Masdar Muid, MD., Paed.

Department of Child Health Saiful Anwar Hospital - Brawijaya University

Bacterial Meningitis
Description: Bacterial meningitis is an inflammation process of the meningen cause by pathogenic bacteria. This disease cause significant morbidity and mortality in the whole world Should be treated as an emergency Clinical suspicion is needed for diagnosis to prevent mortality

bacterial meningitis
Etiological bacteria causing meningitis: 2 months to 5-year-old children H. Influenza, S. Pneumonia, and N. Meningitidis > 5-year-old group: S. Pneumonia, N. Meningitidis and H. Influenza

bacterial meningitis
Historically, meningitis usually preceded by upper

respiratory tract infection or gastrointestinal tract infection, such as fever, cough, diarrhea and vomiting
Fever, headaches and meningismus, with or

without decrease in consciousness are suggestive for meningitis, although none are specific
Most of the meningitis symptoms are age related, for

example, children less than 3 years old rarely complain of headache

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Case Study
A 10 month-old-boy, admitted with prolonged seizures and fever for 1 day. In the Emergency room, the boy had no seizure, but he had decreased of consciousness and his temperature was 39,8oC

Assesment
1. What examination should be done immediately to assess the boy? What are your reasons? Answer: Solve the problem sistematically Diagnosis: Findings should be achieved are: Risk factor identification Assess the clinical condition Immediate laboratory examination: complete blood examination, urine, culture, and resistance test, lumbal puncture, electrolyte serum, liver and renal function 2. Based on these finding, what is the diagnosis? Answer: Bacterial meningitis
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Planning and Intervention

3. Based on the diagnosis, what is the management? Answer: For seizure: stop the seizure using anti-seizure drug For low intake: check blood glucose level For high fever: do tapped sponge and give antipyretic For decrease of consciousness: do head CT or MRI 4. Based on the diagnosis, do proper management? Answer: Etiological treatment: antimicrobial, first choice drug: cephalosporin, such as ceftriaxone 80-100 mg/kg/day for 10-14 days Give corticosteroids If there is hydrocephalus, consult the Surgery Department
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Reassessment
5. Before the treatment, what do we say to the parents and why? Answer: Explain to the parents about the progress of the disease and the possible complications and suggest vaccination for the family

Assessment Instrument
Initial Questionaires

Instruction: choose T if true and F if false 1. In the Children less than 12 months with fever and prolonged seizures, should be thought about bacterial meningitis (T/F) Answer: T (purpose 1) 2. The definitive diagnosis for bacterial meningitis is based on culture and blood resistancy test (T/F) Answer: F (purpose 1) 3. The treatment of bacterial meningitis is based only on empirical antibiotics and adequate food intake (T/F) Answer: F (purpose 2)

Mid Questionaires: MCQ

1. The etiology of bacterial meningitis: a. Always caused by S. Typhi b. Can not be caused by E. Coli c. Can not be caused by S. Paratyphi B d. Commonly caused by S. pneumococcus e. Can not be caused by H. Influenza
Answer: B

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MCQ
2. Contraindications of lumbal punction in children with bacterial meningitis: a. Hyperpyrexia b. Disturbance of hematology study c. Decrease of consciousness (sopor) d. Seizure e. Increase of intracranial pressure
Answer: A
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MCQ
3. Clinical manifestation of bacterial meningitis: a. Not age related b. Commonly high fever for 1-3 days c. Recurrent seizure or prolonged seizure d. Unconscious post seizure e. Always found meningeal sign
Answer: D

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MCQ
4. Treatment of bacterial meningitis: a. Only antibiotic b. If severe, with double antibiotic c. First choice: cephalosporine d. Should administer mannitol
Answer: C

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MCQ
5. Duration of treatment: a. 7-14 days b. Based on patient age c. Based on the etiology d. Based on the blood culture and resistention test e. Based on the severity

Answer: A

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MCQ
6. Surgery should be done in the: a. Every severe bacterial meningitis b. Every patients with bacterial ventriculitis c. Every patients with hydrocephalus d. Every patients cerebral abscess e. Patients with increasing intracranial pressure
Answer: B

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MCQ
7. The most common sequel of bacterial meningitis: a. Extremity spasticity b. Epilepsy c. Hearing disturbance d. Mental retardation e. Epilepsy
Answer: C

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Lumbal Puncture
Purpose: to obtain cerebrospinal fluid for diagnostic and measuring CSF pressure Indication: 1. Meningitis 2. Intracranial infection 3. Fever observation Contraindication 1. Raised intracranial pressure 2. Air inside the myelogram/ encephalogram (in a well-planned lumbal puncture) 3. Lokal skin infections over proposed puncture site Complication: 1. Herniation (if the intracranial pressure increased) 2. Headache 3. Infection

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Masdar Muid, MD., Paed. Department of Child Health Saiful Anwar Hospital - Brawijaya University

MENINGITIS TUBERCULOSA
Description: Meningitis Tuberculosa one of tuberculosis complication High morbidity and mortality Indonesia incidens equal with tuberculosis itself Usually as primary tuberculosis spreading, in which other focus infection Diagnosis clinical feature, history of TB contact (sometimes asymtomatic), tuberculin test (+), CNS disorder
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description
Treatment adequate and proper management is

needed: 1. Proper kemoterapi 2. Fluid and electrolyte correction 3. Decrease intracranial pressure Usually without treatment patient died Prognosis 1. Depend on stage of disease where treatment start 2. Patient age

Case Study
Male,10 month-old, admitted with subfebrile for 14 days. 7 days before admission the boy was irritable and 3 days before admission the boy look sleepy. The boy was seizing 1 day before admission. The boy often cough, have cold followed by subfebrile and difficult gained the weight.

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Assesment
1. What examination should be done immediately to assess the boy? What are your reasons? Answer: Solve the problem sistematically Diagnosis: Findings should be achieved are: Risk factor identification Assess the clinical condition Immediate laboratory examination: complete blood examination, LED, cerebrospinal fluid examination, tuberculin test, chest x-ray, EEG and CT-scan if needed. 2. Based on these finding, what is the diagnosis? Answer: Meningitis Tuberculosa
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Planning and Intervention

3. Based on the diagnosis, what is the management? Answer: For dehydration: check electrolyte serum For low intake: check blood glucose level For shortness of breath: do chest x-ray For sign of hydrocephalus: do head CT-scan
4. Based on the diagnosis, do proper management? Answer: Etiological treatment: 4 kinds of antituberculosis drugs: INH, Rifampicin, Pyrazinamid, Ethambutol and Corticosteroid For seizure: give anticonvulsant drug If there is hydrocephalus, consult the Surgery Department
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Reassessment
5. Before the treatment, what do we say to the parents and why? Answer: Explain to the parents about the progress of the disease and the possible complications and suggest to find the source of disease

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Assessment Instrument
Initial Questionaires
Instruction: choose T if true and F if false 1. In the Children with prolonged fever and seizures,

should be thought about meningitis tuberculosa (T/F) Answer: T (purpose 1) 2. The treatment of meningitis tuberculosa are 4 regimen antituberculosis drugs (T/F) Answer: F (purpose 2)

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Mid Questionaires: MCQ

1. Clinical manifestations of meningitis tuberculosa, except: a. Nervus Craniales parese b. Seizure c. Decrease of consciousness d. Involuntary movement e. Hemiparesis
Answer: D
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MCQ
2. Causes of meningitis tuberculosa: a. Lymphogenic spread of mycobacterium tuberculosis b. Tubercle in meningen is explode c. Hematogenic spread of mycobacterium tuberculosis d. Immune compromise e. Degree of bacterial virulence
Answer: B
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MCQ
3. Specific feature of cerebrospinal fluid in meningitis tuberculosa: a. Protein and glucose are increase b. Protein and glucose are decrease c. A thousand cell counts with polymorphonuclear domination d. A hundred to thousand cell counts with lymphocyter domination e. A hundred cell counts, glucose level and protein are normal
Answer: D
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MCQ
4. Complications of meningitis tuberculosa: a. Hydrocephalus b. Blindness c. Epilepsy d. Neuropathy perifer e. Mental retardation
Answer: A

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MCQ
5. Treatment of meningitis tuberculosa: a. 3 regimen of antituberculosis drugs and corticosteroid b. 4 regimen of antituberculosis drugs c. 4 regimen of antituberculosis drugs and acetazolamid d. 4 regimen of antituberculosis drugs and corticosteroid e. 4 regimen of antituberculosis drugs, acetazolamid and corticosteroid
Answer: D
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MCQ
6. Surgery should be done in the: a. Ventriculitis b. Obstructive hydrocephalus c. Brain swelling d. Tuberculoma e. Increase intracranial pressure
Answer: B

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MCQ
7. Prevention: a. Immunomodulator b. Gamma-globulin administration c. Vaccination and avoid contact to TB patient d. Explanation and information arent necessary to family e. Vaccination
Answer: C
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MCQ
8. The most common sequel of meningitis tuberculosa: a. Mental retardation b. Extremity spasticity c. Seizure d. Blindness e. Hearing disturbance

Answer: B
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Masdar Muid, MD. Paed.

Department of Child Health Saiful Anwar Hospital - Brawijaya University

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ENCEPHALITIS
Description: HSV type 1 transferred through airway and saliva Primary infection usually occurs in children and adolescent HSV type 1 cause encephalitis in all age, but most common in patient > 20 th suggested that encephalitis cause by endogenous virus reactivation from the primary infection Neurologic disorder is a complication from reactivation
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description
HSV type 1- Primary infection virus became

latency in ganglia trigeminal few years later: a non-specific stimulation causing reactivation (usually the manifestation is herpes labialis); virus can reach the brain through the branch of trigeminal nerve to the meningen basal, causing localization from encephalitis in temporal region and fronto-orbital lobes

Encephalitis Herpes Simplex (EHS) in neonate

HSV type 2 from vagina mother with active genital herpes commonly causing meningitis
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Description-Physical examination
Neurologic examination sometimes reveals

hemiparesis (important focal manifestation)

Some case with afasia, ataxia, autonomi system

disturbance, craniale nerve paresis, meningeal sign (+) and papil edema
Some case with clinical manifestation look like

aseptic meningitis without clear manifestation of meningitis

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Description Clinical manifestations

EHS manifest acute and sub acute 1. Prodromal stage: malaise, febrile for 1-7 days 2. Clinical manifestation of encephalitis: headache,

vomiting, personality change and memory alteration difficult to detect in children 3. Then patient had seizure (general or focal) and decrease of consciousness 4. Consciousness decreased to coma and lethargic oftentimes die or recovered with severe sequelae

Coma is worst prognostic factor; patient with coma

Death occurs usually in the first 2 weeks
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Description - Diagnosis
From feature above clinical manifestation is very unspesific,

especially in children and EHS diagnosis need a strong clinical suspicion

In practice we should always think about EHS if find a

children with febrile, seizure, especially focal seizure and focal neurologic symptoms such as hemiparesis or aphasia with progressif decrease of consciousness

Diagnosis establish based on: 1. Clinical manifestation 2. Laboratory examination 3. EEG, scanning 4. Brain biopsy (rare) 5. Polymerase Chain Reaction (PCR)

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Description Laboratory Examination

Complete blood examination is not specific
Cerebrospinal fluid normal in 1/4th cases and the other

abnormal with increasing pressure, pleiositosis, increasing protein level, sometimes colour xantochrome caused by bleeding Virus isolation in cerebrospinal fluid is not performed routinely because positive result was rare

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Description - EEG
EEG periodic lateralizing epileptiform discharge or

focal delayed in temporal and fronto-temporal region

EEG usually showed general delayed that revealed

disseminated brain dysfunction

EEG sensitivity 84% and specificity 32,4%

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Description - Scanning
Scanning can help establish the diagnosis of EHS is

head CT-scan and MRI Specific feature on CT-scan show in 50-75% cases Hypodens area in temporal or frontal lobe, sometimes extend to occipital lobe This hypodens area caused by brain tissue necrosis and brain swelling Specific appearance on CT-scan have seen earlier after the first week MRI more sensitive and shows earlier result comparing with CT-scan

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Description - Therapy
Symptomatic treatment and supportive treatment same as

other therapy, including management of: 1. Seizure 2. Brain swelling 3. Increasing intracranial pressure 4. Hyperpirexia 5. Respiratory disturbance 6. Secondary infection

Main different in EHS treatment can give specific

antivirus with acyclovir : dose 30 mg/kg/day divided into 3 doses for 10 days
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Description - Prognosis
Prognosis EHS if it is not cure death 70-80% after 30

days and increase to 90% in 6 months 28%

Early treatment with acyclovir can decrease mortality to

Sequelae symptom more often found and severe in

uncuratif case

Delayed of treatment > 4 days poor prognosis Coma oftentimes die or recovery with severe sequeleae

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Case Study
Children,3 years 6 months, admitted with main complaint seizures for 20 minutes, focal in the right side followed by decrease of consciousness. 2 days before admission, chilren was febrile and vomiting. We found paralysis in the right side.

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Assesment
What examination should be done immediately to assess the children? 2. What should be done immediately based on your assesment? Answer: a. Emergencies detection based on general appearance of the patient Consciousness, breathing, circulation If status epilepticus occurs b. Other Metabolic disturbance detection Dehydration Acidosis Hypoglycemia c. Electrolyte disturbance detection
1.
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Assesment
From assesment, we found: Consciousness: sopor, temperature 39.50C, normal breath, fast pulse rate adequate, blood pressure 90/60 mmHg Meningeal sign (-), increase physiological reflex, pathological reflex (babinsky) (+), clonus (+), right side hemiparesis lesi UMN 3. Based on these finding, what is the most posssible diagnosis in this children? Answer: Encephalitis
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Planning and Intervention

4. Based on the diagnosis, what is the management? Answer: Check blood glucose level and electrolyte serum Do lumbal puncture, if there is no contraindications Do EEG examination Check antibody titer serum for HSV and Japanese 5. Based on the diagnosis, do proper management? Answer: First line antiviral drugs acyclovir 30 mg/kg/day divide 3 doses intravenously for 10 days If seizure or status epilepticus occurs give anticonvulsant drugs according to the seizure protocol management Give mannitol to lower the increasing intracranial pressure
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Reassessment
6. What should we monitor for patient follow-up? Answer: After the emergencies take care do general appearance observation: improvement of consciousness and declining temperature Do follow-up after 3-5 days of treatment if there is no improvement and clinical condition was worsening, need to reevaluate: Is there no improvement for the complication and Is there any secondary infection? Counceling the parents about the course of disease, sequel and physiotherapy
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Assessment Instrument
Initial Questionaires

Instruction: choose T if true and F if false 1. Encephalitis in children caused by Herpes Simplex virus (T/F) Answer: T (purpose 1) 2. Encephalitis not always followed by fever (T/F) Answer: F(purpose 1) 3. Japanese Encephalitis can prevented by immunization (T/F) Answer: T(purpose 3)

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Mid Questionaires: MCQ

1. The Herpes Simplex virus route of transmission: a. Direct spread from near foci in the brain b. Metastatic came from far foci hematogenously c. Airway and saliva d. Food e. All true
Answer: C
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MCQ
2. Diagnosis of encephalitis establish based on: a. Clinical manifestation b. Laboratory examination c. EEG d. Scanning e. All true
Answer: E

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MCQ
3. We usually found on cerebrospinal fluid examination: a. Cell counts > 1000/mm3 b. Low protein level c. Sometimes the colour was xanthochrom caused by bleeding d. Very low glucose level e. All false
Answer: C
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MCQ
4. We often find a feature in EEG examination: a. Hypsarryhtmia b. Suppression burst c. Spike-slow wave d. General delayed e. All false
Answer: D

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5. Treatment for HSV encephalitis : a. Ceftriaxone for 1 week b. Acyclovir for 10 days c. Ampicilline + Chloramphenicole for 10 days d. Cefotaxime for 10 days Answer: B

MCQ

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MCQ
6. Treatment for Japanese B encephalitis : a. Ceftriaxone for 1 week b. Acyclovir for 10 days c. Ampicilline + Chloramphenicole for 10 days d. Supportive treatment
Answer: D

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MCQ
7. Sequel symtoms that may be occurs and need to informed to the parents when discharge: a. Mental retardation b. Kognitif disturbance c. Seizure d. Behaviour disturbance e. All true
Answer: E
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MCQ
8. The most common sequel of encephalitis: a. Mental retardation b. Extremity spasticity c. Seizure d. Blindness e. Hearing disturbance

Answer: B
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