MENINGITIS

An acute inflammation of the pia and arachnoid coverings of the brain with spread into the cerebro-spinal fluid (CSF). It is important to diagnose and start treatment early in order to prevent complications.

The predominant causative bacterial organisms (pyogenic meningitis) vary with the age of the child.

  • Haemophilus influenzae commonly affects children under 5 years
  • Streptococcus pneumoniae (pneumococcus) tends to be more common after age 5 years.
  • Hib immunization, however, is reducing the incidence of meningitis due to H. influenzae. Viruses (aseptic meningitis), Tubercle bacilli (Tuberculous meningitis), and fungi (fungal meningitis) also cause meningitis.
  • Neisseria meningitidis (meningococcus) tends to cause meningitis in epidemics and affects all ages.

Predisposing factors for meningitis in children are:

  • Low immunity,
  • Prematurity,
  • Septicaemia,
  • Infections in the nose, sinuses, ears, throat and lungs
  • Penetrating injuries of the skull and spinal column, and
  • Congenital malformations of the brain and spine.

Clinical Features (Child >2 months)

  • Fever
  • Refusal to feed
  • Vomiting
  • Repeated convulsions
  • Irritability
  • Altered level of consciousness
  • Headaches
  • Photophobia
  • Neck stiffness
  • Positive Kerning’s sign.
  • Young children may also have bulging anterior fontanelle and high pitched cry.
  • Signs of increased intracranial pressure include
    • Sutural daistasis
    • Increased head circumference
    • Unequal pupils
    • Focal neurological signs
    • Irregular breathing.
  • Patients presenting late in the progression of the disease may have decerebrate rigidity or opisthotonos.
  • For tuberculous meningitis, the onset is more gradual and non specific.
  • Child may complain of headache, vomiting, and poor feeding for several days before features of meningitis appear.
  • Gradually the child becomes stiff and loses consciousness.

Complications

These include

  • Subdural effusion
  • Hydrocephalus
  • Blindness
  • Deafness
  • Secondary epileptic fits
  • Mental retardation
  • Cerebral palsy.
  • The child may also have retardation in their physical development.

Investigations

  • Lumbar puncture (after fundoscopy to rule out papilloedema)
  • Haemogram
  • Blood glucose
  • Chest x-ray
  • Mantoux test, if there is history of contact with TB or fever lasting >7 days
  • Indian ink staining in patients with HIV infection (cryptococcal infection)
  • HIV test if not known

CSF Characteristics

  • Refer to Table for CFS charactisitcs.
  • Always treat as pyogenic meningitis if the CSF is cloudy, blood stained, or cannot be obtained.
  • Admit patient if meningitis is suspected. Initiate treatment immediately.

CFS characteristic

Nature of CSF Colour Protein Sugar Cells
Normal Crystal clear Below 0.4g/L Above 2.5mmol/L 0–5(x10/L)
Pyogenic Cloudy High Low or NIL Hundreds to thousands,
mainly polymorph
Tuberculous Clear OR opalescent Moderately raised Low A few hundreds
mainly lymphocytes
Viral Clear OR opalescent Moderately raised Normal A few hundreds
mainly lymphocytes

Management – General

  • Follow the patient’s progress:
    • For children up to 24 months do daily head circumference.
    • Monitor the condition (how “well” or “ill” child is).
    • Take the temperature and pulse.
    • Feel the fontanelle.
    • Assess neck stiffness/Kerning’s sign.
    • Maintain fluid and electrolyte balance.
    • Ensure child is passing urine well.
    • Continue anticonvulsant if there were convulsions.
    • Ensure adequate nutrition for age.
  • Treat for malaria if in malarious area.

Management – Pharmacological

Antibiotics – Pyogenic Meningitis
  • Give penicillin + chloramphenicol for children under 5 years; penicillin only for
    5 years and above as follows:

    • Benzyl (crystalline) penicillin:
      • Under 1 year of age: 100,000 units/kg IV STAT, then 250,000 units/kg/24
        hours IV in 4 divided doses
      • 1–6 years of age: 1,200,000 units IV STAT then 2,500,000–5,000,000
        units per 24 hrs IV in 4 divided doses
      • 7–12 years of age: 2,400,000 units IV STAT, then 5,000,000–10,000,000
        units per 24 hours in 4 divided doses
    • Chloramphenicol:
      • Up to 1 month of age: 25mg/kg IV STAT, then 50mg/kg 24 hours in 4
        divided doses
      • Over 1 month of age: 50mg/kg IV STAT, then 100–150mg/kg 24 hours in
        4 divided doses.
  • After 2–5 days of intravenous therapy and provided there is satisfactory
    improvement, benzyl penicillin can be given IM and the chloramphenicol can
    be given orally in the same doses
  • Treatment should continue for:
    • 5–7 days in meningococcal meningitis
    • 21 days in salmonella meningitis
    • At least 14 days in all other cases of pyogenic meningitis.

Tuberculous meningitis

See Section on Tuberculosis.

Cryptococcal meningitis

  • Fluconazole loading dose 10mg/kg (max 400mg), then 3–6mg/kg/24hours
    (max 12mg/kg/24 hours)
  • Refer, re-evaluate, or consult if:
    • There is no improvement after 3–4 days of full treatment.
    • The condition is deteriorating.
    • Patient develops a widespread skin rash, or easy bleeding before or during
      treatment.
    • All children with complications as they will need specialized therapy
      according to the disability.
    • After full treatment, child is brought back with fits with or without fever.

Prophylaxis for Meningococcal Infections

  • All close contact or household members
  • Sulphadiazine 500mg–1g BD PO for 2 days (if the organism is susceptible)
    OR
  • Rifampicin: Neonate – 10mg/kg/24hours; > 1 month 20mg/kg/24 hours; maximum 600mg BD PO for 2 days,
    OR
  • Minocycline children over 8 years – 4mg/kg/dose maximum 200mg BD PO for 2 days
  • Purified capsulate polysaccharide vaccine is available to control outbreaks but it must be administered within 3–7 days of case identification to prevent an epidemic. The vaccine is not suitable for children <2 years.

Notify the medical officer of health if meningococcal meningitis is
diagnosed.