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Paeds: Acute Presentation > Meningitis and encephalitis > Flashcards

Meningitis and encephalitis Flashcards

1
Q

What is the most common cause of meningitis?

A

viral infections

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2
Q

What is the most common prognosis for meningitis?

A

most are self-resolving

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3
Q

When can meningitis be more severe?

A

bacterial meningitis

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4
Q

How common is TB meningitis and who does it affect?

A

rare in countries with low TB prevalence. mainly affects children under 5

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5
Q

How common are fungal and parastic meningitis?

A

rare in children, predominantly affect immunocompromised individuals

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6
Q

What are 2 causes of noninfectious meningitis?

A

malignancy and autoimmune disease

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7
Q

What are 7 types of meningitis?

A
  1. Viral
  2. Bacterial
  3. TB
  4. Fungal
  5. Parasitic
  6. Malignant
  7. Autoimmune
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8
Q

What proportion of patients with bacterial meningitis are under 16?

A

80%

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9
Q

What is the mortality of bacterial meningitis in children?

A

5-10%

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10
Q

What proportion of survivors of bacterial meningitis are left with long-term neurological impairment?

A

over 10%

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11
Q

What usually causes bacterial meningitis?

A

Usually follows bacteraemia - damage caused by meningeal infection results from host response not organism itself

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12
Q

How does the immune response to bacterial meningitis affect the brain? 3 things

A
  1. release of inflammatory mediators and activated leucocytes, with endothelial damage, leads to cerebral oedema, raised intracranial pressure, and decreased cerebral blood flow
  2. inflammatory response below meninges causes vasculopathy resulting in cerebral cortical infarction
  3. fibrin deposits may block resorption of CSF by arachnoid villi, resulting in hydrocephalus
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13
Q

What do the bacteria that cause bacterial meningitis vary with?

A

age group of child

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14
Q

What are 3 types of vaccinations that have changed the organisms that commonly cause bacterial meningitis?

A
  1. H. influenzae type B (Hib)
  2. Meningococcal group C (recently A, C, W and Y)
  3. Multiple pneumococcal serotypes
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15
Q

Which type of meningococcal vaccine has not yet shown an effect on the individual and population level?

A

Group B meningococcal

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16
Q

What are the 3 most common bacterial causes of meningitis aged neonatal to 3 months?

A
  1. Group B streptococcus
  2. Escherichia coli and other coliforms
  3. Listeria monocytogenes
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17
Q

What are the 3 most common causes of bacterial meningitis aged 1 month to 6 years?

A
  1. Neisseria meningitides
  2. Streptococcus pneumoniae
  3. Haemophilus influenza
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18
Q

What are the 2 most common causes of bacterial meningitis aged >6 years?

A
  1. Neisseria meningitides
  2. Streptococcus pneumoniae
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19
Q

What makes early diagnosis of meningitis difficult?

A

early signs and symptoms are nonspecific, especially in infants and young children

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20
Q

What makes it difficult to detect headache, neck stiffness, photophobia?

A

only children old enough to talk can describe these

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21
Q

What are 2 other situations when neck stiffness can be seen in addition to meningitis?

A
  1. Tonsilitis
  2. Cervical lymphadenopathy
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22
Q

Due to the risk of children with meningitis also having sepsis, what are 4 signs to look for and why?

A

looking for signs of shock:

  1. tachycardia
  2. tachypnoea
  3. prolonged CRT
  4. hypotension
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23
Q

What should you assume purpura in a febrile child are due to?

A

meningococcal sepsis - even if not unduly ill at the time

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24
Q

Is meningitis always present in meningococcal sepsis?

A

not always

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25
Q

What are 10 things to look for in the history of meningitis and encephalitis?

A
  1. Fever
  2. headache
  3. Photophobia
  4. Lethargic
  5. Poor feeding/ vomiting
  6. Irritability
  7. Hypotonia
  8. Drowsiness
  9. Loss of consciousness
  10. Seizures
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26
Q

What are 10 things to look for on examination in meningitis/encephalitis?

A
  1. Fever
  2. Purpuric rash (meningococcal disease)
  3. Neck stifness (not always present in infants)
  4. bulging fontanelle in infants
  5. Opisthotonus (arching of back)
  6. Positive Brudzinski/Kernig signs
  7. Signs of shock
  8. Focal neurological signs
  9. Altered conscious level
  10. Papilloedema (rare)
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27
Q

What are 8 blood tests to perform in suspected meningitis?

A
  1. FBC and differential count
  2. Blood glucose
  3. Blood gas (for acidosis)
  4. Coagulation screen
  5. CRP
  6. U+Es
  7. LFTs
  8. Blood culture
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28
Q

What are 4 places to culture for bacteria in suspected bacterial meningitis/ encephalitis?

A
  1. Blood culture
  2. Throat swab
  3. Urine
  4. Stool
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29
Q

What are 4 places to sample for viral PCRs in meningitis?

A
  1. Throat swab
  2. Nasopharyngeal aspirate
  3. Conjunctival swab
  4. Stool sample
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30
Q

What test can be done for meningitis organisms and what are 3 sources to perform it on?

A

Rapid antigen test (RAT)

  1. Blood
  2. CSF
  3. Urine
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31
Q

What are 7 investigations in addition to blood tests to perform in suspected meningitis/ encephalitis?

A
  1. Culture of blood, throat swab, urine, stool for bacteria
  2. Rapid antigen test for meningitis organisms (can be done on blood, CSF or urine)
  3. Samples for viral PCRs (throat swab, nasopharyngeal aspirate, conjunctival swab, stool sample)
  4. Lumbar puncture for CSF unless CIed
  5. Serum for comparison of convalescent titres
  6. PCR of blood and CSF for possible organisms
  7. Consider CT/MRI brain scan and EEG
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32
Q

What are 6 additional investigations to perform is TB is suspected in meningitis/ encephalitis?

A
  1. Chest X-ray
  2. Mantoux test
  3. Interferon-gamma release assay
  4. Gastric aspirates or sputum for microscopy and culture
  5. PCR of gastric aspirates/ sputum if available
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33
Q

What are Brudzinski’s and Kernig signs testing for?

A

neck stiffness

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34
Q

What does Brudzinski sign involve?

A

flexion of the neck with child supine, causes flexion of the knees and hips

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35
Q

What does Kernig sign involve?

A

with child lying supine and with hips and knees flexed, there is back pain on extension of the knee

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36
Q

What are 4 things found on lumbar puncture in meningitis?

A
  1. Appearance: turbid
  2. WBCs: increased polymorphs (e.g. neutrophils)
  3. Protein: raised
  4. Glucose: low
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37
Q

What are 4 things that would be found on LP in viral meningitis?

A
  1. Appearance: clear
  2. White blood cells: increased lymphocytes, but initially may be polymorphs
  3. Protein: normal (bit hight)
  4. Glucose: normal (bit low)
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38
Q

What are 4 things that would be found on LP in tuberculous meningitis?

A
  1. Appearance: turbid/clear/viscous
  2. WBCs: raised lymphocytes
  3. Protein: raised
  4. Glucose: reduced
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39
Q

What are 4 things that would be found on LP in encephalitis?

A
  1. Appearance: clear
  2. WBCs: normal/ lymphocytes
  3. Protein: normal/ bit high
  4. Glucose: normal/ bit low
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40
Q

What are 3 reasons to perform a lumbar puncture in uspected meningitis?

A
  1. Confirm diagnosis
  2. Identify organism
  3. Antibiotic sensitivities
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41
Q

What is one example of when lymphocytes might predominate in bacterial meningitis?

A

Lyme disease

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42
Q

What is one example of when glucose might be low in viral meningitis?

A

enterovirus meningitis

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43
Q

What are 7 contraindications to lumbar puncture?

A
  1. Cardiorespiratory instability
  2. Focal neurological signs
  3. Signs of raised intracranial pressure, e.g. coma, high BP, low heart rate or papilloedema
  4. Coagulopathy
  5. Thrombocytopenia
  6. Local infection at the site of LP
  7. If it causes undue delay in starting antibiotics
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44
Q

Why should you not perform a lumbar puncture if there are signs of raised ICP?

A

coning of cerebellum through foramen magnum

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45
Q

What should be done about the lumbar puncture in suspected meningitis if there are signs of raised ICP/ other contraindications?

A

postpone lumbar puncture until child’s condition has stabilised

46
Q

How can a bacteriological diagnosis be achieved in meningitis even without a lumbar puncture, in about 50% of cases?

A

from blood, by culture or polymerase chain reaction (PCR), and rapid antigen screens can be performed on blood and urine samples

47
Q

What are 2 things that can be obtained from throat swabs in suspected meningitis?

A

bacterial culture, viral PCRs

48
Q

How can a diagnosis be made subsequent to the presenting illness if necessary?

A

serological diagnosis on convalescent serum (obtained after recovery from infectious disease), 4-6 weeks after presenting illness

49
Q

What is the management of bacterial meningitis?

A
  • Antibiotics, depending on pathogen
  • Third generation cephalosporin e.g. ceftriaxone covers most bacterial causes (+ amoxicillin to cover Listeria)
  • Length of course depends on causative organism and response
50
Q

In addition to antibiotics what is another possible pharmacological treatment of meningitis beyond neonatal period?

A

Dexamethasone with antiobiotics - evidence it reduces risk of long-term complications e.g. deafness, beyond neonatal period

51
Q

What are 6 possible complications of meningitis?

A
  1. Hearing impairment
  2. Local vasculitis - cranial nerve palsies or other focal neurological lesions
  3. Local cerebral infarction - focal or multifocal seizures, may result in epilepsy
  4. Subdural effusion
  5. Hydrocephalus
  6. Cerebral abscess
52
Q

What can cause hearing impairment as a long term complication of meningitis?

A

Inflammatory damage to cochlear hair cells

53
Q

What should be done following meningitis infection due to the risk of hearing impairment?

A

should have audiological assessment done promptly, as children with hearing impairment may benefit from hearing amplification or a cochlear implant

54
Q

What are 2 problems that local vasculitis as a complication of meningitis may cause?

A
  1. Cranial nerve palsies
  2. Other focal neurological lesions
55
Q

What might local cerebral infarction as a result of meningitis lead to?

A

focal or multifocal seziures, which may subsequently result in epilepsy

56
Q

What 2 types of meningitis are particularly associated with subdural effusion as a complication?

A
  1. H. influenzae
  2. Pneumococcal meningitis
57
Q

What can be used to confirm whether subdural effusion is present following meningitis?

A

CT or MRI scan

58
Q

What is the usual outcome of subdural effusion as a result of meningitis?

A

most resolve spontaneously, some require neurosurgical intervention

59
Q

What 2 things can cause hydrocephalus as a complication of meningitis?

A
  1. impaired resorption of CSF (communicating hydrocephalus) OR
  2. blockage of cerebral aqueduct or ventricular outlets by fibrin (noncommunicating hydrocephalus)
60
Q

What management may be required for hydrocephalus as a complication of meningitis?

A

ventricular shunt

61
Q

What signs are there that a cerebral abscess may have developed in meningitis?

A

clinical condition deteriorates with or without emergence of signs of space-occupying lesion, temperature continues to fluctuate

62
Q

How can the presence of a cerebral abscess be confirmed?

A

cranial CT or MRI scan

63
Q

What is the management of a cerebral abscess?

A

drainage

64
Q

When is prophylactic treatment for meningitis given and what 2 types of medication can be used?

A
  • given to all household contacts for meningococcal meningitis and Hib infection
  • rifampicin or ciprofloxacin to eradicate nasopharyngeal carriage
  • household contacts of patient with group C meningococcal meningitis should be vaccinated with meningococcal group C vaccine
65
Q

Is the patient required to take prophylactic treatment following meningococcal meningitis or Hib infection?

A

not if given third-generation cephalosporin as this will eradicate any nasopharyngeal carriage

66
Q

What can be the result if children are given oral antibiotics for nonspecific febrile illness that is early meningitis?

A

partial treatment wtih oral antibiotics may cause diagnostic problems

67
Q

What will the results of a lumbar puncture for partially treated bacterial meningitis be?

A

raised white cells but cultures usually negative

68
Q

What diagnostic tests can be helpful when a child with suspected meningitis has received early oral antibiotic treatment and the LP is inconclusive?

A

Rapid antigen screens and PCR

69
Q

What should be done if a clinical diagnosis of partially treated bacterial meningitis is suspected?

A

full course of antibiotics should be given

70
Q

What proportion of nervous sustem infections are viral?

A

more than two thirds

71
Q

What are 4 causes of viral nervous system infection?

A
  1. Enteroviruses
  2. Epstein-Barr virus (EBV)
  3. Adenoviruses
  4. Mumps
72
Q

How does viral meningitis compare in terms of severity with bacterial meningitis?

A

usually much less severe, most cases make a full recovery

73
Q

What are 6 ways a diagnosis of viral meningitis can be confirmed?

A
  1. Culture or PCR of CSF
  2. Culture or PCR of stool
  3. Culture or PCR of urine
  4. Culture or PCR of nasopharyngeal aspirate
  5. Culture or PCR of throat swabs
  6. Serology
74
Q

When should you suspect unusual / uncommon pathogens as a cause of meningitis?

A

atypical clinical course, failure to respond to antibiotic and supportive therapy

75
Q

What are 4 uncommon pathogens as causes of meningitis to consider?

A
  1. Mycoplasma species
  2. Borrelia burdoferi (Lyme disease)
  3. TB
  4. Fungal infections
76
Q

In which patient group are uncommon pathogens particularly likely?

A

immunocompromised i.e. immuunodeficiency or receiving chemotherapy or immunsuppressive medication

77
Q

What are 2 things that could cause recurrent bacterial meningitis?

A
  1. Immunodeficient
  2. Structural abnormalities of skull or meninges that facilitate bacterial acess
78
Q

What are 2 situations when aseptic meningitis may be seen?

A
  1. Malignancy
  2. Autoimmune disorders
79
Q

What are 2 time frames in the neonate when meningitis may occur?

A
  1. Early onset - <48 hours of birth: bacteria from birth canal ascent to amniotic fluid which enters fetal lungs/ via placenta following maternal infection
  2. Late-onset infection, >48 hours: from infant’s environment
80
Q

What are 13 features of neonatal sepsis and what are additional 2 features specific to meningitis?

A
  1. Fever/ temperature instability/ hypothermia
  2. Poor feeding
  3. Vomiting
  4. Apnoea and bradycardia
  5. Respiratory distress
  6. Abdominal distension
  7. Jaundice
  8. Neutropenia
  9. Hypoglycaemia/ hyperglycaemia
  10. Shock
  11. Irritability
  12. Seizures
  13. Lethargy/ drowsiness

Meningitis:

  1. tense or bulging fontanelle
  2. head retraction (opisthotonos)
81
Q

What is the mortality and morbidity due to neonatal meningitis?

A

20-50% mortality

one third of survivors have serious sequelae

82
Q

At what stage in neonatal meningitis are bulging fontanelle and opisthotonos likely to occur?

A

late stage, rarely seen in newborn infants

83
Q

What is the management of meningitis if thought likely in a newborn?

A

ampicillin or penicillin + third generation cephalosporin (e.g. cefotaxime, which has CSF penetration)

84
Q

What are 5 complications of neonatal meningitis?

A
  1. Cerebral absces
  2. Ventriculitis
  3. Hydrocephalus
  4. Hearing loss
  5. Neurodevelopmental impairment
85
Q

What are 2 types of infective agent which may cause meningitis in a neonate?

A
  1. Group B streptococcus
  2. Listeria monocytogenes
86
Q

What are 2 conditions to be urgently excluded or treated in a neonate with seizures?

A
  1. Hypoglycaemia
  2. Meningitis
87
Q

Why is it so important to rapidly recognise and treat meningitis?

A

can cause sepsis and kill in hours

88
Q

What should be done if a child is seen in the community and is febrile with a purpuric rash?

A

IM benzylpenicillin immediately and transferred to hospital

89
Q

What is encephalitis?

A

inflammation of brain substance, although meninges often also affected

90
Q

What are 4 things that can cause encephalitis?

A
  1. Direct invasion by neurotoxic virus e.g. herpes simplex virus (HSV)
  2. delayed brain swelling following dysregulated neuroimmunoloical response to an antigen, usually virus (postinfectious encephalopathy) e.g. following chickenpox
  3. Slow virus infection e.g. HIV infection or subacute sclerosing panencephalitis (SSPE) following measles
  4. Noninfectious e.g. metabolic abnormality
91
Q

What is a common neurotoxic virus that can cause encephalitis by direct invasion of the brain?

A

Herpes simplex virus (HSV)

92
Q

What is a type of virus that can cause postinfectious encephalopathy due to dysregulated neuroimmunological response to an antigen?

A

chickenpox

93
Q

What is a virus that can cause a subacute sclerosing panencephalitis (SSPE)?

A

measles

94
Q

What are 2 types of slow virus infection that can cause encephalitis?

A
  1. HIV
  2. subacute sclerosing panencephalitis (SSPE) due to measles
95
Q

How do the clinical features of noninfectious encephalitis e.g. metabolic abnormality compare with infectious causes?

A

similar clinical features

96
Q

What are 4 key symptoms most children with encephalitis present with?

A
  1. Fever
  2. Altered consciousness
  3. Seizures
  4. may include behavioural change - insidious
97
Q

How does the presentation of encephalitis compare with that of meningitis and what should be done as a result?

A

initially may not be possible to clinically differentiate, so treatment for both should be started

98
Q

What are the 3 most common causes of encephalitis in the UK and what are 3 types of herpes viruses that can cause it?

A
  1. Enteroviruses (e.g. coxsackievirus)
  2. Respiratory viruses (influenza viruses)
  3. Herpesviruses: herpes simplex virus, varicella zoster virus, human herpesvirus 6 (HHV-6)
99
Q

What is the most comon cause of encephalitis in the UK?

A

herpes simplex virus

100
Q

Worldwide, what are 5 microorganisms that can cause encephalitis?

A
  1. Mycoplasma
  2. B. burgdorferi (Lyme disease)
  3. Bartonella henselae (cat scratch disease)
  4. Rickettsial infection e.g. Rocky Mountain spotted fever
  5. Arborviruses
101
Q

How should all children with encephalitis be initially treated and why?

A

High-dose IV aciclovir - HSV can cause childhood encephalitis and can have devastating long term complications, and is a very safe treatment so can use until HSV ruled out

102
Q

Do children affected with herpes simplex virus show outward signs of infection beside encephalitis? What might these be?

A

mostly not; could be cold sores, gingivostomatitis, skin lesions

103
Q

What are 3 investigations to performed in suspected encephalitis, specifically to test for HSV?

A
  1. PCR to detect HSV in CSF
  2. EEG
  3. CT/MRI - latter two may show focal changes esp. in temporal lobes with uni or bilaterally as it’s a destructive infection
104
Q

What regions of the brain are particularly susceptible to damage by HSV encephalitis?

A

temporal lobes, uniltearlly or bilaterally

(image: gross atrophy from loss of neural tissue in temporoparietal regions)

105
Q

Why and when should testing for HSV in encephalitis be repeated?

A

may be normal initially, so need to be repeated after a few days if child not improving

106
Q

How can later confirmation of HSV infection in encephalitis be made?

A

HSV antibody production in CSF

107
Q

What is the management of proven cases of HSV encephalitis, or where there is a high index of suspicion?

A

IV aciclovir for 3 weeks

108
Q

What re 2 situations when prolonged (3 week) treatment with aciclovir should be used in encephalitis and why?

A
  1. proven HSV encephalitis
  2. high index of suspicion for HSV

relapses may occur after shorter courses

109
Q

What is the mortality rate from untreated HSV encephalitis?

A

over 70%

110
Q

What is often the outcome in survivors of HSV encephalitis?

A

neurological sequelae

Paeds: Acute Presentation (14 decks)

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