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Neurology ModuleNeurology ModulePEDIATRICS II

ES, 16 months old, admitted because of convulsionsFive days PTA cough and feverTwo days later grand mal seizures for 10 minutes Birth, neonatal, developmental history unremarkable First attack of febrile seizures at 6 months of age Father and cousins with febrile seizures

Salient Points:Salient Points:

Pertinent Physical Examination Findings:

Febrile, awake, with mild dehydrationCongested pharyngeal wall, no exudates, (+) crackles on both lungs

Neurological Examination Findings:

Essentially normalNo meningeal signs

Salient Points:Salient Points:

Is there a neurologic Is there a neurologic disease?disease?

The description of event appears to be a seizure.

Seizures refer to excessive neuronal

discharge with change in motor activity or behavior.

Is there a neurologic Is there a neurologic disease?disease?

Non-neurologicMetabolic disordersElectrolyte imbalanceHypoglycemiaHypoxiaFeverSystemic infectionsToxinsDrug-related

NeurologicTumorsCNS malformationVascular disordersIdiopathic epilepsy

Causes of seizure:

In this patient, the seizures are ushered in by feverand respiratory infection.

Benign Febrile SeizuresBenign Febrile Seizures should be ruled out.The typical benign FS is characterized by: 1. Grand mal lasting for <15 min 2. Occurring once in the same illness 3. Age incidence: 3 months to 5 years 4. Occurs at temperature 380 C and above 5. Normal neurological examination 6. Family history (+) for FS 7. CNS infection absent

What is the What is the neurologic disease?neurologic disease?

Atypical - May occur more than once in an illness, focal seizure,

more than15 minutes May need investigation to rule out

epilepsyWith focal manifestations

Complex Febrile Complex Febrile SeizureSeizure

Benign febrile seizuresIn the presence of fever, pneumonia and seizure, a CNS infection should be considered.An infant may not show any meningeal signs even in the presence of meningitis.

Diagnostic Diagnostic possibilities:possibilities:

Search for cause of feverNo anticonvulsants neededAntipyretics Education of parentsOral diazepam at onset of febrile

episode (1 mg/kg/24 hrs) for 2-3

days

Management of BFC:Management of BFC:

Not necessary if clear-cut BFC Tests mainly to determine cause of fever and rule out meningitisIf done, CSF examination is normalEEG - Normal and not useful in BFCNeuroimaging - No roleBlood tests / chest X-ray, etc are done to diagnose the cause of fever, not the BFC

Laboratory Tests:Laboratory Tests:

Tests are usually directed towards ruling out meningitis especially in infants where meningeal signs are often lacking.

Do lumbar puncture and CSF examination

Diagnosis:Diagnosis:

While in the hospital, he developed another seizure. Fever persisted. On examination, he was ill-looking, irritable, with some resistance on neck flexion.

Patient E.S.Patient E.S.

CNS Infections

Differential Diagnosis:Differential Diagnosis:Fever with SeizuresFever with Seizures

Forms:MeningitisEncephalitisBrain Abscess

Etiology Viral Bacterial (Acute

Suppurative)TuberculousFungal

CNS InfectionsCNS Infections

Acute Meningitis-Acute Meningitis-Causes:Causes:

Bacterial 0 - 2 months: Grp B and D strep gram-negative

enteric bacilli Listeria 2 mo – 2 yrs: S. pneumoniae N. meningitis H. influenza B Older children: S. pneumoniae N. meningitides

Acute Route of Infection

HematogenousContiguous focus of infectionCSF leak (trauma, congenital defect)Neurosurgical procedure

Bacterial MeningitisBacterial Meningitis

Signs and Signs and symptomssymptoms

NeonatesNeonates Older infants and childrenOlder infants and children

NonspecificNonspecific Fever or hypothermia, abnormally sleepy or lethargic, disinterest in feeding, poor feeding, cyanosis, grunting, apneic episodes, vomiting

Fever, anorexia, confusion, irritability, photophobia, nausea, vomiting, headache, seizure

Meningeal Meningeal inflammationinflammation

+/- Neck rigidity Neck rigidity, Kernig and Brudzinski sign

Increased Increased intracranial intracranial pressurepressure

Bulging fontanel, diastasis of sutures, convulsions, opisthotonus

Headache, bulging fontanel, diastasis of sutures in infants, papilledema, mental confusion, altered state of consciousness

Focal Focal neurologic neurologic signssigns

Hemiparesis, ptosis, facial nerve palsy

Hemiparesis, ptosis, deafness, facial nerve palsy, optic neuritis

Clinical Features:Clinical Features:

1.Lumbar PunctureContraindications

Skin infection over siteIncreased ICP with papilledemaFocal neurologic deficitsSuspected mass lesionHematologic problemsSignificant cardiopulmonary compromise and shock

Laboratory Diagnosis:Laboratory Diagnosis:

CSF Findings

Pressure (mm H20)

Cell Count (white blood cells/mm3)

Glucose (mg/100 ml)

Protein (mg/100 ml)

Normal values 90-180 0-5 lymphocytes 50-75 (at least 50% of simultaneous serum glucose)

15-40

Bacterial meningitis 200-300 100-5,000; neutrophils usually >80%

Reduced, < 40 100-1,000

Tuberculous meningitis 180-300 Usually < 500 lymphocytes

Reduced, < 40 100-200, but up to 1,000 if CSF block is present

Cryptococcal meningitis 180-300 10-200 lymphocytes Reduced, <40 50-200

Viral meningitis 90-200 10-300 lymphocytes; may be >1,000 in echoviral and mumps meningitis and in lymphocytic choriomeningitis; early echoviral meningitis may show up to 80% neutrophilic predominance

Normal; occasionally slightly reduced in mumps meningitis and LCM

50-100

Viral encephalitis 180-300 0-500 lymphocytes Normal 50-100

Contrast enhanced CT image of a 3-month-old baby brain

show brain edema and subdural empyema

Subdural effusion, cerebritis and developing abscess

formation in a patient with bacterial meningitis

2. Neuroimaging

Laboratory Diagnosis:Laboratory Diagnosis:

CSF Analysis: Clear, colorless fluid

OP 130 WBC = 320/cumm, all neutrophils RBC = 0 Protein = 90

Sugar = 40% of blood sugarGram stain = (+) gram-negative coccobacilli

Culture (-)

CBC: Hgb 11, RBC 4.3, WBC 12,000 with lymphocytic

predominance

Patient’s laboratory Patient’s laboratory results:results:

Acute Bacterial Meningitis (Hemophilus)Pneumonia

Diagnosis:Diagnosis:

Bacterial meningitis is a medical emergency; delay in treatment may lead to increased sequelae or deathDrug of choice must be bactericidal for pathogen involvedMust achieve adequate levels in the CSFInitial regimen should cover most likely pathogens for specific age groups, and reach bactericidal levels in the CSF

Treatment:Treatment:

Knowledge of local susceptibility patterns is essential Antibiotics should be guided by the bacteriologic resultsDuration of treatment: 10 -14 days

Treatment:Treatment:

Patient group

Likely etiology

Antimicrobial choicePrimary Alternative

0-2 mos E. coliGram (-) bacilliS. pneumoniae

Ampicillin or Penicillin + Aminoglycoside

Ampicillin + Cefotaxime or Ceftriaxone

2mos – 5 yrs

H. influenzaeS. pneumoniaeN. meningitidis

Ampicillin or Chloramphenicol

Cefotaxime or Ceftriaxone

>5 yrs S. pneumoniaeN. meningitidis

Penicillin G Chloramphenicol

Task Force on Meningitis

Philippine Society of Microbiology and Infectious Diseases

Empiric Therapy for Empiric Therapy for Bacterial Meningitis:Bacterial Meningitis:

Subacute to chronicStaging of symptoms

Stage I: early nonspecificStage II: altered consciousness, minor focal

signs, meningism, abnormal involuntary movements

Stage III: stupor or coma, seizures, severe neurologic deficits and/or abnormal movements

Prognosis is related directly to the clinical stage of diagnosis

Tuberculous Tuberculous MeningitisMeningitis

CSF Findings

Pressure (mm H20)

Cell Count (white blood cells/mm3)

Glucose (mg/100 ml)

Protein (mg/100 ml)

Normal values 90-180 0-5 lymphocytes 50-75 (at least 50% of simultaneous serum glucose)

15-40

Bacterial meningitis 200-300 100-5,000; neutrophils usually >80%

Reduced, < 40 100-1,000

Tuberculous meningitis 180-300 Usually < 500 lymphocytes

Reduced, < 40 100-200, but up to 1,000 if CSF block is present

Cryptococcal meningitis

180-300 10-200 lymphocytes Reduced, <40 50-200

Viral meningitis 90-200 10-300 lymphocytes; may be >1,000 in echoviral and mumps meningitis and in lymphocytic choriomeningitis; early echoviral meningitis may show up to 80% neutrophilic predominance

Normal; occasionally slightly reduced in mumps meningitis and LCM

50-100

Viral encephalitis 180-300 0-500 lymphocytes Normal 50-100

Visual impairmentStrabismus Hearing loss or impairment Locomotion/neuromotor deficitsEpilepsyMental or psychomotor retardationHydrocephalusMicrocephaly

Late Neurologic Late Neurologic Sequelae:Sequelae:

HydrocephaluHydrocephaluss

Cerebral Atrophy

Microcephaly

Majority due to enterovirusesHigher incidence during summer to fall monthsOther viruses associated with meningitis in children:

HSV types 1 and 2MumpsAdenovirusesPoliovirusesLymphocytic choriomeningitis virusEpstein-Barr virusHIVSt. Louis encephalitis virusTick-borne encephalitis virus

Viral MeningitisViral Meningitis

CSF Findings

Pressure (mm H20)

Cell Count (white blood cells/mm3)

Glucose (mg/100 ml)

Protein (mg/100 ml)

Normal values 90-180 0-5 lymphocytes 50-75 (at least 50% of simultaneous serum glucose)

15-40

Bacterial meningitis 200-300 100-5,000; neutrophils usually >80%

Reduced, < 40 100-1,000

Tuberculous meningitis 180-300 Usually < 500 lymphocytes

Reduced, < 40 100-200, but up to 1,000 if CSF block is present

Cryptococcal meningitis 180-300 10-200 lymphocytes Reduced, <40 50-200

Viral meningitis 90-200 10-300 lymphocytes; may be >1,000 in echoviral and mumps meningitis and in lymphocytic choriomeningitis; early echoviral meningitis may show up to 80% neutrophilic predominance

Normal; occasionally slightly reduced in mumps meningitis and LCM

50-100

Viral encephalitis 180-300 0-500 lymphocytes Normal 50-100

Management:1. No specific antiviral therapy

necessary2. Treatment is supportive with IV

fluids3. Outcome is usually a full recovery

Viral MeningitisViral Meningitis

Distinguished from viral meningitis by the extent and severity of cerebral dysfunctionTwo clinical presentations:

Fever and malaise without meningeal signsWith meningeal signs plus cerebral dysfunction (altered consciousness, personality changes, seizures, and paresis) and cranial nerve abnormalities

Viral EncephalitisViral Encephalitis

Causes:Epidemic

ArbovirusPoliovirusEchovirusCoxsakie virus

SporadicHerpes simplexVaricella-ZosterMumps

Viral EncephalitisViral Encephalitis

CSF Findings

Pressure (mm H20)

Cell Count (white blood cells/mm3)

Glucose (mg/100 ml)

Protein (mg/100 ml)

Normal values 90-180 0-5 lymphocytes 50-75 (at least 50% of simultaneous serum glucose)

15-40

Bacterial meningitis 200-300 100-5,000; neutrophils usually >80%

Reduced, < 40 100-1,000

Tuberculous meningitis 180-300 Usually < 500 lymphocytes

Reduced, < 40 100-200, but up to 1,000 if CSF block is present

Cryptococcal meningitis 180-300 10-200 lymphocytes Reduced, <40 50-200

Viral meningitis 90-200 10-300 lymphocytes; may be >1,000 in echoviral and mumps meningitis and in lymphocytic choriomeningitis; early echoviral meningitis may show up to 80% neutrophilic predominance

Normal; occasionally slightly reduced in mumps meningitis and LCM

50-100

Viral encephalitis 180-300 0-500 lymphocytes Normal 50-100

Treatment:Acyclovir 10 mg/kg IV infusion every 8

hours for at least 10 daysSupportive therapy

Prognosis:Mortality rate varies with etiologyPermanent cerebral sequelae more

likely in infants

Viral EncephalitisViral Encephalitis

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