investigations - Fitness for Management

Fact Explanation
Full blood count [1] Will show high neutrophil counts in patients with septicemia [1]
Blood culture [1] Can isolate the organisms giving rise to septicemia and to check the antibiotic sensitivity [1]
References
  1. BAMBERGER DM. Diagnosis, initial management, and prevention of meningitis. Am Fam Physician [online] 2010 Dec 15, 82(12):1491-8 [viewed 15 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21166369

Investigations - Followup

Fact Explanation
CT brain [1] Identify hydrocephalus which is a complication of acute meningitis.It is commonly associated with untreated or partially treated pyogenic meningitis and tuberculous meningitis Identify brain abscess which is a complication of meningitis [1]
Audiology assessment [3] Sensorineural hearing loss or vestibular dysfunction are the most frequent complications. They are most frequent with H. influenzae and S. pneumoniae [2]
Development assessment [2] Should assess the growth and development of the child as neurological damage due to meningitis can give rise to growth and development defects [2]
References
  1. CHáVEZ-BUENO SUSANA, MCCRACKEN GEORGE H.. Bacterial Meningitis in Children. Pediatric Clinics of North America [online] 2005 June, 52(3):795-810 [viewed 15 July 2014] Available from: doi:10.1016/j.pcl.2005.02.011
  2. HOFFMAN O, WEBER RJ. Pathophysiology and Treatment of Bacterial Meningitis Ther Adv Neurol Disord [online] 2009 Nov, 2(6):1-7 [viewed 15 July 2014] Available from: doi:10.1177/1756285609337975
  3. RIDAL M, OUTTASI N, TAYBI Z, BOULOUIZ R, CHAOUKI S, BOUBOU M, MAAROUFI M, BENMANSOUR N, ZAKI Z, OULDIM K, BARAKAT H, HIDA M, TIZNITI S, EL ALAMI MN. [Etiologic profile of severe and profound sensorineural hearing loss in children in the region of north-central Morocco]. Pan Afr Med J [online] 2014:100 [viewed 22 September 2014] Available from: doi:10.11604/pamj.2014.17.100.2331

Investigations - Screening/Staging

Fact Explanation
Lumbar puncture - bacterial meningitis [1] Bacterial meningitis Neutrophils: (x 1 000 000/L) 100-10,000 (but may be normal) Lymphocytes: (x 1 000 000/L) Usually < 100 Protein: (g/L) > 1.0 (but may be normal) Glucose: (CSF:blood ratio) < 0.4 (but may be normal) [1]
Lumbar puncture - viral meningitis [1] Neutrophils: (x 1 000 000/L) Usually <100 Lymphocytes: (x 1 000 000/L) 10-1000 (but may be normal) Protein: (g/L) 0.4-1 (but may be normal) Glucose: (CSF:blood ratio) Usually normal [1]
Lumbar puncture - TB meningitis [1] Neutrophils: (x 1 000 000/L) Usually <100 Lymphocytes: (x 1 000 000/L) 50-1000 (but may be normal) Protein: (g/L) 1-5 (but may be normal) Glucose: (CSF:blood ratio) < 0.3 (but may be normal) [1]
CT brain [2] Identify hydrocephalus which is a complication of acute meningitis.It is commonly associated with untreated or partially treated pyogenic meningitis and tuberculous meningitis Identify brain abscess which is a complication of meningitis [2]
References
  1. BAMBERGER DM. Diagnosis, initial management, and prevention of meningitis. Am Fam Physician [online] 2010 Dec 15, 82(12):1491-8 [viewed 15 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21166369
  2. CHáVEZ-BUENO SUSANA, MCCRACKEN GEORGE H.. Bacterial Meningitis in Children. Pediatric Clinics of North America [online] 2005 June, 52(3):795-810 [viewed 15 July 2014] Available from: doi:10.1016/j.pcl.2005.02.011

Management - General Measures

Fact Explanation
Anti pyretic agents [1] To control fever and those will also help in management of headache [1]
Patient education [1] Proper follow up for complications (eg: audiology assessment ) and assessment of growth and development [1]
Prevention (vaccination) [3] Antibodies directed against the bacterial capsular components of H. influenzae, N. meningitides, and S. pneumoniae play a major role in development of immunity against these organisms. The routine use of conjugated Hib vaccines in children has been associated with a reduction of more than 99% of invasive disease, including meningitis. Heptavalent conjugate pneumococcal vaccine, PCV7, is routinely used for infants in some countries. A quadrivalent meningococcal polysaccharide vaccine against serogroups A, C, Y, and W-135 strains is recommended in some countries for high-risk children older than 2 years [2]
References
  1. CHáVEZ-BUENO SUSANA, MCCRACKEN GEORGE H.. Bacterial Meningitis in Children. Pediatric Clinics of North America [online] 2005 June, 52(3):795-810 [viewed 15 July 2014] Available from: doi:10.1016/j.pcl.2005.02.011
  2. BAMBERGER DM. Diagnosis, initial management, and prevention of meningitis. Am Fam Physician [online] 2010 Dec 15, 82(12):1491-8 [viewed 15 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21166369
  3. BERBERIAN G, PéREZ MG, EPELBAUM C, CEINOS MDEL C, LOPARDO H, ROSANOVA MT. Pneumococcal meningitis: a 12 year experience in a children's hospital prior to the universal immunization with a conjugate vaccine. Arch Argent Pediatr [online] 2014 Aug, 112(4):332-6 [viewed 22 September 2014] Available from: doi:10.1590/S0325-00752014000400007

Management - Specific Treatments

Fact Explanation
Antibiotic [1] Factors to consider when selecting the appropriate antibiotic for treating bacterial meningitis include its activity against the causative pathogen and its ability to penetrate and attain effective bactericidal concentrations in the CSF. N. meningitidis: Benzylpenicillin 60mg/kg/dose (max 3g), iv 4 hourly for 7 days S. pneumoniae (Penicillin sensitive) [3] : Benzylpenicillin 60mg/kg/dose (max 3g), iv 4 hourly for minimum of 10 days Haemophilus influenzae type b: Ceftriaxone 50 mg/kg/dose (2g) iv Empirical regimens are selected to cover the most likely etiologic agents.In neonates, during the first 2 to 3 weeks of life,ampicillin with either an aminoglycoside or cefotaxime is commonly used as initial empirical therapy [1]
Dexamethasone [1] Decreasing inflammation, reducing cerebral edema and increased intracranial pressure, and lessening brain damage.Recommended dexamethasone dosing regimens range from 0.6 to 0.8 mg/kg daily in two or three divided doses for 2 days to 1 mg/kg in four divided doses for 2 to 4 days [1]
Anti pyretic agents [1] To control fever and those will also help in management of headache [1]
Chemo prophylaxis - Haemophilus influenzae type b [2] Chemoprophylaxis of Haemophilus influenzae type b and meningococcal meningitis (Neisseria meningitidis) H. influenzae: Individuals for whom chemoprophylaxis is recommended - All household contacts if household includes other children < 4 years of age who are not fully immunised. All household contacts in households with any infants <12 months of age, regardless of immunisation status All household contacts in households with a child 1 to 5 years of age who is inadequately immunised All room contacts including staff in a child care group if Index Case attends > 18 hours / week and any contacts < 2 years of age who are inadequately immunised. (NB. Inadequately immunised children should be immunised.) Rifampicin 20 mg/kg po as a single daily dose (600 mg) for 4 days Infants < 1 month of age: Rifampicin 10 mg/kg po daily for 4 days Pregnancy / contraindication to Rifampicin: Ceftriaxone 125 mg (<12 y) / 250 mg (>12 y) mg im as a single dose [1]
Chemo prophylaxis - meningococcal meningitis (Neisseria meningitidis) [2] Index Case (if treated only with penicillin) and all intimate, household or daycare contacts who have been exposed to Index Case within 10 days of onset. Any person who gave mouth-to-mouth resuscitation to the Index Case. Rifampicin 10 mg/kg po 12 hourly (600 mg) for 2 days Infants < 1 month of age: Rifampicin 5 mg/kg po 12 hourly for 2 days Pregnancy / contraindication to Rifampicin: Ceftriaxone 125 mg (<12 y) / 250 mg (>12 y) mg im as a single dose or Ciprofloxacin 500 mg po as a single dose [1]
Notification [1] Bacterial meningitis is a notifiable disease [1]
Manegement of viral meningitis [2] Admission is required if bacterial meningitis cannot be excluded or intravenous hydration is required. Ensure adequate analgesia [2]
Manegement of TB meningitis [2] Initial treatment is a combination of isoniazid (5 mg per kg per day in adults, 10 mg per kg per day in children, up to 300 mg); rifampin (10 mg per kg per day in adults, 10 to 20 mg per kg per day in children, up to 600 mg); pyrazinamide (15 to 30 mg per kg per day, up to 2 g); and ethambutol (15 to 25 mg per kg per day). Streptomycin (20 to 40 mg per kg per day, up to 1 g) should be used in lieu of ethambutol in young children. Adding dexamethasone to the treatment regimen improves mortality in patients older than 14 years with tuberculous meningitis [2]
References
  1. CHáVEZ-BUENO SUSANA, MCCRACKEN GEORGE H.. Bacterial Meningitis in Children. Pediatric Clinics of North America [online] 2005 June, 52(3):795-810 [viewed 15 July 2014] Available from: doi:10.1016/j.pcl.2005.02.011
  2. BAMBERGER DM. Diagnosis, initial management, and prevention of meningitis. Am Fam Physician [online] 2010 Dec 15, 82(12):1491-8 [viewed 15 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21166369
  3. ABATE HJ, FALASCHI A, BALBI L, GARCíA B. Nineteen-years of pneumococcal invasive disease surveillance in a children's hospital in Mendoza, Argentina. Arch Argent Pediatr [online] 2014 Aug, 112(4):352-7 [viewed 22 September 2014] Available from: doi:10.1590/S0325-00752014000400011