CNS infections in children

Question 1

Definition of meningitis vs Encephelitis

Answer 1

Meningitis -infection of the meninges

Encephelitis -inflammation (not always infect) of the parenchyma of the brain

Question 2

Organisms of meningitis in children

Answer 2

Less 3months -
Group B streptococci, E.coli, Listeria

3mo-6y - Neisserissa meningitidies, strep pneumoniae,
Heamophilius

6y> -Neisserissa meningitidies, strep pneumo

Question 3

Organisms of encephalitis in children

Answer 3

Depends on aetiology of the inflammation
Direct invasion by some virus -HSV
Post infectious inflammation -measles
Slow viral infection -most common in UK:
Herpes 1/2, HSV, VZV, Resp virus (influenza), enteroviruses
Rarer -chickenpox, fungal

HSV-1 responsible for 95% of cases in adults but VERY RARE in children -but its very very dangerous
typically affects temporal and inferior frontal lobes

very high mortality

Question 4

Signs and Sx of meningitis in children

Answer 4

can be vague in children/toddlers -
Fevers, headache, neckstiffness, rash, photophobia
FAILURE to thrive, No E+D, dehydration

Signs - maculopapular rash, non blanching (meningoccocal)
tender neck, diffculties extending
child lethargic and barely functioning

overextended neck
Fontanelle Bulging (riased ICP)

Kernings sign- pain on leg extension
Brudzinkis sign-when extend neck supine-flex knees

OBS -HR high to compensate brain ischemia (from ICP)
but baroreceptors detect high BP -drop HR
Cushings triad - Low HR, High BP, Irregular RR

Very late signs!

Question 5

Investigation of meningitis in children

Answer 5

Obs -cushings triad (low HR, high BP, irregular RR)

In order -

LP -Counter indicated with high ICP - (can CT to check)
bacterial -cloudy, Low gluc, high prot, lots of different cells
Viral -clear, norm gluc, raised prot, Lymphocytes

Blood culture
FBC, UE, LFT,
Clotting -watch for DIC
if repeat meningitis -complement

Question 6

Mangement of bacterial and viral menigitis in children

Answer 6

START BEFORE TESTS -

Age dependent -

If BACTERIAL -
Under 3mo -treat for Heam B-
IV cefotaxime, IV amoxicillin

Above 3mo-treat for Strep/Neisser
IM Benzylpenicillin -(if pen allergy -vancomycin)
IV Cefotaxime -duration depending on organism

If KNOW FOR A FACT not menigococcal but bacterial -dexamethasone for ICP

Mannitol for ICP
IV fluids

treat contacts with Ciproflaxin

If Viral - discharge home or admit for maintenance
Also consider treating encephelitis at the same time

Question 7

Complications of meningitis in children

Answer 7

Brain damage
hearing loss, development delays, neuro issues
Skin, skeletal and phsyc problems
Renal problems

Purpura fulminans - consequence of DIC after generalised infection -heamorrhagic skin ischemia
Black spots all over skin

Question 8

Signs of Encecephelitis in children

Answer 8

in children -can be identical looking to meningitis
just more neuro signs/Sx

main ones – fever, headache, psychiatric symptoms, seizures, vomiting
focal features e.g. aphasia

signs to look for LP contraincidaction -
Cushigns triad
Neuro signs, 
Coagulopathy
indications it could be meningococcal meningitis

peripheral signs of HSV (like cold sores) -no relation

Question 9

Investigations of encephelitis in children

Answer 9

OBS -cushings triad

LP if ICP normal
usually viral -clear, norm gluc, high prot, lymphocytes
PCR for HSV
CT vs MRI -MRI will have better view of frontal/temporal lobes usually affected

Question 10

Management of encephilits in children

Answer 10

Often hard to differentiate immediatly from menigitis -esp before tests (need to start EARLY)
so treat for both until results

Encephelitis - IV aciclovir -HSV rare cause in children but dangerous-empirical treatment
If known CMV-add gangiclovir