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4 OCT 20074 OCT 2007

History

A 4-month-old boy Chief complaint: high-grade fever 1 day Present illness:

3 d PTA he had low grade fever with no other symptoms.

1 d PTA he had high grade fever with chill without URI symptoms, N/V, or diarrhea.

He exhibited lethargy and food refusal. The bulging of his anterior fontanelle was observed. He had no seizure.

History

Present illness: He took only acetaminophen every 4 hours but

his symptoms did not relieved. On the day of admission, he sought for a doctor

and was diagnosed as brain edema. He was suggested to go to a hospital.

He had no history of trauma. Nobody in his family had symptoms like him.

History

Pertinent underlying disease: none Significant medical history: none (healthy) Significant neonatal history: none Developmental history: normal

Smile, hold head up, crawl, localize sounds, glare Dietary history: absolute breast feeding

History

Immunization: BCG, 1OPV, 1DPT, 2HBV Current medication: none Significant family history:

Father - HBV carrier Mother - Euthyroid goiter

Physical examination

T 38.5oC, RR 50/min, HR 180/min, BP91/62mmHg

BW 8.1 kg , Ht 50 cm GA: look sick, drowsiness, not pale, no

jaundice, no edema, dry lips, slightly sunken eye ball, anterior fontanelle-bulging, 2x3 cm

HEENT: pharynx-not injected, normal TM both ears

Physical examination

RS: normal breath sound, no adventitious sound

CVS: normal S1&S2, no murmur Abd: soft, not tender, liver and spleen-not

palpable Genitalia: WNL

Physical examination

CNS: pupil 3 mm BRTL, no facial palsy motor power grade IV+ all DTR 3+ all Stiff neck : positive Brudzinski’s sign : positive Kernig sign : positive

Brudzinski sign

Problem list Fever for 3 days Drowsiness for 1 day Bulging ant.fontanelle and presence of

meningeal signs Mild dehydration

Differential diagnosis Meningitis Sepsis

Approach to Acute Febrile Illness

Definition of fever temperature -Rectal >38ºc

-Oral >37.6

-Axillary >37.3 Acute fever - fever with source

- fever without source

History taking Fever : character, pattern, duration Associate organ/systemic symptom

- RS : cough, rhinorrhea, dyspnea

- GI : nausea, vomiting, diarrhea,

- GU : abnormal urine

- NS : alteration of consciousness, seizure, severe headache

History taking Behavior activity e.g. drowsy, food/milk

intolerance Sick contact Previous treatment, past medication Underlying disease, recent immunization

Physical Examination Vital signs : GA : irritability, sign of dehydration, pale,

jaundice HEENT : TM, nasal discharge, tonsils &

pharynx Skin rash , sign of soft tissue infection CVS : new onset of murmur, embolic

phenomenon

Physical Examination RS : breath sound, adventitious sound,

percussion Abdomen : BS, hepatosplenomegaly NS : level of consciousness, fontanelle, motor

system, meningeal irritation sign Bone and joint system

Investigation CBC ,UA Indication for LP in children with fever

- alteration of consciousness

- age<18 months with first episode of febrile seizure or complex febrile seizure

- age<3 months with sepsis

- suspected meningitis

Meningitis with sepsis

Clinical presentation Depend on the patient’s age

- newborn: nonspecific

- infancy: fever, vomiting, irritability, convulsion, tense& bulging fontanelle

- children: fever, chills, vomiting, severe headache

Meningococcemia : purpura fulminans

purpura fulminans

Clinical presentation Meningeal irritation sign

- significantly less frequent in neonates

- Brudzinski sign, stiff neck, Kernig sign

Kernig’s signSevere stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees.

Brudzinski’s sign

Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed.

AGE COMMON ORGANISM EMPIRICAL ANTIBIOTIC

Newborn infants GBS

E.coli and other gram negative enteric bacteria enterococci

Ampicillin + Gentamicin

Or Cefotaxime

Infants & children < 5 yo H.influenzae type b

S.pneumoniae

Salmonella

N.meningitidis

Cefotaxime

Children older than 5 yo S.pneumoniae

N.meningitidis

Cefotaxime

Treatment Dexamethasone in Hib meningitis with in min

after first dose of ATB can reduce risk for hearing and neurologic complication

- 0.15 mg/kg q 6hr for 4 days or

0.4 mg/kg q 12 hr for 2 days

gram negative diplococci within a neutrophil, typical for Neisseria

meningitidis

GBS

S.pneumoniae

H.Infuenzae type B

E.coli

Salmonella sp.

Diagnosis definite diagnosis: CSF examination and C/S CSF gram stain Rapid antigen testing:

GBS, E.coli K1, S.pneumoniae, Hib, N.meningitidis

Hemoculture

Investigation :admission D1 Blood for H/C , CBC , BUN , Cr ,

Electrolyte , BS LP and CSF analysis, CSF culture, gram stain UA ,MUC

Lab : Admission day1 CBC : Hct 35.4, WBC 21160, N72.7, L 15.3,M11.9,

Plt 371,000, MCV79.2 BUN7, Cr0.3 , Na133, K 4.3, Cl 97, HCO3

16,AG20, BS 137 U/A : pH 6.0 ,sp.gr1.015, WBC0-4, Glu3+, Protein -,

Ketone - CSF : Glu 56, TP 100, RBC 10,000, WBC 1,960

(correct WBC : 1,946) CSF G/S : no bacteria was seen, few PMN

Lab : Admission Day2 Bacterial Ag profile: Hib, N. Meningitidis A,

B/Ecoli, C, Y/W, Strep. Agalactiae, Strep. Pneumo : All Negative

CSF profileCondition Normal CSF Normal CSF

(newborn)

Bacterial meningitis

Color

Pressure (mm.H2O)

WBC (mm3)

Protein (mg/dl)

Glucose (mg/dl)

Comments

Clear

50-80

<5, 75% lymphocyte

20-30

>50, 75% BS

Clear

0-30,

2-3% PMN

19-149

32-121

Cloudy

Usually elevated

> 1000

PMNs > 50%

Usually 100-500

Depressed

Organism may be seen by gram stain/

culture

CSF profileCondition Viral

meningitis

TB

meningitis

Pressure (mm.H2O)

WBC (mm3)

Protein (mg/dl)

Glucose (mg/dl)

Comments

Normal or slightly elevated

100-500

PMN<40%

50-100>30

Usually elevated

10-500, PMN early but lymphocyte predominated

100-3,000<50

AFB almost negativeM.TB may be detected by

PCR/C/S

Nelson Textbook of Pediatrics 16th ed.

Diagnosis

Bacterial

meningitis

Treatment1 1.Empirical antibiotics Cefotaxime (300mg/kg/day) 300mg iv q 6hr Gentamicin (5mg/kg/day) 15mg iv q 8hr 2.supportive treatments Paracetamol(120mg/5ml)4ml oral prn for fever

q4-6 hr IV fluid

Treatment2 3.monitoring Record v/s q 4hr Record neuro sign q4hr HC,BW OD Record I/O

Lab : Admission Day2 H/C : gram –ve rod MUC : no growth Bacterial Ag profile: Hib, N. MeningitidisA,

B/Ecoli, C, Y/W, Strep. Agalactiae, Strep. Pneumo : All Negative

Treatment3 Ciprofloxacin <40 MKD>

sig 110 mg iv q 8 hr

TreatmentCausal organism Duration(days)

GBS,L.monocytogenase 14-21

H.influenzae,S.pneumoniae

N.meningitidis

Salmonella

Gram negative bacilli

10-14

7-10

28

21

-Add ciprofloxacin in Salmonella meningitis to prevent relapse

-Change ATB to PGS in mennigococcal meningitis if sensitive

Lab : Admission Day3 CSF culture : Salmonella groupD H/C :Salmonella groupD Drug sensitivity : Cefotaxime, Ciprofloxacin

Repeated LP For diagnosis : in questionable case repeated

LP in 24 hrs For evaluate response of treatment(48-

72hrs after treatment)- cases with poor response- resistant organism- neonatal meningitis

-those received steroid

Complication Seizure Subdural effusion 20-30%,subdural empyema

1% SIADH Hearing loss (require hearing evaluation at the

end of treatment) Hydrocephalus brain abscess

Progress note

Progress note

Plan Continue ATB 28 days

Special thanks

A. Kulkanya Chokephaibulkit, A. Jeeranda Santiprapob A. Panjama