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Meningitis and Encephalitis in Pediatrics

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Mike Burbridge

on 21 November 2015

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Transcript of Meningitis and Encephalitis in Pediatrics

Michael Burbridge, DO, FAAP
Assistant Professor of Pediatrics
VTCSOM, Carilion Clinic Children's Hospital

4-5 cases bacterial meningitis per 100,000 children < age 5
Bacteria, virus, fungi, mycobacteria
Etiology varies dramatically in different age groups
Vaccines have changed landscape of meningitis over the past 20 years

CASE 1: 3 week old presents with fever, decreased PO intake, fussy
Temp 101.2, HR 165, RR 60, SpO2 94%
CASE 3: 2 yr male with fever, lethargy, rash, decreased PO intake, and decreased urine output
Temp 104.3, HR 170, RR 48, SpO2 94%
WBC 3.3, Hgb 9.9, Hct 28.9, Plt 112, Neut 54%, Lymph 10%, Bands 36%
UA: Nit neg, WBC esterase neg, WBC 24, RBC 0
Na 127, K3.5, Cl 90, CO2 12, BUN 12, Crt 0.4, Gluc 112
CASE 2: 7 wk female with fever, fussy, decreased PO intake, normal urine output, watery stools
Temp 100.8, HR 145, RR 42, SpO2 96%
Neonatal Disease
Group B Strep
Group B Strep
Early: PNA and sepsis (0-6 d)
Late: sepsis and meningitis (> 6d)
IAP: >80% reduction in early onset disease;
Early: vertical transmission
maternal infection from food-borne sources
Septic appearance
papular truncal rash
Late onset: horizontal transmission
exposure to undercooked poultry, unwashed vegetables or unpasturized milk
E. coli or Gram-neg rods
Perinatal transmission from maternal genital tract
Associated with prematurity, maternal intrapartum infection, PROM
Nosocomial sources: Citrobacter, Enterobacter, Serratia
Herpes Simplex Virus (HSV)
Isolated lessions, encephalitis, disseminated disease
HSV-2 is most common (75%)
Perinatal transmission: vaginally
Horizontal transmission
Frequently no maternal history or active infection is present
Incubation period ~ 2 weeks
Enterovirus Meningitis
"Aseptic meningitis"
Most common in summer but anytime
Usually non-toxic appearing
Under 1yr age (but any age)
Other Causes of Meningoencephalitis
Epstein-Barr virus
Rabies virus
Borrelia burgdorferi (Lyme Dz
Human herpes virus-6
Rickettsia-rickettsii (RMSF)
Ehrlichia sp
Kawasaki disease (aseptic meningitis)
CSF: WBC 2,800, RBC 9, Neut 99%, Gluc 10, Prt 121
WBC 20.3, Hgb 10.3, Hct 30.1, Plt 231, Neut 58%, Lymph 22%, Bands 10%
Na 132, K5.0, Cl 107, CO2 18, BUN 18, Crt 0.3, Glu 84
UA: normal, no WBC, no organisms
CSF: WBC 658, RBC 68, Neut 95%, Lymph 5%, Glu 24, Prt 78
Listeria monocytogenes
Escherichia coli
Herpes simplex virus
Emperic Treatment
Ampicillin 400mg/kg/d divided q 6hr
Cefotaxime 200mg/kg/d divided q 6hr or Gentamicin 4mg/kg q24
Acyclovir 60mg/kg/d divided q 8hr
Duration of Treatment
Group B Strep: 14 days
Listeria: 14 days
E. coli: 21 days
HSV: 14-21 days
Lumbar Puncture
CBC w/ diff
WBC elevated in GBS, e. coli, pneumococcus
WBC decreased in meningococcus and rickettsia
CMP: Na, CO2, BUN, Crt, Glucose, ALT
Urine cx
WBC 12.1, Hgb 10.1, Hct 29.9, Plt 360, Neut 45%, Lymp 40%, Bands 10%
UA: normal
CSF: WBC 450, RBC 245,000, Neut 55%, Lymph 45%, Glu 55, Prt 140
CSF: WBC 152, RBC 0, Neut 80%, Lymph 20%, Gluc 55, Prot 80
Fever can be 100.5 to 105
"Feel better" after LP
Fecal-oral transmission
Coxsackie and Echovirus
PCR is gold standard
Benign course
Intrauterine transmission is associated with disseminated disease and high mortality
Lactic acidosis
Prerenal azotemia or renal insufficiency
Serum glucose 2 x CSF
contraindications: focal deficits, increased ICP, coagulopathy, cardiopulmonary compromise
cell count, glucose, protein, gram stain, cx
WBC < 30 neonate, <10 infants/children
HSV and enterovirus pcr if indicated
neutrophil predominance
Glucose usually less than 1/2 serum
lower cell count
neutrophil predominance early shifting to lymph in 1-2 days
Neisseria meningitidis
Invasive disease
Sudden onset
petechial rash
Neisseria meningitidis
Gram-neg diplococcus
13 serogroups
, B,
C, Y & W-135
Incidence: 1.5 per 100,000 people
Children < age 2 or 16-21 years of age
Most common cause of bacterial meningitis in children
Spread from asymptomatic colonization of upper resp tract
Daycares, schools, colleges, military
Neiserria meningitidis
Blood or CSF culture
Lessions have low yield
PCR can be useful
Early detection is essential!
Ceftriaxone 100mg/kg/d divided q12 or 24hr or
Cefotaxime 200mg/kg/d divided q 6hr
Penicillin G, ampicillin, meropenem
5 - 7 days
Neiserria meningitidis
Supportive therapy
PICU until stable
Hemodynamics/IV fluids
Increased ICP
Skin care
Household contacts
Direct exposure to oral secretions
Initiate within 24 hours
Meningococcemia with purpura fulminans
Note relative sparing of the trunk
Note characteristic petechia and purpura in coalescent angular pattern.
Necrotic lession
Meningococcal endophthalmitis
Cellulitis secondary to N. meningococcus
Case 4: 6 mo male with fever, runny nose, and cough x 2 days. Today has been extremely irritable and not eating at all.
Temp 103.4, Pulse 192, Resp 68, SpO2 83% on RA
WBC 39.3, Hbg 10.2, Hct 31.2, Plt 425,000
BMP: Na 130, K5.5, CO2 18, Gluc 114
UA: pos leuk esterase, WBC 8, RBC 3, nitrite neg
CSF: WBC 1,234, RBC 35, Poly 98%, Gluc 39, Prt 135
Streptococcus pneumoniae
Segmental lobar pneumonia
Ceftriaxone 100mg/kg/d div q12
Vancomycin 60mg/kg/d div q 6hr
Strep pneumoniae
2nd most common cause of bacterial meningitis
Subdural hygromas
Sinusitis, otitis media, conjunctivitis
Periorbital cellulitis
Septic arthritis
Strep pneumoniae
Gram-positive diplococci
>90 serotypes
PCV13: 13 most common serotypes to cause invasive disease
PCV23 indicated for high risk populations
Transient colonization of URT common
Infection most common in winter and secondary to viral URI
Invasive disease: infants and young children, asplenia (sickle cell), immunodeficiency
Strep pneumoniae
PCV 7 (2000): decreased invasive disease by 76% in < 5yo
Serotype replacement - PCV13
Emperic treatment: Combination therapy (resistant strains more prevalent)
Ceftriaxone 100mg/kg/d div q 12/24hr
Vancomycin 60mg/kg/d div q 6hr
Strep pneumoniae
Beta-lactam allergic:
Vanco 60mg/kg/d div q 6hr +
Rifampin 20mg/kg/d div q 12hr or
Meropenem 40mg/kg q 8hr
Tx duration: 10-14 days
Periorbital cellulitis with associated bacteremia
Strep pneumo sepsis in asplenic pt
Segmental pneumonia
Pneumococcal pneumonia with massive effusion
note mediastinal shift
Lobar pneumonia with empyema
BCx + Strep pneumo
Pericarditis due to Strep pneumo
Lobar pneumonia
BCx + strep pneumo
Subdural hygromas
Left thalmic infarct
Rochester Criteria
Febrile infants at LOW RISK for serious bacterial infection
Well appearing!
Full term and previously healthy
No unexplained hyperbili
Normal NBN admission
No prior hospitalizations
No skin, bone, soft tissue or EAR INFECTION
WBC between 5,000 - 15,000
Band count < 1,500
UA <10WBC on micro
Diarrhea: stool <5 WBC on micro
Important cause of neuroinvasive disease
Aseptic meningitis
Acute flaccid paralysis
Flu-like prodrome followed by acute neurologic symptoms
stiff neck
mental status changes
focal neurologic deficits
Hemorrhagic fever
petechiae, bleeding, GI bleed
septic shock
Dengue fever
West Nile Virus
Usually asymptomatic
Transmitted by mosquitoes
Acute febrile prodrome
headache, myalgia, arthalgia
GI symptoms
maculopapular rash
Neuroinvasive disease (~1%)
seizures, focal neurologic deficits, movement disorder
anterior horn cells - respiratory failure
CSF: lymphocytic pleocytosis
MRI is normal
Anti-WNV IgM Ab (>10 d illness)
10% Fatality rate
Meningitis; Mann, K and Jackson, M; Pediatrics in Review, 2008; 29; 417

Red Book Online, AAP, 2012

No financial disclosures
Group B Strep
Gram-positive diplococci
Intrapartum transmission from mother to infant
Diagnosis: Blood or CSF cultures
Treatment (14 days):
<7 do: Pen G 400,00 U/kg/d div q 8hr
>7 do: Pen G 500,000 U/kg/d div q 6hr
or Ampicillin 400 mg/kg/d div q6-8hr
Meningitis Vaccines
introduced in 1985
children 2mo -5 yrs
99% decrease in cases of invasive HiB
2010 (PCV-7 in 2000)
children 2 mo - 5 years
99% effective against serotypes in vaccine
MCV4 (Menactra)
adolescents > 11 yo
high risk children >9 mo
99% post-vaccine immune response
CXR only if resp sx
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