Meningitis

Question 1

Name the 3 organisms that most commonly cause bacterial meningitis. Name 3 more that can cause meningitis in neonates (under 3 months)

Answer 1

Strep pneumoniae
Hib
Neisseria meningitidis

Under 2 months:
Group B strep (Strep agalactiae)
Listeria
E. coli

Question 2

Name 3 viruses that can cause encephalitis

Answer 2

HSV
Enterovirus
Other herpes viruses (EBV, CMV, VZV, HHV6)

Question 3

Name 5 symptoms of meningitis in an infant/child

Answer 3

Irritability, poor feeding, lethargy
Reduced conscious state
Headache, photophobia
Fever
Seizure
Petechial/purpuric rash

Question 4

Name Ddx for a petechial rash

Answer 4

Viral infection (enterovirus, influenza)
Bacterial infection (Neisseria, Strep pneumoniae, HiB)
HSP
ITP
Leukaemia

Question 5

Name 5 signs on examination of meningitis

Answer 5

Full fontanelle
Neck stiffness
Purpuric rash
Kernig’s sign (flexion of straight leg = pain in back and leg)
Brudzinski’s sign (neck flexion results in reflex hip flexion)

Question 6

What sign distinguishes meningitis from encephalitis?

Answer 6

Decreased conscious state/focal neurology

Question 7

Name 3 Ix for a child with meningitis

Answer 7

FBE, blood culture, UEC
LP
Glucose (Ddx)

Question 8

Name 3 C/I for an LP

Answer 8

Child in a coma or really sick that you’re going to treat anyway
Signs of raised ICP (diplopia, abnormal pupils, papilloedema)
Focal neurological signs/seizures
Local infection over LP site
Cardiovascular or respiratory compromise

Question 9

Where do you aim for in an LP and why? What landmarks do you use in a child? What position should they be in?

Answer 9

Aim for L3-4 or L4-5 interspace (conus medullaris, distal part of spinal cord, ends at L3). Draw a line between top of iliac crests. Child should be lying on side, or sitting up and curled over so that back is 90 degrees to bed.

Question 10

What CSF values suggest bacterial, viral or TB meningitis?

Answer 10

Bacterial - raised neutrophils, low glucose, high protein
Viral - raised lymphocytes, normal glucose, normal-high protein
TB - raised lymphocytes, really low glucose, really high protein

Question 11

If you’ve given antibiotics before an LP, can you still culture the LP

Answer 11

Only if antibiotics were less than 24 hours ago

Question 12

What is the empirical management of bacterial meningitis if under 2 months, and over 2 months?

Answer 12

Under 2 months - IV ben pen and cefotaxime

Over 2 months - IV cefotaxime and IV dexamethasone

Question 13

Is it routine to give full maintenance fluids to a child with meningitis? Why/why not?

Answer 13

No - usually 2/3rds maintenance fluids. In acute illness, there’s a physiological response to increase ADH levels to retain fluid (evolutionary theory that if sick, it’s harder to find water in environment). Don’t give full, otherwise risk overloading them, potentially causing hyponatraemia and cerebral oedema.

Question 14

Name 3 things to do to follow-up a case of bacterial meningitis

Answer 14

Notify DHS (all bacteria are notifiable diseases)
Arrange audiology follow-up (can cause hearing loss)
Chemoprophylaxis to contacts (only if Neisseria meningitidis, or Hib and unvaccinated contacts)