BACTERIAL MENINGITIS IN CHILDREN

By : Sarah Kamilah 030.08.217 FACULTY OF MEDICINE TRISAKTI UNIVERSITY JAKARTA 2011

ABSTRACT

Bacterial meningitis has become an uncommon disease in the developed world. Unfortunately, because of limited economic resources and poor living conditions, many developing countries are still affected by the devastating consequences of this life-threatening systemic infection. Some studies explain that bacterial meningitis in children have no pathognomonic sign of meningeal irritations such as stiff neck, Kernig's and brudzinski's sign and also the tripod phenomenon. Therefore, this required some examination such as CT scan and lumbar puncture. This paper comprises aspects of the epidemiology, pathophysiology, clinical manifestations, diagnosis, management and prognosis of the bacterial meningitis in children.

INTRODUCTION

Bacterial meningitis, an inflammation of the meninges affecting the pia, arachnoid, and subarachnoid space that happens in response to bacteria and bacterial products, continues to be an important cause of mortality and morbidity in neonates and children. However, mortality and morbidity vary by age and geographical location of the patient and the causative organism. Patients at risk for high mortality and morbidity include newborns, those living in low-income countries, and those infected with Gram-negative bacilli and Streptococcus pneumoniae. Severity of illness on presentation (eg, low score on Glasgow coma scale), infection with antimicrobialresistant organisms, and incomplete knowledge of the pathogenesis of meningitis are additional factors contributing to mortality and morbidity associated with bacterial meningitis. (1)

DISCUSSION

Epidemiology Endemic meningitis among children takes the form of sporadic cases or small clusters with an endemicity rate of 1.5/100,000 and 20/100,000 population in the developed and developing countries, respectively. At least 890,000 cases [500,000 in Africa; 210,000 in pacific countries; 100,000 in Europe and 80,000 in America] are estimated to occur annually. Of these cases, 160,000 and 135,000 of them are disabling and fatal, respectively. (2) Etiology In many developing countries, E coli and other gram-negative enteric bacilli such as species of Klebsiella, Enterobacter, and Salmonella, are the leading cause of meningitis in newborns. In infants and small children, Streptococcus pneumoniae, Neisseria meningitidis, and H influenzae type b (rare in areas with routine Haemophilus vaccination) are the most common meningeal pathogens. Children older than 5 years and adults are almost exclusively affected by S pneumoniae and N meningitidis. In immunocompromised hosts and in patients undergoing neurosurgical procedures, meningitis can be caused by various different bacteria such as Staphylococcus species, gram-negative enteric bacilli, or Pseudomonas aeruginosa. (3) Signs and Symptoms Meningeal irritation, was defined as presence of one or more of the following six symptoms: neck stiffness, Brudzinskis nape of the neck and/or contralateral leg sign, Kernigs sign, or the tripod-phenomenon in children 1 year and one of the previous signs or irritability or a bulging fontanel in children 1 year. The Brudzinskis, Kernigs and contralateral leg sign tests aim to stretch the inflamed nerve roots and meninges of the cervical region by flexion of the neck, causing protective muscle spasm manifesting as neck stiffness. In children with missing

information on some tests, but with at least one of these signs present, meningeal irritation was considered present. Fever (body temperature 38.0o C) could be present or absent. (4) How to perform Kernigs and Brudzinskis sign : Today, the maneuver is usually performed with the patient supine with hips and knees in flexion. Extension of the knees is attempted: the inability to extend the patients knees beyond 135 degrees without causing pain constitutes a positive test for Kernigs sign. With the patient supine, the physician places one hand behind the patients head and places the other hand on the patients chest. The physician then raises the patients head (with the hand behind the head) while the hand on the chest restrains the patient and prevents the patient from rising. Flexion of the patients lower extremities (hips and knees) constitutes a positive sign. Brudzinskis neck sign has more sensitivity than Kernigs sign. (5) Systemic signs of infection include fever; malaise; and impaired heart, lung, liver, or kidney function. General features suggesting CNS infection include headache, stiff neck, fever or hypothermia, changes in mental status (including hyperirritability evolving into lethargy and coma), seizures, and focal sensory and motor deficits and also increased intracranial pressure. The Absence of meningeal irritation in children with bacterial meningitis was substantially more common in those younger than 12 months. (1, 7) Diagnosis A definitive diagnosis of meningitis is dependent on examination and culture of CSF. When meningitis is suspected, a lumbar puncture should be undertaken. Early diagnosis followed by appropriate medical treatment can have a favorable effect on outcome. In neonates, the procedure should be considered when sepsis is suspected, because meningitis accompanies sepsis in 2025% of cases. (3)

Patients with suspected meningitis should receive a lumbar puncture after a mass lesion has been ruled out on clinical grounds or by CT scan of the head, and if there is no cardiopulmonary compromise.
(1)

When papilledema or focal motor signs are present, a lumbar

puncture may be delayed until a neuroimaging procedure has been done to exclude brain abscess or other space-occupying lesion.
(7)

In addition, study of 302 infants and children with bacterial

meningitis found that brain herniation developed in 6% of patients, occurring within 8 h after lumbar puncture in all patients. lumbar puncture. Laboratory Findings Examination of the CSF of a patient with acute bacterial meningitis characteristically reveals a cloudy fluid, consisting of an increased white blood cell count and predominance of polymorphonuclear leucocytes, a low glucose concentration in relation to serum value, a raised concentration of protein, and a positive stained smear and culture for the causative microorganism. (3) A Gram stain of CSF will show whether bacteria are present, and a positive Gram stain shows bacterial counts higher than 1103 cells per mL in CSF. Gram stain is positive in about 90% of children with pneumococcal meningitis, about 80% of children with meningococcal meningitis, half of patients with Gram negative bacillary meningitis, and a third of patients with listeria meningitis. CSF culture can be negative in children who receive antibiotic treatment before CSF examination. (1) Bacterial meningitis was defined as the presence of elevated leukocyte count (5 cells / mm3) in cerebrospinal fluid (CSF) and a positive pathogenic bacterial culture of CSF and/or blood. (4)
(6)

That's the reason why the CT scan must be performed prior to

Pathophysiology When the pathogens have entered the central nervous system, they replicate rapidly and liberate active cell wall or membrane associated components. These potent inflammatory substances can stimulate macrophage-equivalent brain cells (eg, astrocytes and microglia), cerebral capillary endothelia, or both, to produce cytokines. The cytokines activate adhesion promoting receptors on cerebral vascular endothelial cellsand leucocytes, attracting neutrophils to these sites. Subsequently, leucocytes penetrate the intercellular junctions of the capillary endothelium and cause injury to the vascular endothelium and alteration of blood-brain barrier permeability. (3) The alterations in permeability allow penetration of serum proteins of low molecularweight into the CSF, and lead to vasogenic oedema. Additionally, large numbers of leucocytes enter the subarachnoid space and release toxic substances that contribute to the production of cytotoxic oedema. As a result of the high protein and cell content, the increased viscosity of the CSF contributes to generation of interstitial oedema. (3) The outcome from the vasogenic oedema, cytotoxic oedema and interstitial oedema lead to increased intracranial pressure. This can reduce the global perfusion and finally the neuronal injury apoptosis. (3) Treatment The initial treatment approach to the patient with suspected acute bacterial meningitis depends on early recognition of the meningitis syndrome, rapid diagnostic evaluation, and emergent antimicrobial and adjunctive therapy.(6) In patients with suspected bacterial meningitis for whom immediate lumbar puncture is delayed due to pending brain imaging study or the

presence of disseminated intravascular coagulation, blood cultures must be obtained and antimicrobial treatment should be initiated immediately.(1) For Meningococcal meningitis, Sulfadiazine is the drug of choice, but it is often given in combination with penicillin. Initially when the CSF is being examined, physiologic saline solution with 5 % glucose can be given by i.v. Sulfadiazine should be continued for 7 8 days. Total daily dose is approximately 150 mg/kg/day. (8) For Streptococcal and Pneumococcal meningitis, Penicillin is the drug of choice but many clinicians also use sulfadiazine in conjunction with it. Chloramphenicol is sometimes added to the penicillin-sulfadiazine regimen. The total daily dose is 100 mg intramuscularly, or 200 mg orally. Adequate fluid intake must be maintained. (8) Prognosis Most patients can and do survive. Both survival and the extent of the residual damage are related to the promptness of therapy and to its adequacy. (8) Complications Hydrocephalus and subdural collections of fluid are frequent and important complications, and also may be variety of infection outside the nervous system such as empyema, pericarditis, peritonitis and arthritis. (8)

CONCLUSION

Bacterial meningitis is a disease in children which commonly found in developing countries. Etiology of bacterial meningitis is usually caused by meningococcus, streptococcus, and Haemophilus influenza. Signs of meningeal irritations are not significant for children. To diagnose bacterial meningitis, the clinicians must conduct a CT scan and lumbar puncture to obtain CSF. Later on, the CSF cultured to determine the specific bacteria for medical purposes. Antibiotics which commonly used are sulfadiazine and penicillin. The prognosis is usually good with adequate treatment.

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