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Year 4: Paeds > Infections: Fever, Meningitis > Flashcards

Infections: Fever, Meningitis Flashcards

1
Q

What defines fever? [1]

A

Temp above 38 degrees

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2
Q

Paeds:

What are key signs to look for in a patient presenting w fever?

A

ID signs of shock:
- Elevated RR
- Tachycardia
- Poor perfusion
- Hypotension (late sign)

Hx:
- How many days of fever?
- How high was fever?
- Other symptoms: cough & runny nose, breathing difficulties, irritability, D&V, pain on passing urine, tugging at ears, limping, skin rash

More Hx:
- Anyone else sick in family?
- Vaccination - ask about each age
- Hx of travel?
- PMH
- FH
- DH

Exam:
- ENT
- Resp: RR and work
- CV: HR, perfusion and BP
- Abdominal exam: liver and spleen
- Skin for rash
- Bones and joints: swelling, redness etc
- CNS - neck stifness and irratbility, full fontanelle

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3
Q

Describe how you thinko about a child < 3 months presenting with fever [3]

A

Children < 3 months have really non-specific symptoms such as poor feeding or lethargy
- May fall ill rapidly
- Can’t compartmentalise infections
- LOW THRESHOLD FOR FULL SEPTIC SCREEN !!!

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4
Q

Describe a septic screen would perform for child < 3 months w fever [+]

A
  • Urinanalysis - send for MC&S
  • IV cannula
  • FBC, CRP, blood cultures, U&E, LFT, clotting and lactate
  • Consider CXR if respiratory symptoms
  • Condsider LP
  • IV Abx within an hr
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5
Q

When do you perform an LP? [1]

A

When want to rule out meningitis

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6
Q

When would you suspect meningitis in a child? [+]

A

Remember - can be non-specific

Classic:
- Neck stiffness, photoboia, headache

Infants:
- Poor feeding, irritability, hypotonia, altered cry, bulging fontanelle

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7
Q

When is an LP contraindicated? [5]

A
  • New focal neurology (focal seizures, posturing)
  • GCS < 9
  • Abnormal pupils
  • Extensive or rapidly spreading purpura (CV unstable and abnormal coagulation)
  • Infection at LP site
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8
Q

Why do you think about meningitis and septicaemia together? [1]

A

Some children present purely with sepsis and some w pure meningitis. But often they’re combined as its a spectrum

Also often caused by same organism

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9
Q

Which organisms would you consider causing men / sep in v young children < 3 months [3] and > 3 months [4]

A

< 3 months:
* GBS
* E coli
* Listeria

> 3 months:
- Neisseria meningitidis
- Strep pneumoniae
- Haemophilus influenza
- Group A strep

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10
Q

What are the classic presentation of meningitis?

A
  • Neck stiffness
  • Kernig’s test involves lying the patient on their back, flexing one hip and knee to 90 degrees and then slowly straightening the knee whilst keeping the hip flexed at 90 degrees. This creates a slight stretch in the meninges. Where there is meningitis it will produce spinal pain or resistance to movement.
  • Brudzinski’s test involves lying the patient flat on their back and gently using your hands to lift their head and neck off the bed and flex their chin to their chest. In a positive test this causes the patient to involuntarily flex their hips and knees.

Purpura
Photophobia
Fever
Non-blanching rash

  • Convulsions
  • Coma
  • Shock
  • Fever
  • Irritability
  • Drowsiness
  • Poor feeding / vomiting
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11
Q

How would you investigate a child for ?meningitis [+]

A

Bloods:
- FBC
- CRP
- U&E
- Blood culture
- Gas

LP:
- Specific PCR
- 16s PCR (broad range PCR - looks for all types of bacteria)

Imaging (if indicated)
- CT brain (Hydrocephalus, abscess, subdural collection)

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12
Q

Meningococcal septicaemia is the cause of which symptom? [1]
- why is this clinically significant? [2]

A

Meningococcal septicaemia is the cause of the classic “non-blanching rash” that everybody worries about.
- This rash indicates the infection has caused disseminated intravascular coagulopathy (DIC) and subcutaneous haemorrhages.

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13
Q

What is the most common cause of meningitis in children and adults are [2]

What is the most common cause in neonates? [1]

A

Bacterial meningitis is inflammation of the meninges caused by a bacterial infection. The most common causes of bacterial meningitis in children and adults are Neisseria meningitidis (meningococcus) and Streptococcus pneumoniae (pneumococcus).

In neonates the most common cause is group B strep (GBS). GBS is usually contracted during birth from GBS bacteria that live harmlessly in the mother’s vagina.

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14
Q

Describe the CSF changes in meningitis for bacterial, viral and TB infections
- appearance
- cell type present
- protein content
- glucose content

What else do you need to do when getting an LP? [1]

A

Bacterial
- Cloudy
- Neutrophils
- High protein
- Glucose < 60% of blood

Viral:
* Clear
* Lymphocytes
* Normal/raised protein
* Normal glucose

TB:
- Slight cloudy, fibrin web, opalescent
- Lymphocytes
- High protein
- Glucose < 60% of blood

Also need paired blood test to compare to LP

NB: beware a partially completed bacterial infection as it presents as a lymphocytic / viral picture

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15
Q

Describe the tx of meningitis in a hospital setting

A
  • A-E
  • Perform LP for CSF
  • Send blood tests for meningococcal PCR if meningococcal disease is suspected.
  • IV Dexamethasone (if strongly suspected) ASAP
  • Under 3 months – cefotaxime plus amoxicillin (the amoxicillin is to cover listeria contracted during pregnancy)
  • Above 3 months – ceftriaxone
  • Admit to PICU - treating raised ICP
  • Notify public health

NB:
- IV Dex not usually given in children under 3 months
- Vancomycin should be added to these antibiotics if there is a risk of penicillin resistant pneumococcal infection, for example recent foreign travel or prolonged antibiotic exposure.

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16
Q

A child has been treated for meningitis and discharged.

You arrange a follow up - when and what for? [2]

A

Follow up in 4 weeks for audiology and neurodevelopment

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17
Q

You give IX dexamethasone for ?meningitis.

Once microscopy has come back you continue this tx. Which organisms would mean you do this? [2]

A

Continue IV dex if pneumococcus or HiB

18
Q

Contacts of a patient with a patient with meningococcal infections such as meningitis or septicaemia should be given what as PEP? [1] When? [1]

A

The usual antibiotic choice for this is a single dose of ciprofloxacin. It should be given as soon as possible and ideally within 24 hours of the initial diagnosis.

19
Q

Children seen in the primary care setting with suspected meningitis AND a non blanching rash should receive an urgent stat injection of [] prior to transfer to hospital, as time is so important. The dose will depending on their age.

A

Children seen in the primary care setting with suspected meningitis AND a non blanching rash should receive an urgent stat injection (IM or IV) of benzylpenicillin prior to transfer to hospital, as time is so important. The dose will depending on their age.

20
Q

How do the symptoms of viral meninigitis differ from bacterial meningitis? [2]

A

viral meningitis
- Both can present with symptoms such as headache, fever, neck stiffness, and photophobia.
- often have a less severe course of illness compared to those with bacterial meningitis.
- They are generally less systemically unwell and may lack the marked neurological signs seen in bacterial meningitis.

21
Q

How do the symptoms of encephalitis meninigitis differ from bacterial meningitis? [2]

A

Can present similarly to meningitis.

However, encephalitis typically presents with altered mental status or focal neurological deficits not usually seen in bacterial meningitis
- The presence of seizures at onset is more common in encephalitis than in bacterial meningitis.

22
Q

How do the symptoms of SAH differ from bacterial meningitis? [2]

A

A subarachnoid haemorrhage often presents acutely with a severe headache, which can be similar to the presentation of bacterial meningitis.
- However, a key differentiating factor is that patients with SAH often describe their headache as the ‘worst ever’ or of sudden onset, also known as a ‘thunderclap’ headache.
- Other symptoms such as vomiting, seizures, and loss of consciousness may also occur in both conditions. However, focal neurological signs or a rapidly deteriorating level of consciousness are more indicative of SAH than bacterial meningitis.

23
Q

Lumbar puncture should be delayed in which circumstances? [5]

A
  • signs of severe sepsis or a rapidly evolving rash
  • severe respiratory/cardiac compromise
  • significant bleeding risk
  • signs of raised intracranial pressure
  • focal neurological signs
  • papilloedema
  • continuous or uncontrolled seizures
  • GCS ≤ 12
24
Q

If an LP has been performed, the CSF should be tested for: [+]

A
  • glucose, protein, microscopy and culture
  • lactate
  • meningococcal and pneumococcal PCR
  • enteroviral, herpes simplex and varicella-zoster PCR
  • consider investigations for TB meningitis
25
Q

Label A-G [6]

A
26
Q

You suspect meningitis

They have had a previous bad reaction to penicillin.

What do you give instead? [1]

A

If the patient has a history of immediate hypersensitivity reaction to penicillin or to cephalosporins the BNF recommends using chloramphenicol.

27
Q

What is this specific rash called? [1]

A

Meningococcal skin rash (purpura fulminans)

28
Q

Particularly in meninigitis cases caused by H. influenzae, [] is a significant side effect [1]

A

Hearing loss: Sensorineural hearing loss is a frequent sequela, may be permanent.

29
Q

Seizures are a complication of bacterial meningitis.

What is the most likely pathogen causing this? [1]

A

Seizures: These may be either focal or generalised, and are more common in patients with pneumococcal meningitis caused by Streptococcus pneumoniae.

30
Q
A

Streptococcus pneumoniae

31
Q
A

Cloudy appearance, glucose 70% of plasma, protein 0.5 g/l, WCC 500 per mm^3 (lymphs) - viral meningitis

32
Q

The following CSF report is received for a patient with fever and headache: cloudy appearance, glucose 25% of plasma, protein 1.5 g/l, WCC 2,000 per mm^3 (neuts)

What is the most likely cause? [1]

A

Bacterial

33
Q
A

E. coli

34
Q
A

Neisseria meningitidis

35
Q
A

Listeria monocytogenes

36
Q
A

intravenous cefotaxime + amoxicillin

37
Q
A

0 - 3 months
* Group B Streptococcus (most common cause in neonates)
* E. coli
* Listeria monocytogenes

38
Q

Meningitis: causes - 3 months - 6 years? [3]

A

Neisseria meningitidis
Streptococcus pneumoniae
Haemophilus influenzae

39
Q

Meningitis: causes - 6 years - 60 years [2]

A

Neisseria meningitidis
Streptococcus pneumoniae

40
Q

The following CSF report is received for a patient with fever and headache: slightly cloudy appearance with fibrin web, glucose 25% of plasma, protein 4 g/l, WCC 500 per mm^3 (lymphs)

A

TB

41
Q
A

CD4 50-100

Year 4: Paeds (13 decks)

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