Peds Meningitis sudy guide with complete solutions

Pathophysiology of Meningitis Hematogenous spread blood to subarachnoid space Mechanical disruption Fracture of the base of the skull Direct extension from; ear mastoid air cells S/s of meningitis Fever A ...

Pathophysiology of Meningitis Hematogenous spread blood to subarachnoid space Mechanical disruption Fracture of the base of the skull Direct extension from; ear mastoid air cells S/s of meningitis Fever Altered consciousness Irritability Photophobia Vomiting Poor appetite Seizure Children with meningeal irritation often resist walking or being carried Bulging fontanel Stiff neck/nuchal rigidity Meningismus (stiff neck + Brudzinski + Kernig) Absence does not rule out intracranial infection 00:02 01:26 Physical Exam of Meningitis fever, tachypneic/irregular patterns, tachycardic/bradycardic Integumentary rashes HEENT Funduscopic exam - Papilledema Neuro 2-12 Cerebellar Meningeal specific testing cushing's triad Increased systolic BP, widened pulse pressure; bradycardia; irregular respirations- this is a late sign of ICP Purpura Fulminans What disease does N. Meningitis cause Classic Triad for Meningitis Fever, Headache and Stiff neck With Fever what will have a corresponding rise Heart rate usually 10 bpm for every degree of fever. Age related confounding results Young and Old have underdeveloped or weakened immune system may not present in classically way with a fever. Nuchal Rigidity Extreme stiffness of neck from inflamed meningeal membranes, meningitis. - looks like they really don't want to move the neck Brudzinski's sign Sign of meningitis; positive when a patient's legs lift involuntarily when lifting a patient's head Kernig sign inability to fully extend the knees with hips flexed. Key Difference btw Meningitis and Encephalitis Encephalitis will have altered mental status. DDx for Meningitis -Encephalitis -Influenza -*Viral Syndrome- most lawsuits missed dx? -Strep Pharyngitis -Subarachnoid Hemorrhage- can develop a low grade temp, and stiff neck from the blood coagulation. -Epidural Abscess -Brain Abscess -Meningococcemia- college dorms and military barracks Diagnostic testing for Meningitis Complete Blood Count Serum Electrolytes Blood Glucose Renal Functions Blood Culture UA/Urine culture LP: Cytology WBC Protein Glucose glucose will decreased in the CSF fluid RBC Gram Stain Cultures Viral Bacterial Fungal other Differentials for different types of meningeal infections CSF fluid analysis Haemophilus INfluenza gram stain Gram Neg CoccoBacill Treatment of Meningitis neonates Ampicillin (covers Listeria), 100 mg/kg AND Cephalosporin active against gram negative bacilli may be used instead of an aminoglycoside because; Much less toxic No serum drug levels to follow Not excreted in bile therefor not inhibit bowel flora Cefotaxime, 50 mg/kg or Aminoglycoside Gentamicin, 2.5 mg/kg (May cause heating loss-Ototoxicity) Bacterial ABX with Infants and children Ampicillin (covers Listeria), 100 mg/kg AND Cephalosporin active against gram negative bacilli may be used instead of an aminoglycoside because; Much less toxic No serum drug levels to follow Not excreted in bile therefor not inhibit bowel flora Cefotaxime, 50 mg/kg or Aminoglycoside Gentamicin, 2.5 mg/kg (May cause heating loss-Ototoxicity) Pneumococcal infection? Meningitis Penicillin and cephalosporin resistance is possible Vancomycin is the only antibiotic to which all strains of pneumococci are susceptible Add Vancomycin, 15 mg/kg Additional Corticosteroid tx with meningitis Dexamethasone, 0.15 mg/kg IV administered prior to or along with the initial antibiotics has been shown to decrease ICP, cerebral edema & CSF lactate. Treatment durations Neonates: 14 - 21 days Gram negative meningitis: 21 days Pneumococcal, H flu: 10 days Meningococcal: 7 days Viral Meningitis Summer, fall Severe headache Vomiting Fever Stiff neck CSF results; pleocytosis (monos), Normal protein, Normal glucose Enteroviruses: most common - Oral fecal rout Less common- Mumps, HIV and HSV-2 tx: Antiviral Rx-IV acyclovir No antibiotics Analgesia Fever control Often feel better after LP Meningitis Inflammation of the leptomeninges caused by infectious or noninfectious processes. Infectious Causes = Bacterial, Viral, Tuberculous and Fungal Acute Bacterial; Aseptic; and Subacute to chronic Most common noninfectious causes are: Subarachnoid hemorrhage, Cancer, and Sarcoidosis Know Bacterial Presentation in different age groups What is the most common age of patient presenting with bacterial meningitis 75% are under 15 years of age. Neisseria meningitidis ( Gram negative Cocci) Adult bacterial meningitis commonly know as meningococcal meningitis. Humans are the natual host and bacteria remain int he upper respiratory tract of asymptomatic carriers. Droplet infection.Bacteria reaches the meninges via blood. Outbreaks are occur in area where large populations live together such as military barracks and in college dorms.Diagnosis: Gram negative cocci seen in CSF. Prevention: MENINGOCOCCAL VACCINE currently given to military personnel and dorm college students. Haemophilus influenzae an upper respiratory infection that does not cause influenza, but does affect the epiglottis. worst case scenario, it can cause an inflammation of the covering of the brain. type B causes most infections, a HIB vaccine is now available to be given at 3 mo of age. children are most succeptible to this virus when they are between 6 months and 5 years old. Pneumococcal meningitis Streptococcus pneumoniae most common cause of meningitis in adults, and the second most common cause of meningitis in children older than 6 years old, G(+)diplococci or in chains.Alpha Hemolytic. Optochin sensitive. Increased pressure in skull and spinal cord from swelling. Vaccine: Pneumovax (Adults) and Prevnar (Children) becoming increasing resistant to penicillin Frequency of bacterial meningitis **Pneumococal = 40-55% Meningococcal = 3-13% Listerial = 10-13% H. influenzae = 4-8% Pathology of Meningitis Bacteria that cause most of the community-acquired meningitis transiently colonize the oro and nasopharynx of healthy individuals Can occur after bacteremia from an upper respiratory site Especially with N. meningitidis or H. influenzae) Can occur from pneumonia or a sinus infection Gram-negative bacterial meningitis occurs mainly in severely debilitated persons or those with damaged or breached meninges Head trauma, neurosurgery, tumor Clinical presentation: Meningitis Bacterial: fever, confusion, headache, irritabilit, lethargy, and stiff neck 3 modes of onset: -fulminant (high mortality) -meningeal symptoms- 1-7 days -May superimpose itself *not always with stiff neck *will have petechial or pupuric rash *may have seizures *may have focal neurological findings Definitive test for Dx: Meningitis evaluation of cerebrospinal fluid by lumbar puncture -Have a low threshold for performing procedure in right clinical setting -*For those patients with a high clinical suspicion, a lumbar puncture should be performed as soon as possible In a situation where a patient is critical, empiric antibiotics should be administered as soon as possible. Normal Lumbar Puncture Ranges Opening Press: 5-18 cm H2O in lateral neutral position; Color: clear and colorless Total Protein: 15-45 mg/100 ml Glucose: 50-80 mg/100 ml or 2/3 serum glucose WBC: 0-5 per HPF RBC: 0 per HPF Bacterial Antigens: Negative Gram Stain: No WBCs or Organisms seen Management of Increased Intracranial Pressure Recognition: worsening mental status, papilledema, bulging fontanelle, widening of cranial sutures Treatment Elevate head of bed to 300 Controlled ventilation to keep end tidal PCO2 between 30 and 35 mmHg Mannitol, 0.25 - 1 g/kg Furosemide, 1 mg/kg Aseptic Meningitis meningitis that is associated with: Negative gram stain and negative bacterial cultures Viral infections are the most frequent cause of aseptic meningitis -enteroviruses -HSV -Leptospira Medication have also be implicated - NSAIDs (Ibuprofen), Antimicrobials (Cipro/Bactrim), Ranitidine S/S Similar to that of bacterial meningitis with fever, headache, neck stiffness With development of neurologic changes or findings the diagnosis shifts to encephalitis or meningoencephalitis Diagnosis Like bacterial meningitis, mainstay of diagnosis is lumbar puncture Subacute / Chronic Meningitis - A clinical syndrome that develops over a course of several weeks, clinically takes the form of meningitis or meningoencephalitis and is associated with a predominantly mononuclear pleocytosis in the CSF. -usually immunosuppressed: HIV, Mycobacterium tub, Cryptococcus neoformans Dx: Clinical history India ink preparation = Cryptococcus VDRL = Syphillis Borrelia burgdorferi = Lyme disease Histoplasma antigen Acute Bacterial Meningitis Tx: 1. Ceftriaxone 2gm IVPB and Vancomycin 1gm IVPB -If there is a severe-PCN allergy than use Meropenem instead of Ceftriaxone -Cefotaxime is the preferred alternate to Ceftriaxone for neonates under 4 weeks of age (Kernicterus) 2. Dexamethasone 10mg IVP should be given with the first dose of antibiotics to help decrease morbidity and mortality. 3.Ampicillin is good for Listeria monocytogenes infections as well as Group B streptococcus and Enterococcus 4. Ceftazidime is good for suspected Pseudomonas infections Aseptic Meningitis typically a self-limited disease which does not require a specific treatment or medication Unless Herpes simplex virus is implicated with primary genital herpes infection. Then Acyclovir should be used Subacute and Chronic Meningitis: more than 50-100 cells/mcL than an infectious disease is likely and antimicrobial therapy should be started If the pleocytosis is low-grade (less than 50 cells/mcL) than a non-infectious cause is likely and care is usually supportive or symptomatic Encephalitis Acute inflammatory process of the brain tissue. Causes include viral infections, vector -borne viral infections, and fungal infections. Etiology of Encephalitis Arthropod-borne viruses peak in summer and fall (West Nile, LaCrosse) Western equine peaks in August and St. Louis encephalitis after that Tick-borne infections (Rocky Mountain spotted fever) in early summer Enterovirus infections in late summer and fall Mumps virus in winter and spring Herpes simplex virus is the most frequent, treatable and devastating cause of sporadic, severe focal encephalitis. - Usually 1-7 days of prodrome. Implicated in 10% of all encephalitis cases in North America Dx of Encephalitis Lumbar puncture will help establish definitive diagnosis Order a HSV DNA by Polymerase chain reaction TX of Encephalitis Timely treatment with IV Acyclovir is essential Very little downside to starting treatment versus side effects Untreated - mortality is approximately 70%