Paeds- Cerebral Palsy + Meningitis Flashcards
Is cerebral palsy genetic?
a) Yes
b) No
c) Certain types can be
b) No
It is caused by an injury to the brain while it is still developing either in the womb, during or after birt
What can be a symptom of CP?
a) Baby doesn’t roll over in either direction
b) Baby cannot bring their hands together
c) Baby has difficulty bring their hands to their mouth
d) All of the above
d) All of the above
It is mainly motor symptoms so all of these answers could be seen in a baby with CP
What is the most common type of cerebral palsy?
a) Mixed
b) Ataxic
c) Spastic
d) Athetoid
c) Spastic
The most common type is spastic cerebral palsy
What is ‘Cerebral Palsy’
Cerebral Palsy is an umbrella term for a non-progressive injury to the brain originating during the antenatal, perinatal or early postnatal period which can affect development in movement and posture. CP is often also accompanied by disturbances in sensation, cognition, communication, perception, behavior, epilepsy and secondary MSK problems.
Epidemiology of cerebral palsy?
• 1 in 400 babies born in the UK have a type of cerebral palsy
Cerebral palsy
• Injury to the brain may be due to any of the following:
- Interrupted or limited oxygen supply to the brain
- A bleed within the baby’s brain
- A premature or difficult birth
- The mother becoming infected during pregnancy
- Idiopathic
Causes for cerebal palsy can be divided into?
o antenatal, perinatal and postnatal factors:
What are some antenatal causes of cerebral palsy?
- Prematurity & low birth weight
- Multiple births
- Maternal illnesses & infections
- Pregnancy complications
70-80% of patients with CP
perinatal causes of cerebral palsy?
- Birth asphyxia
- Complicated labour and delivery
10% of patients with CP
Postnatal Causes of cerebral palsy?
- Non-accidental injury
- Head trauma
- Meningitis/encephalitis
- Cardio-pulmonary arrest
Around 25% of babies who survive neonatal seizures have CP
patho of cerebral palsy Part 1
• Ischemia/hypoxia: The white matter of the neonatal brain is supplied by the adjacent cerebral arteries. Although collateral blood flow from two arterial sources protects the area when one artery is blocked this area is susceptible to damage from cerebral hypoperfusion. Autoregulation of cerebral blood flow usually protects the fetal brain from hypoperfusion, however, it is limited in preterm infants due to immature vasoregulatory mechanisms and underdevelopment of arteriolar smooth muscles.
Patho of cerebral palsy part 2
Infection and inflammation: This process involves microglial (brain macrophage) cell activation and cytokine release, which causes damage to a specific cell type in the developing brain called the oligodendrocyte. The oligodendrocytes are a type of supportive brain cell that wraps around neurons to form the myelin sheath, which is essential for white matter development. Intrauterine infections activate the fetal immune system, which produces cytokines (e.g., interferon γ and TNF-α) that are toxic to premyelinating oligodendrocytes. Premyelinating oligodendrocytes have immature defences and so causes damage to myelin sheath.
Patho of cerebral palsy part 3
Excitotoxicity is a process where increased extracellular glutamate levels stimulate oligodendrocytes to increase calcium influx, which stimulates reactive oxidative species release. Glutamate is increased because hypoxia causes white matter cells to reduce reuptake of glutamate due to lack of energy to operate glutamate pumps. Glutamate is also released from microglial cells during the inflammatory response.
Cerebral palsy is classified according to
o motor impairment, anatomical distribution and functional level.
What are the different types of CP
Symptoms of CP
- Delays in reaching developmental milestones
- Seeming too stiff or too floppy
- Weak arms or legs
- Figety, jerky or clumsy movements
- Random, uncontrolled movements
- Walking on tip-toes
Signs of CP
- Feeding/drooling or swallowing difficulties
- Constipation
- Problems speaking or communicating
- Seizures
- GORD
- Scoliosis
- Urinary incontinence
- Learning disability
An 18-month-old child with a history of prematurity presents with failure to meet developmental milestones. The child sat independently at 1 year, has few words vocally, does not pull to stand, and exhibits increased deep tendon reflexes in the lower extremities and sustained clonus at both ankles. There is good upper-extremity function.
What in the history suggests CP
• An 18-month-old child with a history of prematurity presents with failure to meet developmental milestones. The child sat independently at 1 year, has few words vocally, does not pull to stand, and exhibits increased deep tendon reflexes in the lower extremities and sustained clonus at both ankles. There is good upper-extremity function
A 2-year-old boy, born after a normal pregnancy and delivery, presents with an asymmetric gait. Examination reveals mild spasticity of the left upper and lower extremity, hyperactive left knee and ankle deep tendon reflexes, and decreased dorsiflexion of the left ankle compared with the right. When walking, the patient walks on his left toes, and his left arm is held mildly flexed at the elbow with the palm facing the floor.
What are the features of the history that suggest CP?
A 2-year-old boy, born after a normal pregnancy and delivery, presents with an asymmetric gait. Examination reveals mild spasticity of the left upper and lower extremity, hyperactive left knee and ankle deep tendon reflexes, and decreased dorsiflexion of the left ankle compared with the right. When walking, the patient walks on his left toes, and his left arm is held mildly flexed at the elbow with the palm facing the floor.
Ix for CP
Differential Diagnosis CP
- Spinal muscular atrophy – DNA testing is available for most subtypes
- Muscular dystrophy – Muscular dystrophy is progressive and there will be loss of function and muscle weakness after three years of age. Muscle biopsy will reveal degeneration of cells
- Familial/primary dystonia – Will have family history. Genetic testing is available.
- Myelodysplasia – Usually non-spastic. Associated with lack of sensation below a specific spinal segment.
Examples of Upper motor neuron lesion
Spasticity
Increased tone
Hyperactive deep reflexes
Clonus
Babinski sign
Little to no muscle atrophy
Examples of lower motor neuron lesion?
Flaccid paralysis
Decreased or absent deep tendon reflexes
Fasciculations and fibrillations
Severe muscle atrophy (from disuse)
OSCE Tips for suspected CP
- Assess general appearance
- Ask child/adult to walk run if appropriate and observe gait
- Comment on ability to take object
- Feel tone of upper and lower limbs
- Examine power and reflexes
- Assess primitive reflexes (grasp, plantars, stepping, rooting reflex, coordination)
- Note involuntary movements
- Plot height and weight
- Assess developmental milestones
Tx for CP
Which of these is not a classic symptom of viral meningitis?
a) Fever
b) Photophobia
c) Neck stiffness
d) Rash
d) Rash
What is the classic sign of meningococcal disease?
a) Non-blanching rash
b) Photophobia
c) Neck stiffness
d) Septic shock
a) Non-blanching rash
Which of these viruses is not a cause of meningitis?
a) Adenovirus
b) Epstein Barr virus
c) Norovirus
d) Enterovirus
c) Norovirus
What is Meningitis?
- Meningitis is inflammation of the meninges (the membranous coverings of the brain and spinal cord).
- It generally occurs in response to bacterial or viral infection, but can also be due to fungal infection.
Bacterial causes of Meningitis?
; group B strep, E.coli, neisseria meningitidis, strep pneumoniae and H.influenzae
Viral causes of Meningitis?
enterovirus, EBV, adenovirus + mumps
Symptoms of meningitis?
• Classic meningitis symptoms; headache, neck stiffness, fever + photophobia (and a rash if bacterial)
Meningitis
Differences in paediatrics:
- Often results in sepsis so may present with; tachycardia, tachypnoea, prolonged capillary refill time + hypotension
- Classic symptoms tend to only be described by older children who can explain their symptoms
- Babies + young children may present with non-specific symptoms; fever, lethargy, poor feeding, vomiting, irritability, hypotonia, drowsiness, seizures, bulging fontanelle + focal neurological signs
Non-blanching petechial/purpuric rash is present in….
meningococcal disease/meningococcal septicaemia.
What look out for in a hx for suspected meningitis?
- In neonates ask about delivery (especially maternal infection or pyrexia at time of delivery)
- In babies < 3 months ask about general, non-specific symptoms e.g. hyperthermia, hypothermia, change in eating or sleeping habits, any irritability or lethargy, vomiting, seizures or high-pitched crying
- In children < 3 months ask about fever, vomiting, irritability, lethargy or changes in behaviour
- In children over 3 ask parents if they have complained about headache, stiff neck + photophobia
- Also ask about duration of symptoms, a more sudden onset of symptoms is associated with Neisseria Meningitidis
Ix for meningitis
- Bloods – FBC, blood glucose, ABG, CRP, coagulation, U+E, LFTs, blood cultures
- Sputum, urine + stool cultures
- PCR (throat swab, nasopharyngeal aspirate, blood, CSF) – tests for viral infection
- Lumbar puncture (see next slide)
- CT or MRI of the brain, or an EEG, should also be considered
What are in the changes in CSF with meningitis
Normal
Bacterial
Viral
- Normal CSF – clear, 0-5 WBCs/mm3, 0.15-0.4g/L protein, glucose > 50% of blood
- Bacterial meningitis CSF – turbid, WBCs increased, proteins increased, glucose decreased
- Viral meningitis CSF – clear, WBCs mildly increased, proteins mildly increased, glucose mildly decreased
• Contraindications to lumbar puncture; for meningitis
cardiorespiratory instability, focal neurological signs, signs of raised ICP, coagulopathy, thrombocytopenia, local infection @ LP site + if performing LP causes undue delay in starting antibiotics
Differential Diagnosis for meningitis?
Clinical examination for meningitis
In meningitis the younger the child, the less specific the symptoms, so examination more useful in older children. On examination look for;
- Kernig + Brudzinski signs
- Non specific erythematous maculopapular rash (or petechial/purpuric rash in meningococcal disease)
- Focal neurological signs (present in around 15% of children with meningitis)
- Generalised or focal seizures (present in around 33% of children with meningitis)
- Other systemic signs of infection e.g. fever
OSCE tips for menignitis
Paediatric meningitis history – remember to ask for time frame of symptoms, and also ask about non-specific symptoms leading up to this episode (e.g. has child recently been irritable?), check immunisations are up to date to rule out other infections, if the patient is an infant ask about birth history, if the patient is an older child ask about classic meningitis symptoms
Paediatric meningitis examination – not hugely helpful, but consider meningitis if child is lethargic, uninterested and generally unwell, also remember Kernig + Brudzinski signs
Interpreting lumbar puncture results – mildly abnormal results more likely to be viral, markedly abnormal results likely to indicate bacterial meningitis
Which age group would group B strep be likely to cause meningitis in?
a) Infants under 3 months
b) Infants aged 3-6 months
c) Children over 6 months
d) Teenagers
a) Infants under 3 months
Which of the following would not be a finding on a lumbar puncture of a child with bacterial meningitis?
a) Raised WBCs
b) Clear CSF
c) Raised proteins
d) Decreased glucose
b) Clear CSF
Which of the following children would you carry out a lumbar puncture on?
a) A child with high blood pressure
b) A child with focal neurological signs
c) A child with a low heart rate
d) A child with a temperature above 39°C
d) A child with a temperature above 39°C
