1. Infectious diseases of nervous system Lecturer Gorishna Ivanna Lubomyrivna

2. Plan of the lecture • Etiology, Clinical Peculiarities, laboratory tests of meningitis in children • Differential Diagnosis with meningism, and different meningitis • Treatment of meningitis • Meningococcal Infection (Etiology, Epidemiology, Pathogenesis, Clinical Peculiarities of different forms, Complications, laboratory tests, Differential Diagnosis, treatment, prevention

3. Meningitis - • The inflammation of the meninges overlying the brain and spinal cord

4. MeningitisEtiology: • bacterial pathogens (group B Streptococci, gramnegative enteric bacilli (Klebsiella, Enterobacter, and Serratia species), Escherichia coli, Listeria monocytogenes, Haemophilus influenzae type b, Neisseria meningitidis, Streptococcus pneumoniae); • viral agents (herpes simplex, mumps and measles, chicken pox); • fungal, • tuberculosis, • protozoal.

5. The classic symptoms of meningitis: • fever, • headache, • vomiting, • photophobia (extreme sensitivity to light), • irritability, • consciousness is confused or lost; coma • hallucination • lethargy, • stiff neck. • seizures

6. Stiff neck, meningeal pose

7. Nuchal rigidity (stiff neck) and positive upper Brudzinsky’s sign Positive Kernig’s and lower Brudzinsky’s sign

8. Plan of examination • Funduscopy (papilledema) • Lumbar puncture and examination of cerebrospinal fluid; • Blood cultures; • Cultures of the nose and throat; • CT scan.

9. Clinical Manifestation Infants under 1 month of age • tend to exhibit irritability, lethargy, unusual cry, seizure, poor feeding, and vomiting. • high fever and signs of meningeal irritation may be absent. • Lessage’s symptome

10. Clinical Manifestation in infants older than 4 months • typically produces fever, • stiff neck, • irritability and seizures, • signs of increased intracranial pressure (including and bulging anterior fontanel, vomiting) • Lessage’s symptome • funduscopic changes are usually absent at the time of diagnosis.

11. Clinical Manifestationin older children • Symptoms of headache • muscle and back pain • stiff neck, and photophobia • In addition to resistance of the neck to forward flexion, • other signs of meningeal irritation include Kernig sign and Brudzinski sign. • Other manifestations of systemic bacterial infection include pneumonia, pericarditis, otitis media, septic arthritis, and buccal cellulites, skin eruptions ranging from maculopapules to petechiae and purpura; cranial nerve involvement.

12. Syndrome of meningism • The brain membranes irritation with appearing positives meningeal signs without inflammatory data in CSF Clinical manifestation • fever, • headache, • vomiting, • irritability, • stiff neck. • Upper Brudzinski sign positive. • Kernig and lower Brudzinski signsare negative

14. CSF in case of purulent meningitis

15. Glasgow Coma Scale

16. Favorable prognosis for recovering 13-15 points • Doubtful prognosis 9-12 points • Unfavorable prognosis less 8 points

17. Treatment • Bed regime • Antibacterial therapy • BENZYLPENICILLIN Na 300-500 000 lU/kg/day every 4 hours i/v; • Ceftriaxone 100 mg/кg/day or cefotaxime 200 mg/кg/dayi/v, • Ampicillin Na 100-400 mg/kg/day i/v, • Chloramphenicol 50-100 mg/kg/day (25 mg/kg/day for newborn) • Amikacin 15-30 мg/кg/day, or Netylmicin 6-9 мg/кg/day

18. Lumbar puncture and examination of cerebrospinal fluid is prescribed after normalization of body temperature, negatives meningial signs, and blood analyses normalization ; • Antibacterial therapy withdrawal when • number of cells in CSF <50 in mcl, number of neutrophils is less then 30%.

19. Corticosteroidstherapy (Dexametazon 0,15 мg/kg every 4 hrs. The first doses is prescribe 10-15 min before a/b injections) • Detoxycation therapy (with saline or isotonic glucose). • Dehydration – Mannit 1 gr/kg/day or Furasemid 1-2 mg/kg/day • In case of convulsions – phenobarbital or diazepam

20. In case of viral meningitis • Acyclovir 10 mg/кg 3 times per dayduring 7-10 days; • In case of encephalitis – 15-30 мg/кg 3 times per dayduring 10-14 days, after that 200-400 мg 5 times (per os) during 14 days

21. Complications of meningitis • Hydrocephalus • Cranial nerve palsies • Mental retardation • Subdural effusion • Deafness • Blindness • Epilepsy

22. Meningococcal Infections • Etiology:Neisseriameningitidis, Gram negative diplococcus. • Epidemiology: • Sourse of infection - ill person or carrier. • Transmission - by direct contact, including droplet spread • (Only 15% of contact persons may be infected, 98% of them become carriers, only 2% - ill.) • Susceptibility is high in children 6 mouths -5 years old.

23. Meningococci

24. Pathogenesis • Inocculation and reproduction of bacteria in upper respiratory tract. • Local inflammation, lymphoid tissue hyperplasia (nasopharyngitis) • Bacteraemia, dissemination • Toxemia (meningococcemia) • Rupture of hematoencephalic barrier meningitis, meningoencephalitis.

25. Meningococcal Infections • Incubation period • Short (seven days) • Isolation period • for two days after starting treatment

26. Classification of Meningococcal Infections: • Localized forms • Meningococcal carrying, • acute nasopharyngitis; • Generalized forms Typical • meningococcemia, • meningitis, • meningoencephalitis. • combined forms (meningitis + meningococcemia or meningoencephalitis + meningococcemia).

27. Generalized forms Atypical • fulminant form • chronic meningococcemia, - Rare forms – meningococcal endocarditis, arthritis, pneumonia, iridocyclitis.

28. Diagnostic criterions • Nasopharyngitis: • intoxication (headache, malaise, pain, fever); • catarrhal syndrome (cough, sore throat, corryza, conjunctive hyperaemia); • pharyngeal hyperaemia, mucous exudate, hyperplasic follicles.

29. Meningococcemia: • acute beginning from intoxication, high temperature (39-40°C); • prime maculopapulous rashes on the 1st day • typical rashes on the 1-2nd day: purpuric or petechial lesions. • Petechiae are pinpoint, may have a raised vesicular or pustular center. Lesions are more common on the trunk and extremities but may also occurs oh the palms, soles and mucosa. • Other features - irritability, myalgia, arthralgia and hypotension.

30. Exanthema at meningococcemia

31. Exanthema at meningococcemia

32. Exanthema and bruises at meningococcemia

33. Exanthema at meningococcemia

34. Exanthema at meningococcemia

35. More fulminant meningococcal infections are often associated with extensive purpuric lesions and with large, well circumscribed ecchymotic patches covering large areas of the body. Necrotic bullae may develop within the ecchymotic patches with resultant sloughing.

36. Fulminant form

37. Fulminant form

38. Rash in purpura (meningococcemia) fulminans

39. Necrotisation

40. Fulminant form, hypostases

41. Fulminant form, hemorrhages into suprarenal glands

42. Meningitis • has sudden onset; • toxic syndrome (hyperpyrexia, vomiting without nausea, headache); • meningeal syndrome • hyperesthesia, • stiff neck, positive Kerning’s and Brudzinski’s signs, • tenderness in sites of trigeminal nerve endings, • suppression of skin rephlexes • Lethargy and obtundationprogress to stupor or even coma.

43. Cerebrospinal fluid (CSF) examination • polymorphonuclear pleocytosis, • protein enlargement, • high pressure of CSF, • glucose and chlorides are low decreased or normal.

44. Example of diagnosis • Meningococcal infections, localized form, acute nasopharyngitis. • Meningococcal infections, generalized forms, typical, combined form:meningitis, meningococcemia.

45. Laboratory tests • Bacteriological investigation of nasopharyngeal mucus, • Bacteriological investigation of blood, • Bacteriological investigation of CSF; • Bacterioscopy of blood and CSF; • Serological, • immunological methods.

46. Meningococci

47. Complications: • Toxic shock • DIC-syndrome • cerebral oedema; • cerebral hypotension; • acute suprarenal insufficiency; • acute renal insufficiency.

48. Phenomena that remain: • cerebral asthenia; • epileptiform syndrome; • physical and intellect retardation; • deafness; • blindness; • hydrocephalus; • pulses, paralyses.

49. Hydrocephalus

50. Differential diagnosis • measles, • scarlet fever, • pseudotuberculosis; • thrombocytopenia, • purpura fulminance, • sepsis acquired by Gram-negative strains. • meningismus and viral meningitis in influenza; • spasmophylia; • tuberculosis meningitis.