Ped in Rev - Meningitis - 2008

MeningitisKeith Mann and Mary Anne Jackson Pediatrics in Review 2008;29;417 DOI: 10.1542/pir.29-12-417 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pedsinreview.aappublications.org/content/29/12/417 Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1979. Pediatrics in Review is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2008 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0191-9601. Downloaded from http://pedsinreview.aappublications.org/ at Eccles Health Sciences Lib on September 28, 2014 Associate Director. signs. Pneumococcal and Hib: Haemophilus influenzae type b meningococcal meningitis occur with an annual incidence in HIV: human immunodeficiency virus the range of 4 to 5 and 2. Section Chief. tuberculous. use of enteroviral polymerase chain reaction (PCR) has commercial become routine in most children’s hospitals. a number of developments have occurred in the epidemiology and manage- of an unapproved/ ment of meningitis in the pediatric patient. viruses. University of Missouri-Kansas City School of Medicine. It is crucial for pediatricians to remain vigilant in their understanding of the epidemiology. † Professor of Pediatrics. disclosed no financial 5. Group B Strepto- IAP: intrapartum antimicrobial prophylaxis coccus (GBS) remains the predominant bacterial pathogen in IV: intravenous the neonatal population (Fig. Most pathogens CSF: cerebrospinal fluid are specific to certain age groups. geography. 2. MD. including CNS: central nervous system bacteria. seasonality. Distinguish bacterial. respectively. 1).000 children HSV: herpes simplex virus younger than 5 years of age. readers should be able to: Anne Jackson. viral.5 cases per 100. Abbreviations Epidemiology and Etiology BCG: Bacille Calmette-Guérin A variety of infectious agents can cause meningitis. In the developed world. management. use of adjunctive dexamethasone are now available. Mo. Since the introduction of Hib TST: tuberculin skin test conjugate vaccines in 1988. the incidence of invasive disease in WBC: white blood cell the United States has decreased 99%. PCR: polymerase chain reaction For physicians who trained prior to 1990. and additional data concerning the effective product/device. *Assistant Professor of Pediatrics. Jackson have 4. Pneumococcal and meningococcal conjugate investigative use of a vaccines have been implemented.org/ at Eccles Health Sciences Lib on September 28. key central nervous system (CNS) pathogens that cause meningoencephalitis or enceph- alitis also are discussed because clinical symptoms. pathogenesis. and morbid- ity and mortality in the child who has bacterial meningitis has not changed in the last 15 years. Identify the long-term sequelae of meningitis.29 No. List the typical clinical manifestations of meningitis. and laboratory findings in these conditions often overlap. Describe key management issues for a child who has bacterial meningitis. Article infectious diseases Meningitis Keith Mann. Pediatric Infectious Diseases. 2014 . This commentary does not Introduction Since the last review of meningitis in Pediatrics in Review in 1998 by Wubbel and contain a discussion McCracken. and CT: computed tomography underlying host factors. Kansas City. meningitis remains one of the most significant infections in children. and mycobacteria. the eradication of SIADH: syndrome of inappropriate antidiuretic meningitis caused by Haemophilus influenzae type b (Hib) hormone likely remains the most dramatic medical development wit- TB: tuberculosis nessed during their careers.12 December 2008 417 Downloaded from http://pedsinreview. University of Missouri-Kansas City School of Medicine. and follow-up of affected patients. Pediatric Residency Program. fungi. Drs Mann and 3. in developing countries.aappublications.* Mary Objectives After completing this article. Children’s Mercy Hospital and Clinics. meningo- GBS: group B Streptococcus coccus and pneumococcus currently cause 95% of cases of GCS: Glasgow Coma Scale acute bacterial meningitis in children. Recognize the common acute complications of meningitis. Pediatrics in Review Vol. MD† 1. and fungal meningitis based on clinical Author Disclosure presentation and cerebrospinal fluid analysis. despite the availability of newer antibiotics and preventive strategies. Although this article focuses on menin- gitis. Mo. Children’s Mercy Hospital and Clinics. However. Kansas City. relationships relevant to this article. Still. Hib remains an important cause of meningitis. Vice Chair of Clinical Affairs-Inpatient Services. the maternal genital tract is the source ation with brain abscesses. adenitis. although ascending infection can occur in the face commonly with meningitis. meningⴝNeisseria meningitidis. Figure derived from Centers for Disease Control and Prevention data. Gram-negative bacillary meningitis 1995. gram-negative neonatal meningitis pathogens such as cytogenes and gram-negative agents. although nosocomial sources within the nurs- certain drugs associated with CNS inflammation also are ery setting also are documented.aappublications. Pathogenic agents of bacterial meningitis in the United States by age group. pneumoⴝStreptococcus pneu. Although typical bacterial and viral causes of menin. Infants typically manifest with signs infant is delivered vaginally through an infected birth suggestive of sepsis. Seventy-five percent of cases are caused by greater than 80% reduction in early-onset disease.29 No. including Esche.and late-onset disease.12 December 2008 Downloaded from http://pedsinreview. It is encountered almost exclusively moniae in neonates. Finally. transmission occurs when an cases still occur. The maternal genital tract is the most likely source for gitis are the focus of this review.3 cases per 1. prematurity. although skeletal infec- tion. such HSV-2. encephalitis. with E coli being the most commonly isolated pathogen. Citrobacter koseri. but less canal. Similar to GBS menin- covered briefly. deficient transfer of antibodies from mother to baby in the preterm infant of less than 32 weeks’ gestation. and patients who have of factors. HSV in the newborn can present as isolated skin or with 75% presenting as early-onset disease (first 7 days mucous membrane lesions. The typical infant who has late-onset disease is 3 to 4 weeks of age and presents with meningitis or bacteremia. and reviewed because delayed diagnosis of this infection is prolonged rupture of membranes are predisposing fac- common and can result in significant sequelae. In the era before intrapartum antimicrobial prophylaxis (IAP). The few cases of GBS disease occurring after 3 months of age generally are seen in infants who were born preterm. and Neonatal Disease an increased ability of bacteria to penetrate the blood- Neonatal Streptococcal Meningitis brain barrier. and Serratia richia coli. tuberculous meningitis is gitis. 1 to Neonatal Herpes Simplex (HSV) Infection 4 neonatal infections per 1. tors. N. 2014 . often with pneumonia. rickettsial infections and infection. GBSⴝgroup is rare in the pediatric population.infectious diseases meningitis Late-onset disease has not been affected by IAP. CNS infection in neonates may relate to a combination the immunocompromised host. S.org/ at Eccles Health Sciences Lib on September 28. or a dissemi- after birth). marcescens. transmission from a caregiver or health-care worker oc- 418 Pediatrics in Review Vol. indwelling foreign bodies are discussed. and the current incidence estimates suggest ap- proximately 0. Neonatal Gram-negative Meningitis Figure 1. this common complication is not well defined.000 live births. horizontal of cases of early-onset GBS disease. The unusual predilection of these organisms for special pathogens that cause meningitis in the neonate. Occasionally. GBS remains the predominant neonatal meningitis Environmental sources are well documented for other pathogen. which is noted in 5% to 10% of intact amniotic membranes. Although IAP has been associated with a nated process. Enterobacter sakazakii. maternal intrapartum infection. including less efficient defense mechanisms. although sporadic cases related to Listeria mono. continue to be important. and cellulitis also oc- cur. In most instances. In addition. These pathogens are notable for their associ- In most cases. the latter often associated with CNS infection.000 live births were reported. B Streptococcus. a figure similar to the cur- rent incidence of early-onset dis- ease. although the pathogenesis of of the pathogen for both early. Pediatrics in Review Vol. with the highest age- occur and result in infection from a transplacental source. strains. exposure to are known. frequently no decreased significantly. A 2005 Pneumococcus has emerged as the leading pathogen review of 76 outbreaks in the United States noted that causing bacterial meningitis in infants and young chil. 7 serotypes (14. Although 90 pneumococcal serotypes risk of colonization is noted with crowding. 18C. An increased choroid plexus. with an recognized. Switzerland. and cases of meningitis continue to be identi- tion compared with those who have recurrent genital fied. or gococcal disease generally occurs in otherwise healthy early-onset infection. creased risk for meningococcal infection has been con- In February 2000. Children younger than 1 before the importance of nasopharyngeal carriage was year of age have the highest risk for meningitis. Wyeth Pharmaceuticals.000 and 3. 1). The pathogenesis of pneumococcal menin. 2014 . Asymptomatic fecal and vaginal carriage also can coccal disease occur each year.) was incorporated into the universal include anatomic or functional asplenia.000 cases per year of invasive Historically. with subsequent bacteremia and seeding of the peaks at age 1 year and after age 15 years. Nasopharyngeal carriage can be intermittent. and travel to the number of invasive pneumococcal infections caused epidemic or hyperendemic regions (Saudi Arabia. emerged. and N meningitidis is the predominant bacterial agent of meningitis in young Common Non-neonatal Bacterial Pathogens adults. emerged as an important cause of invasive pneumococcal infection. Pa. with tion. and active and passive smoking. Secondary cases and outbreaks are well papular truncal rash has been identified. Menin- bles) and can precipitate abortion. cases are associated with Listeria serotypes Ia.12 December 2008 419 Downloaded from http://pedsinreview. Neonatal Listeria Meningitis Maternal infection usually relates to a food-borne source Neisseria meningitidis (unpasteurized milk and soft cheeses. Other con- conjugate vaccine (Prevnar®. Serotype re- Although HSV infection occurs most commonly in placement (emergence of nonvaccine serotypes) has infants born to mothers who have active primary infec. with the other two dren in developed countries (Fig. meningitis is the most common. 6B. A second peak in the 8. sub- by vaccine-serogroup isolates among eight United States Saharan Africa). or exposure at the time of delivery. Since implementation. terminal com- childhood vaccination schedule.aappublications. Data from the thirds occurring in colleges and universities. In the is 2 days to 2 weeks. Although 98% of invasive meningococcal infec- Streptococcus pneumoniae tions are sporadic. and two thirds of cases seen in children younger than Late-onset meningitis may follow exposure at delivery 5 years of age. Such early-onset described in the literature. year 2000 confirmed 17. preterm delivery. An in- strains. and nursing homes. pneumococcal carriage. specific incidence in children younger than 1 year of age ascending infection. unwashed raw vegeta. Nearly 100 years passed deaths in the United States.000 cases of invasive meningo- IVb. undercooked poultry. In our institution. laboratory exposure.000 fections appear within days of acquiring pathogenic population. group was noted in a recent study. 19F.29 No. although pneumococcal menin- maternal history or clinical evidence is available to alert gitis and cases of empyema continue to occur and are the practitioner to this diagnosis. meningococcus was recognized initially pneumococcal disease among children younger than 5 as a cause of meningitis in 1805 after an epidemic oc- years of age. multidrug-resistant serotype 19A has CNS infection are 2 to 3 weeks of age. 4. coccal infection. ditions that predispose to meningococcal infection Philadelphia. outbreaks can and do occur. the incidence of bacteremia has herpes (ⱖ50% versus ⱕ5%. one third were community-based. infectious diseases meningitis curs from a nongenital source.org/ at Eccles Health Sciences Lib on September 28. A septic appearance in the neonate individuals and often has a fulminant presentation with is typical in cases of early onset. a 7-valent polysaccharide-protein firmed following outbreaks of influenza A. primary and Centers for Disease Control and Prevention from the secondary schools. Ib. and Between 2. plement deficiency. usually related to virus children’s hospitals has decreased more than 75% for transfer from mouth or hands. 23F. Among the clinical presentations of invasive meningo- eat meats. gitis occurs primarily through nasopharyngeal coloniza. and 9V) have been noted to account for 78% of invasive concomitant upper respiratory tract infection. The incubation period related almost exclusively to nonvaccine serotypes. and most infants who develop HSV last 2 to 3 years. reports now confirm that most invasive in- estimated incidence of approximately 10 per 100. children 24 months of age and younger. prepared ready-to. including 700 cases of meningitis and 200 curred in Geneva. respectively). and a characteristic high fatality rates.to 11-year age and most often is associated with serotype IVb. Mycoplasma. eastern mid-Atlantic states. with the pathogens generally present. A definitive agent is the setting of systemic lupus erythematosus or Kawasaki established in one in four patients. The World Health Organization estimates that 1. with liver.3 mil- and B4 and echoviruses 6. Pathogens such as HSV.org/ at Eccles Health Sciences Lib on September 28. the sota and Wisconsin).29 No. and muromonab-CD3 (OKT3) United States. and 30. with dissemination from the lung to the Disseminated disease. In contrast. and Y strains have predominated in the United in the immunocompetent infant and child has a benign States. intravenous (IV) immune globulin in treating neonatal ningococcus were identified. litis presentations often predominate. B2. Studies are ongoing to assess the groups have been identified. nonsteroidal anti-inflammatory agents such as ibuprofen. and several viruses can circulate simultaneously in a season. or CSF leaks (rhinorrhea). C. that this pathogen is now the most common cause of nates who have symptoms and signs consistent with bacterial meningitis in sub-Saharan Africa. Some experts recommend the use of encountered most commonly in urban cities. Predominant pathogenic effectiveness of pleconaril (a new antiviral drug) in such serogroups include A. B. where serogroup C conjugate vaccine has been imple. with enteroviruses predominat. cases. likely related sepsis. A review in 2004 provided an and cases of meningitis are recognized most commonly in-depth discussion of tuberculous meningitis. CNS involvement can occur with a variety of other mented. 2014 . In certain parts of the IV immunoglobulin.infectious diseases meningitis In 1909. human herpesvirus-6. uncomplicated enteroviral meningitis B. Ehrlichia sp. although meningeal signs may be yond the newborn period. neurosurgical device. natal infection in up to 70% of infants diagnosed as Pediatric meningitis caused by M tuberculosis tends to having enteroviral disease within the first 10 days after be a complication of primary infection in the child 5 years birth. tuberculosis (TB) globally. including neurosur- lowing lumbar puncture. inhalation. as are rare cases of intrauterine transmission.aappublications. The seasonality of enteroviral meningitis generally is such that the typical pediatric resident who starts training in July becomes adept at recognizing and Less Common Pathogens diagnosing this clinical infection. lion annual cases and 450. most are noted. a history to elicit maternal symptoms should be to the prevalence of human immunodeficiency virus sought. and northern California. with documented herd immunity sufficient to stricted to meningitis. and myocardial lymphatics and to the bloodstream. and often the clinical presentation is not re- occurred. brain. mented. In one study of adults. gery or head trauma within the past month. presence of a A large number of enterovirus serotypes are docu. (HIV) infection. The most common viruses associated with Mycobacterium tuberculosis meningitis outbreaks include Coxsackieviruses A9. including southern New England and the and antimicrobials such as trimethoprim-sulfamethoxazole. meningoencephalitis or encepha- protect unimmunized children. ra- Viral. a nearly 80% reduction in serogroup C cases has agents. Aseptic meningitis can occur in Kawasaki disease. Most children are Non-neonatal Gram-negative Bacilli not severely ill and often present with a nonspecific Meningitis caused by gram-negative bacilli occurs be- febrile illness. noting in children younger than 1 year of age. and since 1996. Primary infection occurs after droplet scribed. generally direct the clinician to this diagnosis. today. is caused by a variety of infec. immunologically distinct serogroups of me. Miscellaneous Infectious. The drugs implicated most commonly include common agents are viral. at least 13 sero. ing in the pediatric population.000 deaths are caused by Enteroviruses are transmitted by the fecal-oral route. and W-135. and by far the most disease. This distri- 420 Pediatrics in Review Vol. occurs in this age group and is associated most cases of TB arise in lower-income groups and are with high mortality. Maternal enteroviral infection may precede neo. Epstein-Barr virus. patients had predisposing factors. In young neo. Borrelia typical mucocutaneous manifestations of that disease burgdorferi is an important cause of CNS infection. and bies virus. In the United States. inflammation in which common bacterial pathogens Cases of noninfectious aseptic meningitis include have not been identified. C. enteroviral infection. 9. defined as a syndrome of meningeal cause encephalopathic signs and symptoms. the upper Midwest (Minne. those that are drug-induced or are related to vasculitis in tious and noninfectious agents.12 December 2008 Downloaded from http://pedsinreview. Vertical transmission to the infant is well de. In the United Kingdom and other countries course and generally has no sequelae. and Rick- Noninfectious Pathogens ettsia rickettsii are examples of pathogens more likely to Aseptic meningitis. and many children improve clinically fol. involvement. The typical cerebrospinal fluid (CSF) findings being nosocomial in origin. of age or younger. 11. arboviruses. with African American children being at highest risk. pressure and meningeal inflammation such as vomiting. Older children and adolescents have viral or bacterial meningitis can present often experience malaise. a spirochete. with a constellation of constitutional. Approximately one quarter of pediatric TB cases in the Clinical Manifestations of Meningitis United States occur in foreign-born children. years of age. and the absence of tick bite history and It is important to record a thorough birth history and typical exanthema are associated with a delay in diagno. age of the patient.29 No. The primary vector for R HIV infection. The tick-borne systemic vasculitis of Rocky Mountain Mechanical risk factors include CNS trauma. depending on the pathogen and the TB rates are recognized both in immigrants and interna. continue Infants younger than 1 month of age who to predominate.org/ at Eccles Health Sciences Lib on September 28. nonspecific signs. irritability. some patients who have meningitis present with an acute and fulminant onset of sepsis and the eastern mid-Atlantic. Recent infections such as otitis media. vomiting. Infants who have infliximab or etanercept. chronic renal disease. Although neurologic manifestations of borre. the upper Midwest. asplenia. The history and physical examination are integral parts of liosis can occur at any stage. headache. multiorgan involvement. and seizures also can occur. and irritability. Infants and children who have meningitis can have myr- monly in children born in Mexico. myalgia. includ- Other risk factors predictive of the development of ing fever. chronic renal failure. and nausea. treatment feeding. 2014 . similar to enteroviral and Borrelia infections. and seizures. Although high latent iad presentations. . The seasonality of Lyme meningitis is similar tance in the child who is suspected of having a CNS infec- to that of enteroviral meningitis. and sickle rickettsii is the Dermacentor variabilis tick in the east and cell disease. after day 5 of symptoms. and symptoms due to meningeal inflammation and in- creased intracranial pressure. recent travel Pediatrics in Review Vol. presentation. neck nonspecific signs. photophobia. anorexia. Approximately 20% to 25% of children who have Rickettsia rickettsii pneumococcal meningitis have a predisposing risk factor. with worse outcomes for those children diagnosed thirds of cases. infants older than 1 month of age and Borrelia burgdorferi young children present with nonspecific constitutional Lyme meningitis usually afflicts children living in Lyme. . is transmitted in most cases by the deer tick Ixodes scapularis or I History pacificus. and north. chronic basilar meningitis the initial evaluation of an infant or child who is pre- occurs most commonly in the early disseminated phase of sumed to have meningitis. . ventricular shunt placement. constellation of constitutional. hypothermia. steroids and tumor necrosis factor antagonists such as apnea. and a CSF leak. cases cluster Medical risk factors include immunodeficiency such as from May through August. and implants. Signs endemic regions such as states in southern New England. sinus- central United States and D andersoni in the west. such as lymphoma.aappublications. Historical factors of impor- infection. lethargy. HSV infection. diabetes. The itis. terial meningitis can present with a similar sepsislike and malnutrition. Similarly. the child traveler also is at risk who have viral or bacterial meningitis can present with a for infection and disease. including cortico. to inquire about contact with ill individuals. Signs and symptoms of increased intracranial with immunosuppressive medications. However. lethargy. cochlear spotted fever can have prominent CNS symptoms. and mastoiditis can predispose a child to bacterial diagnosis most often is made in children younger than 15 meningitis. tion need to be detailed systematically and meticulously (Table 1). and underlying medical condi. Infants younger than 1 month of age tionally adopted children. neonatal enterovirus infection. symptoms such as fever. ern California.12 December 2008 421 Downloaded from http://pedsinreview. and poor tuberculous disease include HIV infection. B burgdorferi. most com. Most cases occur in nonwhite individuals. and bac- tions. stiffness. infectious diseases meningitis bution is exemplified by seven states accounting for two sis. in- cluding mental status changes. It is lateral dilated. maternal GBS coloniza. lethargy. cats. The tick bined with all aspects of the evaluation.org/ at Eccles Health Sciences Lib on September 28. and meningococcal vaccines should examination is essential. Physical findings that should be assessed quickly include children who have had invasive pneumococcal infection the patient’s general appearance and respiratory. unilateral or bi- facilitate chemoprophylaxis in appropriate situations. tuberculous meningitis ● Vectors. The Past Surgical History ● Asplenia pediatric patient who has Lyme ● Central nervous system shunts meningitis tends to be older (mean. nelle in infants. and an assessment of consciousness.aappublications. A history of being exposed to a tick or living in a Past Medical History ● Recent illness wooded endemic area may be a key ● Chronic illness ● Head/facial trauma factor in making this diagnosis. traveled to a country at high risk for TB exposure. mosquitos. an tion status and treatment. or coma. a birth history. and the dates of Following the initial assessment.29 No. and neurologic status. Although identification of the underimmunized infant Physical Examination may not alter the approach to diagnosis and therapy. with cases reported from all states except for Maine. including dates of (1 to 2 days). wooded area/camping) adults who have a positive tubercu- lin skin test (TST) or tuberculous disease or who were born in or history or vector exposures. vector for Rocky Mountain spotted fever is more widespread in the Central Nervous System Infection United States. or a bulging fonta- insufficient to review immunization history without per. a complete physical Hib. Altered levels of consciousness can Infants and children who have bacterial meningitis present as irritability. and an erythema migrans ● Antibiotics rash than is the patient who has Exposures ● Ill contacts enteroviral meningitis. Specifically. It is important for Concerning signs and symptoms of increased intracranial clinicians to ask about and record child care exposure to pressure include papilledema. 2014 . homeless) close contact with adolescents or ● Travel (out of the country. in infants who have no concordant maternal history of using the pediatric Glasgow Coma Scale (GCS) or other HSV. medication intake (specifi. pneumococcal. validated measure. vaccine appropriate for age on recovery. cardio- should complete the full series of doses of pneumococcal vascular. The fontanelle in infants should be documented to ensure proper immunization. A head circum- 422 Pediatrics in Review Vol. breath sounds. ● Cochlear implants 10 years) and has had a longer du- Birth/Perinatal History ● Maternal sexually transmitted infection ration of prodromal symptoms ● Chorioamnionitis ● Prolonged rupture of membranes (1 to 2 weeks) compared with the ● Perinatal infection child who has had viral meningitis Immunizations ● Full review of vaccines. usually have been healthy previously.infectious diseases meningitis Historical Features of the Child Who Has Table 1. poorly reactive pupils. be palpated while the infant is held in a sitting position. The patient who has pneumococcal and meningococcal vaccines Lyme meningitis also is more likely Medications in past ● Nonsteroidal anti-inflammatory agents to have cranial nerve findings. who has meningitis and a history of contacts in jail. Children who have Lyme meningitis generally reside Although not sensitive or specific for meningitis as an in or have traveled to the distinct geographic regions isolated maneuver. diplopia. cally recent antibiotic use). assessment of vital signs (including pulse oximetry). and pulses in addi- in mind that neonatal HSV infection generally occurs tion to vital signs). sonal inspection of the child’s record. assessment of the cardiopulmonary status (work of ally transmitted infection should be elicited. somnolence. and immunization status. the initial evaluation should include an For infants.12 December 2008 Downloaded from http://pedsinreview. and Hawaii. perfusion. ● Child care Finally. this measure is helpful when com- where the implicated tick vector is endemic. and maternal history of sexu. Important Historical Information Key Questions Alaska. keeping breathing. including bites/contact (ticks. should be suspected in any patient bats) ● Tuberculosis exposure (institutionalized contacts. pap- 6 months ● Immunosuppressive agents ● Recent intravenous immune globulin illedema. meningitis.5⫻103/mcL (0. but the clinician skin lesions. the child’s age. and protein mea- be elicited. this sign generally is formed. sis (WBC often greater than 1. and the protein value than 6 weeks of age suggests the diagnosis of HSV often is greater than 1. infectious diseases meningitis ference always should be obtained. Often. For patients who have signs of increased Neutrophil predominance is common early in the course Pediatrics in Review Vol. the different from those of an adult. Serum electrolytes should be measured because the copic and cranial nerve evaluation because papilledema syndrome of inappropriate antidiuretic hormone can be present with Lyme meningitis. borre. platelet counts are within normal ranges. paradoxic irri. clinical suspicion should be high for infants should be aware that Gram stain findings never should be who present with a septic appearance and have negative used to narrow the spectrum of empiric coverage. Bacterial meningitis can present with other thrombocytopenia. 2). A Gram note that the absence of Kernig and Brudzinski signs stain of the CSF should be performed promptly as well as does not exclude meningitis. depending should have their CSF examined unless lumbar puncture on the patient’s clinical presentation and characteristics is contraindicated. and coagulopathy may be present in focal neurologic deficits. If a mass lesion.0⫻109/ liosis (erythema migrans). signs of meningeal irritation should ferential count.5⫻109/L).29 No. compromise. A posi. categories for all types of meningitis. especially in those intracranial pressure. and the patient the infant. for example. often with a WBC sure. and invasive meningococcal or L]). However. Joint involvement can be present in GBS or meningococ. (SIADH) occurs in bacterial meningitis. Besides complete white blood cell (WBC) count may be high in assessing the patient’s perfusion.05 to 0. and cardiopulmonary count of 0.org/ at Eccles Health Sciences Lib on September 28. typically at the knees. not present in the young infant. bacterial meningitis.0⫻103/mcL [1. during the physical examination. meningococcal and rickettsial infection. the patient lies surements. All children who are suspected of having meningitis Other diagnostic tests may be considered. uncorrected coagulopathy. It is important to between serum and CSF glucose as a percentage.aappublications. normal CSF values for an infant are very If knee extension from this position elicits pain. is neurologic deficits. The peripheral Other body systems should be examined. The appearance of vesicles in the infant younger half of the measured serum value. midline shift. characterized by a lower cell count. effacement of the basilar cisterns. and cranial nerve 3. the parent has tant to note that normal findings on CT scan do not noted this behavior and refrains from holding or rocking exclude increased intracranial pressure. bacterial cultures and refractory seizures in the setting of CSF culture remains the gold standard for diagnosing meningitis. Serum glucose tive sign occurs if the patient also reflexively flexes the concentration should be measured to determine the ratio lower extremities. Instead. hemorrhage. Although meningismus is ferred until computed tomography (CT) scan is per- suggestive of meningeal irritation. CSF examination should include cell count and dif- In the older child. although rarely. In assessing the Brudzinski sign. The sulci is noted. The Gram stain infection. 2014 . Viral meningitis. The neurologic examination consists of both fundus. coccal meningitis and viral meningitis. These contraindications include focal of the CSF examination.05 to 0. glucose concentration. should be used in isolation because overlap exists in all the patient lies supine and flexes his or her neck. but in most cases of pneumo- should include evaluation for jugular venous distention. cardiac examination pneumococcal meningitis. the WBC and a sign of possible myocarditis or pericardial effusion. with a predominance of polymorphonuclear leuko- pneumococcal disease (petechiae and purpura) may be cytes. although hypo- 4. Bacterial meningitis is characterized by CSF pleocyto- cal infection. lumbar puncture should be de- who have an open fontanelle. or effacement of the tability is the usual sign of meningeal irritation. it also is important to recognize that is extremely helpful if positive and may indicate the need most infants who have HSV CNS disease do not have to expand antimicrobial coverage. Leukopenia. Marked irritability with a high-pitched cry should be reassessed after lumbar puncture is performed may be noted by the clinician while moving the infant (Fig. cultures of the CSF and blood (Table 2). signs of increased intracranial pres. Exanthems typical for enterovirus. Susceptibility data are critical to adequate therapy and generally are available once identi- Diagnosis fication of a specific bacterial pathogen is confirmed. The glucose concentration usually is less than one present. and 6 palsies can be present with bacterial and Lyme natremia is noted in only 35% of cases. These values must be interpreted based on supine and the thigh is flexed at a right angle to the trunk.0 g/dL (10 g/L). It also is impor- but prefers to remain motionless. lumbar puncture should be deferred and infant who has meningitis does not wish to be handled antimicrobial therapy started promptly. To test for the Kernig sign. None of these values Kernig sign is positive.12 December 2008 423 Downloaded from http://pedsinreview. BUNⴝblood urea nitrogen. during which time treat- ment should not be delayed. respectively). *Meningitis suspected clinically or by cerebrospinal fluid findings. Among the 22 coun- tries in which BCG vaccine use is routine. A higher predom- inance of CSF monocytes and the Figure 2. respec- tively. adjunctive testing may be help- ful. Glucose and protein concentrations frequently are nor- mal. Gram stain is universally negative. For the patient who is suspected of having tuberculous meningitis. 2014 . respec- inappropriate diuretic hormone. Importantly. although culturing of myco- bacteria often requires 4 to 6 weeks. In endemic areas. DICⴝdisseminated intravascular coagulation. based on CSF findings and other epidemiologic clues (Tables 1 and 2).org/ at Eccles Health Sciences Lib on September 28. may be used to guide additional evaluation and management. A TST should be performed. in Brazil and Russia. The prevailing evidence suggests that a positive TST result following BCG vaccine is more likely to represent infection. Ba- cille Calmette-Guérin (BCG) vac- cine can have a variable effect on TST results. SIADHⴝsyndrome of tis (mean of 98% and 1%. The 424 Pediatrics in Review Vol. ICUⴝintensive care unit. enteroviral PCR can confirm the diagnosis and. tively) compared with enteroviral meningitis (52% monocytes and 47% neutrophils. depending on the child’s age and clinical appearance.29 No. Lyme menin- gitis is difficult to distinguish from viral meningitis. IVⴝintravenous. have been reported. although the protein value can be slightly elevated. In cases of en- teroviral meningitis. vaccination usually occurs at birth. CNSⴝcentral relative absence of CSF neutrophils nervous system. Protection against meningitis and disseminated dis- ease is the ultimate goal. shifting to lympho- cytic predominance quickly during the illness.12 December 2008 Downloaded from http://pedsinreview. the BCG vaccination is repeated at school age. Suggested algorithm for suspected bacterial meningitis.infectious diseases meningitis of infection. H/Oⴝhistory of. ICPⴝ have been noted in Lyme meningi- intracranial pressure.aappublications. and effi- cacy rates of 64% and 78%. recognizing that a negative test result does not exclude disease. Pediatr Rev. Therefore. McCracken GH.5 Lymphocyte predominance Negative Often <10 (0.org/ at Eccles Health Sciences Lib on September 28. focal neurologic findings. It is important to recognize the limitations of lumbar pneumococcus usually can be identified in the CSF up to puncture. and appropriate child who have enteroviral meningitis that is confirmed follow-up. ment occurs in the setting of meningitis and microbio- ing CSF obtained from a traumatic lumbar puncture are logic confirmation is not possible. if antimicrobial pretreat- again in such situations. 2014 . or clinical signs of elevated Drug Choice and Duration intracranial pressure. 1998. and Interpretation of CSF antibodies is difficult.12 December 2008 425 Downloaded from http://pedsinreview. CSF PCR for the diagnosis of CNS If the practitioner cannot perform a lumbar puncture borreliosis is not recommended at this time.5 >50% PMNs early (<48 h) Negative (40 to 60) <50% PMNs later (>48 h) Lyme meningitis >1/2 serum 0.05 to 0. PMN⫽polymorphonuclear leukocytes.0 >50% PMNs Often <10 (0. use of the appropri.000 red blood cells). a blood culture should be obtained and antibiotics admin- The Traumatic Lumbar Puncture istered promptly. Adapted from Wubbel L.5 Predominance of lymphocytes Negative and monocytes Tuberculous meningitis <1/2 serum >10 (100) 0. The severity of bacterial meningitis necessitates empiric Therapy should not be delayed if CNS infection is antimicrobial therapy prior to identification of the patho- suspected. especially in the face of a traumatic procedure. cells by assuming 1 WBC/1.29 No. in children whose CSF examination results not recommend using these formulas to guide clinical are abnormal but whose CSF cultures are negative. the practitioner needs described in the literature (some suggest correcting the to continue therapy based on the most likely pathogens.2 to 4.4) (20 to 40) Bacterial meningitis <1/2 serum >10 (100) >1. Patients can be sent appropriate for children whose GCS scores are less than home if they are afebrile and taking fluids well. performing this test. infectious diseases meningitis Table 2. For infants whose CSF is suspicious for bacterial Pediatrics in Review Vol. HSV encephalitis. and a lumbar puncture should be attempted in less than an hour. Appropriate antimicrobials are required in gen. treat- decisions. demonstration of serum antibodies against B burdorferi bacterial meningitis.03 No PMNs Negative (1. timely diagnosis and correct antimicrobial tation with a Lyme disease expert should be sought when choice are critical. Cerebrospinal Fluid Analysis* Glucose Protein White Blood Cell (mg/dL) (g/dL) (ⴛ103/mcL) Gram (mmol/L) (g/L) (ⴛ109/L) Differential Count stain Healthy newborn 30 to 120 3 to 15 <0. Admission to a pediatric intensive care unit is by enteroviral CSF PCR testing.05 to 0.05 to 0. at. several hours after the administration of appropriate Frankly bloody CSF should not be used to make clinical drugs. CSF pleocytosis.7) (30 to 150) Healthy child 40 to 80 2 to 4 <0. such as purpura fulminans with include prompt initiation of therapy. we do For example. 8 or who are in shock or have respiratory compromise.aappublications. Although methods for evaluat. or there are contraindications to CSF examination. in the appropriate clinical setting can confirm infection.01 No PMNs Negative (2. Lyme meningitis. Antibiotics are not necessary for the older infant and tention to anticipated complications. and none should be used in isolation because overlap between values in each of these categories is significant. tuberculous meningitis.6) *Values should be used only as a guide. in all cases.7 to 6. ate antimicrobial with correct dosing and duration. and rickettsial infection.6) Often >90% Enteroviral meningitis >1/2 serum 4 to 6 0. ment for meningitis should continue in those cases in which a positive blood culture for S pneumoniae or N Management meningitidis is confirmed or in cases in which the clinical The critical elements of managing pediatric meningitis scenario is compelling. whereas sterilization of meningococcus may occur decisions. Among common bacterial pathogens. and consul. The first dose should be given before day divided every 6 hours) should be used for empiric or concurrently with antibiotics. Stud- The duration of therapy depends on the organism ies suggest that up to 70% of children who have bacterial cultured and the degree of complications. It is important to emphasize that the results of affect the course of viral meningitis adversely. Although it will not coverage. may manifest as cranial nerve palsy. Other reasons for CT gitis. The dose of dexamethasone for bacterial meningitis is one (100 mg/kg per day given in one dose or divided 0. neurologic sequelae. clinical illness or CSF findings. visual field defects. monoparesis. ipated. If the child is Adjunctive treatment has reduced rates of mortality. GBS. for 21 days. stain suggests pneumococcus. In the young infant. have poor penetration into the CSF and intracranial pressure. For children beyond the neonatal age groups. Consultation with an infectious disease specialist may be and Complications helpful in such cases. Altered level of consciousness. aphasia. Neurologic effects daily) for 14 to 28 days. quence of vascular injuries. acyclovir (60 mg/kg severe hearing loss. Seizures occur in approximately 20% to 30% of pa- Neonatal HSV CNS infection typically is treated with tients who have bacterial meningitis. seizures. The dosing for non-neonates is 30 mg/kg Seizures more than 72 hours after the initiation of ther- per day divided every 8 hours IV for 14 to 21 days. When children present with a focal seizure. Focal neurologic deficits usually are the conse- of treatment for complicated meningitis should be dis. The duration ataxia. apy are less common and more often focal. Monitoring. which increase the risk for long-term still is positive. the presence of a CNS 426 Pediatrics in Review Vol. increased coccal meningitis. cussed in consultation with infectious disease physicians. Meningitis caused by gram. typically are gener- IV acyclovir (60 mg/kg per day divided every 8 hours) alized. defin. subdural effusions. Consultation with infec- An alternative therapy for children who have had tious disease experts is recommended. anaphylactic reactions to penicillin or cephalosporins is a carbapenem or a quinolone in addition to vancomycin. and neurologic sequelae significantly per day divided every 8 hours) should be added if HSV in adults who have community-acquired bacterial men- infection is a concern. generally a minimum of 21 days. vancomycin be considered in cases of pneumococcal meningitis. Supportive Care. or signs or symptoms of increased and cephalexin. it is important to remem. and focal neu- with IV ceftriaxone (50 to 75 mg/kg per day given once rologic deficits are most common. Appropriate parenteral antibi- Seizures and Focal Complications otics should be continued for 7 days for meningococcal Neurologic complications of meningitis should be antic- meningitis and 14 days for Listeria. considered when bacterial meningitis is suspected by itive therapy can be selected.aappublications.infectious diseases meningitis meningitis. Shock Systemic complications of meningitis are common. hemi- negative enteric bacilli requires a longer duration of paresis. and pneumo. A follow-up meningitis require fluid resuscitation during initial eval- CSF examination should be performed in neonates who uation and stabilization. focal ber that certain antimicrobial agents. Lyme meningitis typically is treated intracranial pressure. vancomycin (60 mg/kg available data suggest that the use of adjunctive cortico- per day given every 6 hours) should be added. ampicillin (300 mg/kg per day divided every Adjunctive Corticosteroids in 6 hours) and cefotaxime (200 to 300 mg/kg per day Bacterial Meningitis divided every 6 hours) is appropriate. and pressor support may be nec- considered for any child who has multidrug-resistant essary in cases of hemodynamic instability. Normal saline or lactated Ringer have gram-negative bacillary meningitis and should be solution is appropriate. When expanding coverage. such as clindamycin neurologic deficits. steroids may be beneficial for Hib meningitis and could For children older than 2 months of age. performing a lumbar puncture. recommended in such cases.6 mg/kg per day divided into four doses and adminis- into two doses) or cefotaxime (200 to 300 mg/kg per tered IV for 4 days.29 No. Dexamethasone should be Once culture and susceptibility data are available. younger than 4 to 6 weeks of age. a CT scan must be obtained before are not appropriate in the treatment of bacterial menin. if the Gram ingitis. gaze preference.12 December 2008 Downloaded from http://pedsinreview. and therapy. and occur within the first 72 hours of illness.org/ at Eccles Health Sciences Lib on September 28. scan include recent head trauma. pneumococcal meningitis and those who do not respond appropriately to therapy. it is not the Gram stain should not be used to narrow coverage. 2014 . (60 mg/kg per day divided every 6 hours) plus ceftriax. Such later A follow-up CSF HSV DNA PCR should be evaluated at seizures may signify vascular complications or an intra- day 21 and the course of therapy extended if the result cranial abscess. increased risk for Hib disease. Passengers who Subdural effusions can complicate the course of 10% are seated next to an infected individual on an airline to 40% of infants and young children who have bacterial flight lasting more than 8 hours also are considered at meningitis. serum osmolarity less than 270 mOsm/ attending child care centers with a child who has invasive kg. Rifampin prophylaxis is ity should be assessed initially and monitored every 8 to recommended for all such household contacts regardless 12 hours. Fluids can be liberalized as the serum focal neurologic deficits or focal seizures or does not sodium returns to normal values.12 December 2008 427 Downloaded from http://pedsinreview. Prevailing data on the Unimmunized or underimmunized children younger management of SIADH in the setting of meningitis are than 4 years of age and immunocompromised individuals controversial. The risk of secondary disease in children (135 mmol/L). and tonsillar population.aappublications. Meningococ- quent increase in intracranial pressure. L). and corticosteroids also can be considered. and pregnancy status. high-risk con- gins with fluid restriction. In the face of cerebral edema tacts include those who attend child care or nursery that has signs of increased intracranial pressure. urine sodium greater than 30 mEq/L (30 mmol/ older than age 2 years. coma or obtundation. and rifampin. Chemoprophylaxis is warranted and should herniation. tle. meningococcal vaccine Although SIADH occurs in children who have bacterial may be an adjunct if the outbreak is caused by a vaccine meningitis. school with the index cases and those who have intimate mannitol. espe- more appropriate study to assess complicated meningitis cially if the serum sodium value is less than 130 mEq/L and should be considered in any patient who develops (130 mmol/L). serogroup. infectious diseases meningitis shunt. Although clinical manifestations can be sub. In addition to household contacts. account the patient’s age. contact (including those who have direct contact with a Invasive measurement of intracranial pressure and serial patient’s secretions or anyone who frequently has slept or imaging in patients who have signs and symptoms of eaten in the same dwelling as the index patient) during increased intracranial pressure also should be considered. maintenance fluids can be provided by 24 to 48 hours. drug dosing and duration of therapy should take into vasive management typically is not indicated. calls after diagnosing meningitis in a child. The diagnosis of SIADH is suggested by a of age. and serum electrolytes and osmolal. and the attack rate is 500 to 800 times that of the general tension. high risk. although it is clear that over. Hib disease is reported to be rare when all contacts are larity.29 No. nausea. signs of increased intracranial pressure in the presence of and practitioners should refer to the Red Book: 2006 a subdural effusion or in cases of suspected subdural Report of the Committee on Infectious Disease for de- empyema indicate the need for neurosurgical drainage. tacts. and the absence of clinical findings suggestive of Antibiotic administration should not be delayed in these hypovolemia or dehydration. ported between 7% and 89%. Age-appropriate immunization should be recommended. contacts of a patient who has meningococcal meningitis. Treatment for prophylaxis in children. urine output. Specific signs of increased intracranial pressure is supportive. and in most cases. Magnetic resonance imaging may be a initial moderate fluid restriction with isotonic fluid. When two or more cases of Pediatrics in Review Vol. ranging from Secondary cases generally occur among household headache. Cerebral edema cal and Hib disease create an increased risk for secondary and the resultant increase in intracranial pressure can infection in contacts. and vomiting to altered mental status. the true incidence is unclear. of all ages who are household contacts of a patient who dration can be associated with adverse outcomes. Treatment for patients who are suspected of be provided. and appropriate immunizations for age should serum sodium concentration less than 135 mEq/L be completed. or patients who are improving with therapy and show no ciprofloxacin is appropriate for adult contacts. However. and abnormal respiratory pattern). Cushing triad (bradycardia. the 7 days before the index case’s illness.or underhy. patients who have neurologic abnormalities at the Rifampin generally is the drug of choice for chemo- time of admission are at a higher risk.org/ at Eccles Health Sciences Lib on September 28. ideally within 24 hours to high-risk con- having cerebral edema depends on the severity and be. in. Most experts recommend circumstances. and recurrent meningitis. tailed recommendations. with rates re. Vital has Hib invasive disease should be considered to be at signs. cranial nerve palsies. 2014 . diuretics. The Practitioners should expect to be deluged with telephone increase in intracellular fluid volume leads to a subse. urine osmolarity greater than twice the serum osmo. cause a variety of signs and symptoms. Cerebral edema in patients who have bacterial men- ingitis is caused by a variety of mechanisms that lead to an Care of the Child Exposed to Meningitis increase in the intracellular fluid volume of the brain. weight. In cases in which a meningo- SIADH coccal outbreak has occurred. hyper. respond to therapy. ceftriaxone. can be unilateral or bilateral. but complication of chronic otitis media with mastoiditis. cate with epidural or intradural sites. can be unilateral or bilateral. neurosurgical procedures. and is more common occurs in a child who has a ventricular shunt. pathogen isolated. Long-term se. abdominal trauma. under.org/ at Eccles Health Sciences Lib on September 28. 60 days. all children who have bacterial meningitis should have moval is not necessary. congenital defects. including meningorectal fistulae and dermal sinuses with ered for chemoprophylaxis. and the risk of bacterial Unique Circumstances meningitis persisted beyond 24 months postimplanta- Anaerobic Pathogens tion for those who had positioners. In meningococcal meningitis. particularly Staphylococ- cus epidermidis. including people tract that can extend from the skin and may communi- who have casual contact or indirect contact or health. transplantation. treatment in pneumococcal than meningococcal meningitis. cochlea) were noted to be at higher risk than children who had other implant models.29 No. meningitis and that pneumococcus is the most common and neurologic sequelae are common. It is estimated that more than 10. Fungal meningitis is rare in the pediatric population. and among survivors. diabetes. A dermal sinus is an epithelial cell-lined patient who has meningococcal disease. attendees and child care staff should be consid. there is not enough information to recommend that chronic sinusitis. and severe hearing loss are the most common Ventricular Shunts and Cochlear Implants sequelae. with appropriate antibiotics is required. rates of 138. Children who had implants employing silastic The prognosis for patients having TB meningitis and wedge positioners (that place the electrode closer to the neonatal HSV disease is extremely guarded. In such cases. thereby increasing care professionals who have not had direct exposure to the risk of infection with unusual indolent organisms. 100.000 children have mental follow-up is necessary for all children. plants. Fungal meningitis also can occur in the setting of risk of neurologic sequelae is highest in children who prematurity (Candida albicans) or as a complication of have pneumococcal meningitis. or have bacterial meningitis die.000 person-years scoring the importance of follow-up developmental test. includ- phylaxis is not recommended for low-risk contacts of a ing anaerobes. if meningitis caused by common pathogens such as pneu- mococcus and meningococcus patients. hydrocephalus. the patient’s secretions. Accord. spasticity.000. confirm that such children have an increased risk of gitis and up to 20% in E coli meningitis have been noted. In addition. Hearing loss occurs in approximately 30% of Ventricular shunt infection can be caused by a variety of bacteria. have been reported for children who have cochlear im- ing and interventional services. between 5% and 10% of children who temic lupus erythematosus. 2014 . the cancer. recent craniotomy. sys- Unfortunately. and gram-negative bacilli and occa- Hearing loss occurs in approximately 30% sionally by yeast. generally occurring in the setting of immunosuppression Prognosis related to HIV infection (Cryptococcus neoformans). their hearing evaluated before hospital discharge. may predis- It is equally important to understand that chemopro. extraven- of patients. removal of the shunt. blindness. mortality rates of 10% in GBS menin. but shunt re- ingly. Implants that have Anaerobic meningitis in children generally occurs as a positioners have been withdrawn from the market. and appropriate is more common in pneumococcal than antibiotic therapy before shunt re- placement are crucial for cure. children who have such devices undergo surgical re- 428 Pediatrics in Review Vol.aappublications. pose a child to meningitis caused by mixed flora. Develop. and tricular drainage. Although the risk of pneumococcal quelae occur in 30% of those who have GBS disease and meningitis in the healthy child approximates 4 to 5 per 50% of those who have gram-negative meningitis. Reports For neonates.2 cases per 100. S aureus.12 December 2008 Downloaded from http://pedsinreview. had cochlear implantation to restore hearing. telligence quotient ⬍70). contrast.infectious diseases meningitis invasive Hib disease occur in a child care setting within or abdominal surgery. Intellectual deficits (in. associated dermoid or epidermoid tumors. No specific chemoprophylaxis is necessary for contacts of a patient who has enteroviral or Fungal Meningitis pneumococcal meningitis. geted toward the suspected pathogens. and GBS continues to be the most 297:52– 60 common neonatal pathogen. pediatric bacterial meningitis: defining the time interval for Although many practitioners are comfortable with the recovery of cerebral spinal fluid pathogens after parenteral anti- necessary plan of care and monitoring of the pediatric biotic pretreatment.24:542–545 vancomycin and either cefotaxime or ceftriaxone. Early • Empiric therapy for suspected bacterial meningitis in differentiation of Lyme disease from enteroviral meningitis. J Clin Microbiol. JAMA. et al.95:21–28 have meningococcal meningitis. Supportive care 2004. 2014 . including pediatric nursing. Available at: http:// tients be cared for in a facility that has well-trained www. Smalling TW. all children treated for bacterial invasive meningococcal infections in children. Elk Grove ies. show to detecting herpes simplex virus and enterovirus in the central signs of shock or respiratory compromise. eds. Ill: American Academy of Pediatrics. Baker CJ. Soliemanzadeh P. 2005.org/ at Eccles Health Sciences Lib on September 28. continued vigilance is required in all meningitis should have follow-up hearing testing. once testing is complete. characteristics and outcome related to penicillin susceptibility tered promptly. 18:e979 – e984 McIntyre PB. Ill: American Academy of Pediatrics. et al. Village. Wubbel L. Long SS. infectious diseases meningitis moval. 1998. In: Pick- tion. In addi. Mason EO. In: Pickering LK. infectious disease. Nigrovic LE. McCracken GH. 1998. Chavez-Bueno S.utdol. American Academy of Pediatrics.aappublications. Molecular approach • Children whose GCS scores are less than 8. uation for neurologic sequelae is necessary for all chil- lowed by pneumococcal polysaccharide vaccines is rec. 2005.do?topicKey⫽pedi_id/ ancillary support personnel. Management of bacterial meningitis: 1998. JAMA. Clin Infect Dis. Pediatr Clin North Am. Meningococcal infections. Hutze GE. Dexamethasone therapy for who have pneumococcal and 10% of those who children with bacterial meningitis. UpToDate Online 16. Antimicrobial therapy should be tar. and the practitioner Kanegaye JT. Bradley JS.351:1719 –1720 and monitoring are imperative. Treatment and prognosis of acute bacterial meningitis patient who has meningitis. and child. dren treated for CNS infection. et al. Tuberculous meningitis. Schoeman JF. 2008. 39:1267–1284 • Sensorineural hearing loss occurs in 30% of children Wald ER. of the patient. 2000.102:1087–1097 include a decision about whether adjunctive steroid ther. et al. 2007. 1997. Mason EO. Lumbar puncture in should anticipate and be prepared to treat complications. Bradley JS. Three-year multicenter understanding that timely and appropriate use of antimi- surveillance of pneumococcal meningitis in children: clinical crobials is essential. Long SS. Elk Grove Village. Hodinka RL. McMillan JA. Practitioners initially should focus on Red Book: 2006 Report of the Committee on Infectious Diseases. The practitioner should know the typical pathogens. Clinical predic- • S pneumoniae and N meningitidis remain the most tion rule for identifying children with cerebrospinal fluid pleo- common causes of bacterial meningitis in the infant cytosis at very low risk for bacterial meningitis. Kaplan SL. ommended for these patients.2006:452–560 Arditi MA. Coffin SE. 2006.2. establishing venous access and on initiating supportive 2006:310 –318 care for the hemodynamically unstable patient. Macias CG. 24928&selectedTitle⫽3⬃137 &source⫽search_result critical care. Cerebrospinal fluid findings in aseptic versus bacterial meningitis. Conclusion Suggested Reading The key to a good outcome for those who develop American Academy of Pediatrics. attention to the respiratory and neurologic status ering LK.108:1169 –1174 Kaplan SL. Leake JA. 2001. Empiric therapy should be adminis. 1995. a non-neonate includes a combination of parenteral Pediatr Infect Dis J.29 No. et al. Kelleher KJ. Eval- cases.105: • Young infants who have meningitis may present 316 –319 with nonspecific clinical manifestations. Pediatrics. 2002. Red Book: 2006 should precede initiation of appropriate laboratory stud. Hartman BJ. Tang YW. Shah SS. McCracken GH.19:78 – 84 Pediatrics in Review Vol. and radiologic staff. 27th ed. Pediatr Rev. Pediatrics. it is essential that such pa- in children. and have nervous system.278:925–931 Summary Negrini B. Instead. Kaplan SK. N Engl J Med. 27th ed.52:795– 810 Donald PR. Zaoutis TE. and should and dexamethasone use. Sefers SE. King SM. Pediatrics. Practice guidelines for intracranial pressure should be admitted to a the management of bacterial meningitis. Haijing L. Report of the Committee on Infectious Diseases.com/online/content/topic. Dexamethasone as ad- junctive therapy in bacterial meningitis: a meta-analysis of ran- domized control trials since 1988. Haemophilus influenzae infec- meningitis starts with prompt diagnosis and stabilization tions.12 December 2008 429 Downloaded from http://pedsinreview. and use of pneumococcal conjugate vaccines fol. Bacterial meningitis in children. apy is appropriate. pediatric intensive care unit. Wald ER. eds. Multicenter surveillance of therapy is complete. Berkey CS. 2004. Turnquist J. McMillan JA. Pediatrics.40:2317–2322 focal neurologic findings or clinical signs of elevated Tunkel AR. Baker CJ. Once Kaplan SL. et al. Pediatrics. Kuppermann NK. Herpes simplex virus meningoencephalitis.9ⴛ109/L) white blood cells with 80% polymorphonuclear leukocytes. Of the following. CSF examination reveals 0. None. Intravenous antibiotic therapy with ceftriaxone and vancomycin is begun. E. Coccidiomycosis.4°C). 0. Cerebrospinal fluid (CSF) examination reveals no organisms on Gram stain. and fever for 12 hours. and protein of 25 g/dL (250 g/L).7ⴛ103/mcL (0. The parents express concerns about chemoprophylaxis of exposed children and caretakers.aappublications.8°C). His axillary temperature is 102. glucose of 30 mg/dL (1. Rocky Mountain spotted fever. B.pedsinreview. E. A 14-day-old term newborn girl presents with generalized tonic-clonic seizures.12 December 2008 Downloaded from http://pedsinreview. Blood glucose is 90 mg/dL (5. Gram stain of the CSF is negative. Sibling and all unimmunized children at child care facility.9 mmol/L). D. Lumbar puncture shows 0. E. and all caretakers. and protein of 8. No chemoprophylaxis is necessary for anyone. heart rate is 120 beats/min. D.0 mmol/L).6ⴛ109/ L) white blood cells with 30% polymorphonuclear leukocytes and 70% lymphocytes. E.org. Which of the following is the most appropriate next step? A. Physical examination shows an unresponsive infant who has occasional facial and right extremity twitches.8 mmol/L).0 g/dL (80 g/L). 2014 . photophobia. 4. Of note on physical examination is a Glasgow Coma Scale score of 7 and nuchal rigidity. Tuberculous meningitis. His health had been good until this illness. Blood glucose is 50 mg/dL (2. B. Dexamethasone. the individual(s) who should receive chemoprophylaxis with rifampin is(are): A.8°F (38.9ⴛ103/mcL (0. and blood pressure is 110/60 mm Hg. 1.9°F (39. B. headache. Add ampicillin to the antibiotic regimen. Intravenous administration of cefotaxime and ampicillin is begun. Lyme disease. the rest of the physical examination findings are normal. and protein of 8. A 4-year-old boy is brought to the emergency department with fever and headache for 2 weeks and increasing lethargy over the last 72 hours. Of the following. heart rate is 120 beats/min.3 mmol/L). Add doxycycline to the antibiotic regimen.org/ at Eccles Health Sciences Lib on September 28. the most appropriate addition to therapy at this time is: A. D. C. Continue current antibiotic regimen. 3. C. Six hours later. Isoniazid and rifampin. Change antibiotic coverage to penicillin G. A 2-year-old girl is admitted for treatment of pneumococcal meningitis. respiratory rate is 40 breaths/min.7 mmol/L). Sibling only. Rectal temperature is 101. glucose of 24 mg/dL (1. Computed tomography scan of the head shows no space-occupying lesion.aappublications. Sibling and all children at child care facility. Acyclovir.0 g/dL (80 g/L). C. and blood pressure is 88/ 56 mm Hg.6ⴛ103/mcL (0. 430 Pediatrics in Review Vol. all children at child care facility.25ⴛ109/L) white blood cells with 70% lymphocytes. the laboratory reports that the Gram stain of the cerebrospinal fluid shows gram-negative diplococci. 2. Antibiotic coverage for which of the following is most indicated? A. B.1 mmol/L).7ⴛ109/L) red blood cells. glucose of 20 mg/dL (1. The child was born in Russia and had been adopted at the age of 2 years. A 6-year-old boy is admitted to the hospital with lethargy. Blood glucose measures 88 mg/dL (4.25ⴛ103/mcL (0.29 No. Vancomycin. Discontinue vancomycin and continue cefotaxime. C. She has a 2-month-old sibling at home. 0. She regularly attends a child care facility that cares for children up to the age of 4 years. Sibling.infectious diseases meningitis PIR Quiz Quiz also available online at www. Other than a “full” anterior fontanelle. D. appears in the following collection(s): Fetus/Newborn Infant http://pedsinreview. along with others on similar topics. 2014 .aappublications.aappublications.aappublications.org/cgi/collection/neurologic_dis orders_sub Permissions & Licensing Information about reproducing this article in parts (figures. Meningitis Keith Mann and Mary Anne Jackson Pediatrics in Review 2008.aappublications. 7 of which you can access for free at: http://pedsinreview.29.org/site/misc/reprints.org/ at Eccles Health Sciences Lib on September 28.29-12-417 Updated Information & including high resolution figures.1542/pir.aappublications.aappublications.org/content/29/12/417#BIBL Subspecialty Collections This article.aappublications.aappublications.org/content/29/12/417 References This article cites 13 articles.org/site/misc/Permissions.org/cgi/collection/infectious_dise ases_sub Neurology http://pedsinreview.org/cgi/collection/fetus:newborn _infant_sub Infectious Diseases http://pedsinreview.org/cgi/collection/neurology_sub Neurologic Disorders http://pedsinreview. can be found at: Services http://pedsinreview.aappublications.417 DOI: 10.xhtml Reprints Information about ordering reprints can be found online: http://pedsinreview.xhtml Downloaded from http://pedsinreview. tables) or in its entirety can be found online at: http://pedsinreview.