Department of PediatricsH. Adam Malik General Hospital
Faculty of Medicine North Sumatera UniversityMedan 2012
Serous meningitis
case report
by :Ira Mendrofa 080100005Astinal Eka sari 080100009
Supervisor :
dr. H. Hakimi, Sp.A(K)
INTRODUCTION
2
Incidence of bacterial meningitis infection in Indonesia is not known with certainty. In the U.S. in 1994, found as many as 8.7 cases per 100,000 pediatric patients under 5 years old, and 2.2 cases per 100,000 patients over the age of 5 years. According to data from the Hospital Surabaya Dr.Soetomo year 1986-1992 is estimated incidence of infection of 60-80 cases per year. In Jakarta in 1980, found meningitis infection in 1.9% of inpatients
DEFINITION
EtiologyNew born • Group B streptococci
• Escherichia coli K1 and other gram negative enteric bacilli.
• Listeria monocytogenes• Enterococci
Infants and children • S. pneumonie• Neisseria meningitis • H. Influenza type b
Children older than 5 years • S. pneumonie• N. meningitis
Pathogenesis
causative agent
The invasion of the CNS through the bloodstream
Migrate to the subarachnoid layer
Inflammatory response in piamater, arachnoid, cerebrospinal fluid, and
ventricular
Cont....
Exudate spreads across the cranial nerves and spinal
nerves
neurological damage
Risk FactorsMale gender.Premature babies and low birth weight (LBW)Processes that allow the infection during pregnancy and birth, for example
premature rupture of membranes (PROM), parturition length, and infections in the last trimester of pregnancy.
Low leukocyte bactericidal activity, serum complement deficiency, lowproperdin serum, low concentrations of IgM and IgA in the infant's body.
IGA congenital deficiency, IgG, and IgM in infants.Malignancy in the RES system, leukemia, multiple myeloma, lymphoma,
which led to decrease in immunoglobulin production, making it easier to infection.
Antibiotics, radiation, and immunosuppressants.The state of malnutrition Environmental factors that influence the risk of
meningitis infections are: Densely populated environment Lack of cleanliness of the environmen Low education and low socioeconomic status Transmission at daycare.
Clinical Symptom
Clinical Symptom
Diagnosis
Anamnesis : prodromal symptoms of headache, anorexia, nausea / vomiting, fever subfebris, accompanied by behavioral changes and impairment of consciousness, sub-acute onset, a history of TB or a focus of infection is very supportive
Physical examination : Examination of meningeal stimulation with a stiff neck examination. In patients with meningitis usually have a stiff neck in a positive
Differential Diagnosis
Aseptic meningitisTuberculous meningitisBrain abscessBrain tumorMeningismusLead encephalatomy
Treatment
Age <1 month of : Ampicillin (50-100 mg / kg every 6 hours) + gentamicin (2-5 mg / kg every 8 hours), or cefotaxime (50 mg / kg every 6-8 hours) can be used in patients with suspected gram-negative bacilli.
Age 1-3 months : Ampicillin (50-100 mg / kg every 6 hours + cefotaxim (75 mg / kg every 6-8 hours) or ceftriaxone (50 mg / kg every 12 hours) or vancomycin (15 mg / kg every 6 hours) can be added in patients with suspected meningitis pneumococus (eg gram staining).
Ages 3 months-21 years : cefotaxime (75 mg / kg every 6-8 hours, maximum 2 g per day) or ceftriaxone (50 mg / kg every 12 hours, maximum of 4 g per day) + vancomycin (15 mg / kg every 6 hours, maximum 1 g per day), or rifampicin (10 mg / kg every 12 hours, maximum 600 mg per day) may consider granting dexametason.
Prognosis
Meningitis patients with decreased consciousness and seizures have an increased risk of neurological impairment or death
Poor prognosis occurs in patients with cerebral infarction, cerebral edema, Dissemenated intravascular coagulation, and endotoxic shock
OBJECTIVE
To report a case of Serous Meningitis in a
2 years 11 month old boy
experienced since 1 day before admitted
AnamnesisFever has been found since 2 days agoIs a high fever, fever up and down and
recovered with a febrifugeHeadaches since 2 weeks agoVomiting since 2 weeks ago, with a frequency
of 1-2 times / dayCough with phlegm since 2 weeks ago, a
history of contact with an infected person coughs old grandmother
Rigid body experienced by patients from 1 day ago
Physical Examination
Physical Examination
DiagnosisWorking Diagnosis:
Encephalitis
Differential Diagnosis: Encephalitis Meningitis Meningoencephalitis
ManagementO2 1/2-1 L/iIVFD D5% NaCl 0,9% 32 gtt/i microInj. Cefotaxime 500 mg/12 hour IVInj. Ampicillin 600 mg/6 hour IVParacetamol 3x150 mg Diazepam 5,5 mg if neededDiet SV 1260 kcal with 30 gram protein
•Appear hypodense lesion in the right posterior horn of the lateral periventrikel / lobe occipitalis.•Visible dilatation of the lateral ventricles, third ventricle, IV ventricle.•Sulci, gyri and fissures good Sylvii•Falx middle cerebral•Differentiation of both gray and white Satter•Sisterna magna prominent•Both intact ocular bulbus.•Both ethmoid sinuses. Other paranasalis sinus has not been established
CT-SCAN
Follow Up March 2nd 2012Subjective Objective Assessmen
tPlanning/Treatment
Loss consiusness (+)
Sens: sopocoma (GCS5 – E1V1M5), Temp: 36oCBody weight: 11 kg, Body length: 95 cm, BW/BL: 78,5%Head : Eye : Light reflexes (+↓/+↓), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear and Mouth: within normal limit; Nose: nasal flare (+)Neck : Lymph node enlargement (+) o/t regio colli the left and right, mobile, no tendernessThorax : Symmetrical fusiform , retraction (-), HR: 150 bpm, regular, murmur (-)RR : 30 bpm, regular, ronchi (-/-)Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargementExtremities : Pols : 150 bpm, regular, adequate pressure/volume, CFT<3”, warmGenital : Male, within normal limit
DD :- Encephalitis - Meningitis-Meningoencephalitis
•O2 1/2-1 L/i•IVFD D5% NaCl 0,9% 32 gtt/i micro•Inj. Cefotaxime 500 mg/12 hour IV•Inj. Ampicillin 600 mg/6 hour IV•Paracetamol 3x150 mg •Diazepam 5,5 mg if needed•Diet SV 1260 kcal with 30 gram protein
Follow Up March 3rd 2012Subjective Objective Assessmen
tPlanning/Treatment
Loss consiusness (+)Fever (+)
Sens: sopocoma (GCS5 – E1V1M5), Temp: 38oCBody weight: 11 kg, Body length: 95 cm, Head : Eye : Light reflexes (+↓/+↓), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear: cerumen prop; Mouth: within normal limit; Nose: nasal flareNeck : Lymph node enlargement (+) o/t regio colli the left and right, mobile, no tendernessThorax : Symmetrical fusiform , retraction (-), HR: 120 bpm, regular, murmur (-)RR : 28 bpm, regular, ronchi (-/-)Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargementExtremities : Pols : 120 bpm, regular, adequate pressure/volume, CFT<3”, warmGenital : Male, within normal limit
DD :- Encephalitis - Meningitis-Meningoencephalitis-OMSK Dextra
•O2 1/2-1 L/i•IVFD D5% NaCl 0,9% 32 gtt/i micro•Inj. Cefotaxime 500 mg/12 hour IV•Inj. Ampicillin 600 mg/6 hour IV•Paracetamol 3x150 mg •Diet SV 1260 kcal with 30 gram protein•Diazepam 5,5 mg if needed•Inj. Phenitoin MD 30mg/12 hour IV (in 20 cc NaCl 0,9%, out in 20 minutes)•Suction Reguler
Follow Up March 4th - 5th 2012Subjective Objective Assessmen
tPlanning/Treatment
Loss consiusness (+)Fever (+)
Sens: sopocoma (GCS9 – E4V2M3), Temp: 38oCBody weight: 11 kg, Body length: 95 cm, Head : Eye : Light reflexes (+↓/+↓), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear: cerumen prop; Mouth: within normal limit; Nose: nasal flareNeck : Lymph node enlargement (+) o/t regio colli the left and right, mobile, no tendernessThorax : Symmetrical fusiform , retraction (-), HR: 120 bpm, regular, murmur (-)RR : 36 bpm, regular, ronchi (-/-)Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargementExtremities : Pols : 120 bpm, regular, adequate pressure/volume, CFT<3”, warmGenital : Male, within normal limit
Laboratory Finding :Gastric fluid : Enterobacter aerogenes
DD :- Encephalitis - Meningitis-Meningoencephalitis-OMSK Dextra
•O2 1/2-1 L/i•IVFD D5% NaCl 0,9% 32 gtt/i micro•Inj. Cefotaxime 500 mg/12 hour IV•Inj. Ampicillin 600 mg/6 hour IV•Paracetamol 3x150 mg •Diet SV 1260 kcal with 30 gram protein•Diazepam 5,5 mg if needed•Inj. Phenitoin MD 30mg/12 hour IV (in 20 cc NaCl 0,9%, out in 20 minutes)•Suction Reguler
Follow Up March 6th - 7th 2012Subjective Objective Assessmen
tPlanning/Treatment
Loss consiusness (+)Fever (+)
Sens: sopocoma (GCS9 – E4V2M3), Temp: 37,7oCBody weight: 11 kg, Body length: 95 cm, Head : Eye : Light reflexes (+↓/+↓), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear: cerumen prop; Mouth: within normal limit; Nose: nasal flareNeck : Lymph node enlargement (+) o/t regio colli the left and right, mobile, no tendernessThorax : Symmetrical fusiform , retraction (-), HR: 100 bpm, regular, murmur (-)RR : 32 bpm, regular, ronchi (-/-)Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargementExtremities : Pols : 100 bpm, regular, adequate pressure/volume, CFT<3”, warmGenital : Male, within normal limit
Laboratory Finding :Gastric fluid : Enterobacter aerogenes
DD :- Encephalitis - Meningitis-Meningoencephalitis-OMSK Dextra-Susp. TB paru
•O2 1/2-1 L/i•IVFD D5% NaCl 0,9% 32 gtt/i micro•Inj. Cefotaxime 500 mg/12 hour IV•Inj. Ampicillin 600 mg/6 hour IV•Paracetamol 3x150 mg •Diet SV 1260 kcal with 30 gram protein•Diazepam 5,5 mg if needed•Inj. Phenitoin MD 30mg/12 hour IV (in 20 cc NaCl 0,9%, out in 20 minutes)•Suction Reguler
Follow Up March 8th 2012Subjective Objective Assessment Planning/Treatment
Loss consiusness (+)Fever (+)
Sens: sopocoma (GCS9 – E4V2M3), Temp: 38oCBody weight: 11 kg, Body length: 95 cm, Head : Eye : Light reflexes (+↓/+↓), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear: cerumen prop; Mouth: within normal limit; Nose: nasal flareNeck : Lymph node enlargement (+) o/t regio colli the left and right, mobile, no tendernessThorax : Symmetrical fusiform , retraction (-), HR: 106 bpm, regular, murmur (-)RR : 30 bpm, regular, ronchi (-/-)Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargementExtremities : Pols : 106 bpm, regular, adequate pressure/volume, CFT<3”, warmGenital : Male, within normal limit
Laboratory Finding :Hb/Ht/WBC/PLT9.40% / 28.50% / 12.75 103/mm3 / 536 103/mm3
EletrolitCa/Na/K/Cl/Mg7.8/121/4.1/94/2.10
Serous meningitis + Susp. TB paru
•O2 1/2-1 L/i•IVFD D5% NaCl 0,9% 32 gtt/i micro•Inj. Cefotaxime 500 mg/12 hour IV•Inj. Ampicillin 600 mg/6 hour IV•Paracetamol 3x150 mg •Diet SV 1260 kcal with 30 gram protein•Diazepam 5,5 mg if needed•Inj. Phenitoin MD 30mg/12 hour IV (in 20 cc NaCl 0,9%, out in 20 minutes)•INH 1x500mg (H1)•Rifampicin 1x150mg (H1)•Pyrazinamid 1x300mg (H1)•Etambutol 1x250mg (H1)
Follow Up March 9th - 13th 2012Subjective Objective Assessment Planning/Treatment
convulsions (-), fever (+), spastic (+)
Sens: sopocoma (GCS9 – E4V2M3), Temp: 38oCBody weight: 11 kg, Body length: 95 cm, Head : Eye : Light reflexes (+↓/+↓), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear: cerumen prop; Mouth: within normal limit; Nose: nasal flareNeck : Lymph node enlargement (+) o/t regio colli the left and right, mobile, no tendernessThorax : Symmetrical fusiform , retraction (-), HR: 106 bpm, regular, murmur (-)RR : 30 bpm, regular, ronchi (-/-)Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargementExtremities : Pols : 106 bpm, regular, adequate pressure/volume, CFT<3”, warmGenital : Male, within normal limit
Laboratory Finding :pH/pCO2/pO2/HCO2/O2
7,372/46,7mmHg/78,4mmHg/26.5mmol/L / 93.6%
Serous meningitis + Susp. TB paru
•O2 1/2-1 L/i•IVFD D5% NaCl 0,9% 30 gtt/i micro•Inj. Cefotaxime 500 mg/12 hour IV•Inj. Ampicillin 600 mg/6 hour IV•Paracetamol 3x150 mg •Diet SV 1260 kcal with 30 gram protein•Diazepam 5,5 mg if needed•Inj. Phenitoin MD 30mg/12 hour IV (in 20 cc NaCl 0,9%, out in 20 minutes)•INH 1x500mg (H2-5)•Rifampicin 1x150mg (H2-5)•Pyrazinamid 1x300mg (H2-5)•Etambutol 1x250mg (H2-5)
Follow Up March 14th - 17th 2012Subjective Objective Assessment Planning/Treatment
Lose consiusness (+), fever (+), spastic (+)
Sens: sopocoma (GCS9 – E4V2M3), Temp: 38,3oCBody weight: 11 kg, Body length: 95 cm, Head : Eye : Light reflexes (+↓/+↓), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear/Mouth: within normal limit; Mouth: within normal limit; Nose: nasal flareNeck : Lymph node enlargement (+) o/t regio colli the left and right, mobile, no tendernessThorax : Symmetrical fusiform , retraction (-), HR: 145 bpm, regular, murmur (-)RR : 35 bpm, regular, ronchi (-/-)Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargementExtremities : Pols : 145 bpm, regular, adequate pressure/volume, CFT<3”, warmGenital : Male, within normal limit
Laboratory Finding :Hb/Ht/WBC/PLT7.8% / 24.20% / 9.53 103/mm3 / 224 103/mm3
Serous meningitis + Susp. TB paru
•O2 1/2-1 L/i•IVFD D5% NaCl 0,9% 30 gtt/i micro•Inj. Cefotaxime 500 mg/12 hour IV•Inj. Ampicillin 600 mg/6 hour IV•Paracetamol 3x150 mg •Diet SV 1260 kcal with 30 gram protein•Diazepam 5,5 mg if needed•Inj. Phenitoin MD 30mg/12 hour IV (in 20 cc NaCl 0,9%, out in 20 minutes)•INH 1x500mg (H6-9)•Rifampicin 1x150mg (H6-9)•Pyrazinamid 1x300mg (H6-9)•Etambutol 1x250mg (H6-9)•Blood Transfusion
Follow Up March 18th - 21th 2012Subjective Objective Assessment Planning/Treatment
Lose consiusness (+), fever (+),
Sens: sopocoma (GCS9 – E4V2M3), Temp: 38,2oCBody weight: 11 kg, Body length: 95 cm, Head : Eye : Light reflexes (+↓/+↓), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear/Mouth: within normal limit; Mouth: within normal limit; Nose: nasal flareNeck : Lymph node enlargement (+) o/t regio colli the left and right, mobile, no tendernessThorax : Symmetrical fusiform , retraction (-), HR: 126 bpm, regular, murmur (-)RR : 30 bpm, regular, ronchi (-/-)Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargementExtremities : Pols : 126 bpm, regular, adequate pressure/volume, CFT<3”, warmGenital : Male, within normal limit
Laboratory Finding :Hb/Ht/WBC/PLT9.13% / 27.60% / 9.46 103/mm3 / 432 103/mm3
EletrolitCa/Na/K/Cl/Mg6.9/118/3.8/86
Serous meningitis + OMSK Dextra
•IVFD D5% NaCl 0,9% 30 gtt/i micro•Inj. Meropenem 200 mg/8 hour IV•Inj. Phenitoin MD 30mg/12 hour IV (in 20 cc NaCl 0,9%, out in 20 minutes)•Prednison 3x4 mg•Aspilet 1x80 mg•INH 1x500mg (H10-13)•Rifampicin 1x150mg (H10-13)•Pyrazinamid 1x300mg (H10-13)•Etambutol 1x250mg (H10-13)•Diet SV 1260 kcal with 30 gram protein
Follow Up March 22th - 25th 2012Subjective Objective Assessment Planning/Treatment
Lose consiusness (+), fever (+),
Sens: sopocoma (GCS9 – E4V2M3), Temp: 37,7oCBody weight: 11 kg, Body length: 95 cm, Head : Eye : Light reflexes (+↓/+↓), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear/Mouth: within normal limit; Mouth: within normal limit; Nose: nasal flareNeck : Lymph node enlargement (+) o/t regio colli the left and right, mobile, no tendernessThorax : Symmetrical fusiform , retraction (-), HR: 108 bpm, regular, murmur (-)RR : 34 bpm, regular, ronchi (-/-)Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargementExtremities : Pols : 108 bpm, regular, adequate pressure/volume, CFT<3”, warmPhysiological reflex : APR/KPR : +↑/+↑Pathological reflex : Babinsky (+/+), Oppenheim (+/+), Chaddock (+/+), Gordon (+/+)Meningeal Refleks : +Laboratory Finding :Hb/Ht/WBC/PLT10.9% / 33.20% / 11.62 103/mm3 / 91 103/mm3
Serous meningitis + OMSK Dextra
•O2 1/2-1 L/i•IVFD D5% NaCl 0,9% 30 gtt/i micro•Inj. Meropenem 200 mg/8 hour IV•Phenytoin 2x30 mg•Prednison 3x4 mg •Aspilet 1x80 mg•INH 1x500mg (H14-17)•Rifampicin 1x150mg (H14-17)•Pyrazinamid 1x300mg (H14-17)•Etambutol 1x200mg (H14-17)•Diet SV 1450 kcal with 20 gram protein → 225cc/6hour/NGT
Follow Up March 26th - 29th 2012Subjective Objective Assessment Planning/Treatment
Lose consiusness (+), fever (-),
Sens: sopocoma (GCS10 – E4V2M4), Temp: 36,8oCBody weight: 11 kg, Body length: 95 cm, Head : Eye : Light reflexes (+↓/+↓), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear/Mouth: within normal limit; Mouth: within normal limit; Nose: nasal flareNeck : Lymph node enlargement (+) o/t regio colli the left and right, mobile, no tendernessThorax : Symmetrical fusiform , retraction (-), HR: 108 bpm, regular, murmur (-)RR : 34 bpm, regular, ronchi (-/-)Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargementExtremities : Pols : 108 bpm, regular, adequate pressure/volume, CFT<3”, warm
Serous meningitis + OMSK Dextra
•O2 1/2-1 L/i•IVFD D5% NaCl 0,9% 30 gtt/i micro•Inj. Meropenem 200 mg/8 hour IV•Phenytoin 2x30 mg•Prednison 3x4 mg •Aspilet 1x80 mg•INH 1x500mg (H18-21)•Rifampicin 1x150mg (H18-21)•Pyrazinamid 1x300mg (H18-21)•Etambutol 1x200mg (H18-21)•Diet SV 1450 kcal with 20 gram protein → 225cc/6hour/NGT
Follow Up March 30th - April 3rd
2012Subjective Objective Assessment Planning/Treatment
Fever(+), Spastic (+),
Sens: sopocoma (GCS10 – E4V2M4), Temp: 37,8oCBody weight: 11 kg, Body length: 95 cm, Head : Eye : Light reflexes (+↓/+↓), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear/Mouth: within normal limit; Mouth: within normal limit; Nose: nasal flareNeck : Lymph node enlargement (-), stiff neck (+)Thorax : Symmetrical fusiform , retraction (-), HR: 100 bpm, regular, murmur (-)RR : 29 bpm, regular, ronchi (-/-)Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargementExtremities : Pols : 100 bpm, regular, adequate pressure/volume, CFT<3”, warm
Laboratory Finding :Hb/Ht/WBC/PLT10.8% / 31.50% / 9.76 103/mm3 / 391 103/mm3
Serous meningitis + OMSK Dextra
•O2 1/2-1 L/i•IVFD D5% NaCl 0,9% 30 gtt/i micro•Inj. Meropenem 200 mg/8 hour IV•Phenytoin 2x30 mg•Prednison 3x4 mg •Aspilet 1x80 mg•Asetazolamid 1x65 mg•Lasix 1x15 mg•INH 1x500mg (H22-26)•Rifampicin 1x150mg (H22-26)•Pyrazinamid 1x300mg (H22-26)•Etambutol 1x200mg (H22-26)•Oralit 160cc/time diarrhea•Diet SV 1450 kcal with 26 gram protein •Chest physiotherapy 3x/week
DiscussionTheory Case
Meningitis is characterized by fever, lose consciousness, convulsions, anorexia, myalgia, arthralgia, tachycardia.
This patient was lose consciousness from 1 day before in the hospital, having history fever, fever decreased with fever medicines, headache is felt 2 weeks before in the hospital
Physical examination : Examination of meningeal stimulation with a stiff neck examination. In patients with meningitis usually have a stiff neck in a positive
Physiological reflex : APR/KPR : +↑/+↑; Pathological reflex :Babinsky (+/+), Oppenheim (+/+), Chaddock (+/+), Gordon (+/+); Meningeal Refleks : +
Analysis of cerebrospinal fluid :Color : LiquidProtein : slightly higherGlucose : N/↓
Analysis of cerebrospinal fluid :Color : LiquidProtein : 84 mg/dLGlucose : 20 mg/dL
Treatment : appropriate antibiotic treatment (Ampicillin + cefotaxime) + a combination of anti-tuberculosis
The pateint was given all recommended therapies
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