Narong Auervitchayapat,MD., Assist Prof Department of ...
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Narong Narong AuervitchayapatAuervitchayapat,,MDMD.,., Assist Assist ProfProfDepartment of PediatricsDepartment of Pediatrics
Faculty of MedicineFaculty of MedicineKKUKKU
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1. Bacterial meningitis
2. Tuberculous meningitis
3. Aseptic meningitis
4. Viral encephalitis
5. Brain abscess
5 common diseases:-
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Definitions* Meningitis: Inflammation of meninges
Abnormal number of WBCs in CSF* Bacterial meningitis: Meningitis and evidence of a
bacterial pathogen in CSF* Aseptic meningitis: Meningitis in the absence of
bacterial pathogen in the CSF by usual laboratory techniques
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Definitions
* Encephalitis: Inflammation of the brain
* Meningoencephalitis: Inflammation of the brain accompanied by meningitis
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Bacterial Meningitis
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Introduction
1. Common
2. High morbidity & mortality rates
3. Emergency condition
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EpidemiologyThe causative organism depends on
* Age
* Place
* Underlying disease
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Sirinavin S et al 420 cases of bacterial meningitis in 14 hospitalsAge 0 mo 1-6 mo 7-11 mo 1-5 yr 6-15 yr
PathogensGram negative bacilli 37 8 0 0 0
Strep group B (GBS) 13 8 0 0 0
Salmonella 3 35 6 0 0
H.influenzae 2 87 47 26 0
S.pneumoniae 2 43 19 28 16
N.meningitidis 0 9 2 2 5
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Underlying diseasesUnderlying diseasesSplenectomy & asplenia: S.pneumoniae, H.influenzae type b
,gram negative enteric
Hemoglobinopathies: S.pneumoniae, H.influenzae type b
C5-8 deficiency: Meningococcal infection, Salmonella
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Underlying diseasesUnderlying diseasesCSF leak eg. middle ear defect ; base of skull fracture:
pneumococcal meningitis
Dermal sinus, meningomyelocele: staphylococci,
gram- negative enteric
CSF shunt: staphylococci ( esp. coagulase -ve)
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Pathology
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Clinical manifestations* Fever
* Headache
* Meningeal signs
+
+
Acute onset
Signs of increased intracranial pressure
- Stiffneck
- Kernig’s sign
- Brudzinski’s sign
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Clinical manifestations- Consciousness
- Seizures
- Nausea, vomiting
- Diarrhea
- Poor feeding
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Diagnosis
Lumbar puncture
Beware herniation in:-
1. Papilledema
2. Tensed anterior fontanel
3. Localizing signs
Fever + headache + meningeal signs
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CSF findings- Pressure: Normal, > 300 mmH2O- Appearance: Turbid, xanthochromia- WBCs: 100-50,000, PMN 70-100%- Protein: > 40 mg/dl, most > 150mg/dl
- Sugar: < 50% of blood sugar, < 40 mg/dl- Gram stain, culture/sensitivity
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Bacterial Antigen:
1. Latex agglutination
2. CIE ( Counter-Immuno-Electrophoresis )
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TreatmentSpecific treatment * Emergency antibiotics *
Empiric antibiotics
- Newborn: Ampicillin + gentamicinAmpicillin + cefotaxime
- Beyond the neonatal period:Ampicillin + chloramphenicolCefotaxime or ceftriaxone + vancomycin?
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Dosage of antibiotics for bacterial meningitisIncreased from systemic dosage
Penicillin group: Increase 3-4 folds
Cephalosporins: Increase 2 folds
Chloramphenicol: As same as systemic dosage
Amonoglycosides: As same as systemic dosage
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Duration of antibioticsH.Influenzae
S.pneumoniae
Group B streptococci
Gram negative enteric bacilli
N.meningitidis
Salmonella
10-14 days10-14 days14-21 days
21 days7-10 days42 days
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*Adjunctive Dexamethasone Therapy*
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The use of corticosteroidsThe use of corticosteroids
• Antibiotics and pediatric intensive care:
MR = 5% but 20-30%: long-term sequalae esp. hearing
impairment
• Dexamethasone substantially reduced levels of
cytokines IL-1, TNF & PGE2 within CSF of infected
animal: reduction of ICP, brain edema & CSF lactate:
decreased MR and sequalae in animals.
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Bacterial meningitis
Rapid lysis of bacteria:-Release of endotoxin (H.influenzae)Lipoteichoic acid (S.pneumoniae)
Release of cytokines:*Interleukin 1β*Tumor necrotic factor-α*Platelet activating factorProstaglandin E-2Phospholipase A2
Neutrophil recruitment
Neutrophil induced inflammation
Cerebral edemaVasculitis
Decreased cerebral perfusion
DeadSequelae
Antibiotics
Dexamethasone
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OdioOdio C et al N C et al N EngEng J J MedMed 19911991• 101 children, 6 weeks- 13 years• 79 H. influenzae, 8 S. pneumoniae, 2 N. meningitidis• Cefotaxime + dexa vs Cefotaxime + placebo• Dexamethasone 0.15 mg/kg every 6 hr for 4 days• Given 15 min prior to cefotaxime• rate of neurologic and audiologic sequalae in children
received dexa was significantly lower ( 14%vs 38%)
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WaldWald EE,, Pediatrics Pediatrics 19951995• 143 children, 8wk - 12 yr• 83 H. influenzae, 33 S. pneumoniae, 24 N. meningitidis• Ceftriaxone + dexa vs Ceftriaxone + placebo• Dexamethasone 0.15 mg/kg every 6 hr for 4 days• No significant difference in rate of neurologic and audiologic
sequalae• Bilateral deafness was significantly lower in H. influenzae
meningitis receiveing dexa( 0%) vs placebo (7%)
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Bonadio WA, Pediatrics 1996
“Rate of neurologic and audiologic sequalae in children received dexa was significantly lower”
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Supportive treatment*Critical peroid: first 3-4 days*
Monitor: Vital signs
Neurological signs
Intake-output
Electrolytes
Body weight
Urine specific gravity
SIADH
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Bacterial meningitis with subdural effusion
Brudzinski’s sign positive
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GBS meningitis
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Meningococcemia
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Aseptic meningitisEtiology
- Viral: Enteroviruses
- Postviral: Mumps, measles, chickenpox
- Bacterial: Partially treated bacterial meningitis
- Rickettsiae: Scrub typhus
- Spirochetes: Leptospirosis
- Mycoplasma: M.pneumoniae
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Clinical manifestations
“ As same as that of bacterial meningitis”
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CSF findings
“ As same as that of viral encephalitis”
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Treatments- Viral & postviral: Supportive treatments
- Bacterial: Partially treated bacterial meningitis
- Continue the most appropriated antibiotics
- Rickettsiae: Scrub typhus - doxycycline, chloramphenicol
- Spirochetes: Leptospirosis - doxycycline
- Mycoplasma: M.pneumoniae - macrolides eg. erythromycin
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Tuberculous MeningitisIntroduction
- Common in tropical countries
- HIV
- The result of treatment depended on
the stage of disease
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Clinical manifestationsChronic meningitis: 3 stages
1. Prodromal stage: nonspecific symptoms (low grade
fever, anorexia, nausea, vomiting )2. Transitional stage: prominent neurological symptoms
meningeal signs, CN palsy, fever3. Terminal stage: coma, fixed and dilated pupil,
decreased RR, PR, dead
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Diagnosis
1. History & physical examination
2. Family history
3. CSF findings
4. Other sources of TB (pulmonary, lymph node, miliary TB)
5. Tuberculin test
6. CT brain, ELISA, PCR
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CSF findings of TB meningitisCSF findings of TB meningitis
• Pressure: high
• Appearance: Turbid, xanthochromia
• WBCs: 50-500 cells/mm3 , lymphocytes predominate
( >50% )
• Protein: 200-500 mg/dl, may be 1-2 gram or slightly increased
• Sugar: < 50% of blood sugar, or < 40 mg/dl
• AFB stain
• Culture
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TreatmentGood clinical respond depended on:-
1. Early diagnosis & early treatment
2. Good medications & adequate duration
INH + rifampicin + pyrazinamide + streptomycin for 2 months
INH + rifampicin for 10 months
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3. Reduction of the increased intracranial pressure
Keep CSF pressure < 200 mmH2O
3.1 Lumbar puncture
3.2 Dexamethasone
3.3 Acetazolamide
3.4 Ventriculostomy or ventriculoperitoneal shunt
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4. Good supportive treatments
4.1 Nutrition
4.2 Aspiration
4.3 Bed sore
4.4 Fever
4.5 Seizures
4.6 rehabilitation
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EncephalitisEtiology:-
- Viral: Japanese B encephalitis - 50%
CMV, HSV, EBV, Poliovirus, rabies
- Postviral: Measles, mumps, chickenpox, rubella
- Postvaccinal: Rabies vaccine
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Japanese B encephalitis
- Most common cause of encephalitis in the world
- Common in southeast Asia esp. Thailand
- Northeast Thailand is 2nd common
- Severe, morbidity and mortality rates are high
- No medication for treatment
- Outbreak
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Global distribution of major Global distribution of major neurotropicneurotropic flavivirusesflaviviruses
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Clinical manifestations1. Prodromal stage (2-3 days): Fever, headache, malaise, nausea,
vomiting 2. Acute encephalitic stage (3-4 days): Fever, conscious change,
seizures, neurosigns, meningeal signs (meningoencephalitis)3. Subacute stage (7-10 days): Neurosigns improved, complications
eg. Pneumonia, UTI4. Late stage and sequalae (4-7 weeks): Stable or improved
neurosigns, sequale eg. spastic paralysis, atrophy
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Diagnosis
Fever + conscious change + seizures
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CSF findings
- Pressure: 300-400 mmH2O
- WBCs: 10-1,000 cells/mm3 , lymphocytes predominate
- Protein: normal or slightly increased (50-80 mg/dl)
- Sugar: normal
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Treatment
No specific treatmentSupportive treatment directed to brain edema
1. Airway and breathing
2. Fever
3. Seizures
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Treatment
4. Brain edema: 20%manitol 0.5-1 gm/kg/dose
Steroids - no benefit
5. Complications: Pneumonia, bed sore, SIADH, UTI
6. Nutrition
7. Rehabilitation
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Brain abscess- Common in Thailand
- High morbidity and mortality rates
- Often delayed diagnosis and treatment
- Usually recur
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Clinical manifestations
3 Main groups of signs and symptoms:-1. Infection: Fever, anorexia, fatigue, increased WBCs and
ESR2. Increased ICP: Most common:- headache, vomiting,
diplopia, papilledema3. Focal neurodeficit: Depend on location of the abscess,
silent area - no neurodeficit
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Diagnosis
Fever + headache + neurodeficit
Underlying disease
CT or MRI brain
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Treatment1. Antibiotics
-Empiric: cefotaxime + metronidazole
-Depended on underlying diseases:-
COM: aminoglycosides or 3rd gen cephalosporins
Compound fracture: cloxacillin
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Treatment2. Drainage
All patients except2.1 Small abscess diameter < 2 cm2.2 Multiple abscesses2.3 Abscess in vital area
3. Supportive treatment4. Treatment of the underlying disease
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