meningitis%20-%20acute,%20bacterial%20(pediatric)
MENINGITIS - ACUTE, BACTERIAL (PEDIATRIC)
Acute meningitis is the bacterial infection of the subarachnoid space and cerebrospinal fluid that may cause local and systemic inflammatory response.
Common symptoms in newborns are lethargy, fever, seizures, irritability and bulging fontanelle. While in children the common symptoms are fever, nuchal rigidity (incidence increases with age) and altered consciousness.
Meningeal signs are stiff neck, Kernig's or Brudzinski's signs) are not reliably present in infants <6 months of age.
It may also observe the presence of persistent vomiting, changes in behavior or other psychological/neurologic signs.

Assessment

  • Perform a complete neurologic exam, including a mental status exam if applicable
  • May decide to delay lumbar puncture (LP) if contraindications are noted on assessment [signs of increased intracranial pressure (ICP), severe cardiopulmonary compromise & infection of the skin overlying the LP site]

Look for Signs of Meningeal Irritation

Neck Stiffness

  • Examine the neck for rigidity by gentle forward flexion w/ the patient in supine position

Kernig Sign

  • Position of patient: Supine, w/ the hip flexed at 90o
  • Positive when extension of the knee from this position elicits resistance or pain in the lower back or posterior thigh

Brudzinski Sign

  • Position of patient: Supine
  • Positive when passive neck flexion results in flexion of the knees & hips

Look for Signs of Increased Intracranial Pressure

  • Headache
  • Emesis
  • Bulging fontanel or diastasis (widening) of the sutures
  • Ocular movement disorders (eg Abducens nerve palsy)
  • Hypertension w/ bradycardia
  • Apnea or hyperventilation
  • Altered state of consciousness (eg coma) 
  • Decorticate or decerebrate posturing

Other Signs & Symptoms

Neonates

  • Temperature instability, jaundice, diarrhea, respiratory distress, high-pitched crying, refusal to eat

Children 1-4 years

  • May also suffer antecedent or concurrent respiratory infections

Laboratory Tests

Lumbar Puncture (LP) & Cerebrospinal Fluid (CSF) Exams

  • Perform LP promptly & send CSF specimens for exams, to facilitate initiation of appropriate therapy
  • A positive CSF culture is diagnostic of bacterial meningitis
  • Determine if there are contraindications for a STAT LP
    • Thrombocytopenia is a relative contraindication if patient is immunosuppressed
  • CSF formula: Cell count, glucose, protein
  • Extent of CSF abnormalities depend on causative agent

Findings suggestive of bacterial/purulent meningitis:

  • Elevated opening pressure
  • Elevated protein levels
  • Decreased glucose
  • Neutrophilic pleocytosis

Other tests, as warranted:

  • Gram staining, acid fast bacilli (AFB) smear & tuberculosis (TB) culture, India ink, cryptococcal latex agglutination system (CALAS), latex antigen techniques, polymerase chain reaction (PCR), tissue culture, Limulus lysate test, counter immunoelectrophoresis

Blood Cultures (BC)

  • Obtain BC preferably before instituting empiric antibiotic therapy
  • May be done first if w/ contraindications for a STAT LP

Imaging

Cranial Imaging [Computed Tomography (CT), Magnetic Resonance Imaging (MRI)]

  • Criteria for performing cranial imaging prior to LP include presence of focal neurologic deficits, new-onset seizures, severe altered mental status (Glasgow Coma Scale <10), and severely compromised immune system (ei transplant patients, HIV-positive)
  • Magnetic resonance imaging with gadolinium enhancement & diffusion-weighted imaging may be used for patients with meningitis secondary to medical devices (eg CSF shunt, CSF drain, intrathecal drug therapy)
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