Extern conference

4 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 38.5

o C , 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 -Oral >38 º c >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 sign Severe 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 Newborn infants Infants & children < 5 yo Children older than 5 yo COMMON ORGANISM

GBS

E.coli

and other gram negative enteric bacteria enterococci

H.influenzae type b S.pneumoniae

Salmonella N.meningitidis

S.pneumoniae

N.meningitidis

EMPIRICAL ANTIBIOTIC

Ampicillin + Gentamicin Or Cefotaxime Cefotaxime 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 profile

Condition Normal CSF Color Pressure (mm.H

2 O) WBC (mm 3 ) Protein (mg/dl) Glucose (mg/dl) Comments Clear 50-80 <5, 75% lymphocyte 20-30 >50, 75% BS Normal CSF (newborn) Bacterial meningitis 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 profile

Condition Pressure (mm.H

2 O) WBC (mm 3 ) Protein (mg/dl) Glucose (mg/dl) Comments Viral meningitis TB meningitis 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 negative M.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

Treatment

Causal organism GBS,L.monocytogenase

H.influenzae,S.pneumoniae

N.meningitidis Salmonella Gram negative bacilli Duration(days)

14-21

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

LP in 24 hrs : in questionable case repeated

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