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									How to treat
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                                                                                                                                                                                    inside
                                                                                                                                                                                     Pathogenesis
                                                                                                                                                                                     and aetiology

                                                                                                                                                                                     History and
                                                                                                                                                                                     examination

                                                                                                                                                                                     Investigations

                                                                                                                                                                                     Management

                                                                                                                                                                                     Case studies


                                                                                                                                                                                     The author




                                                                                                                                                                                     DR MIKE STARR,
                                                                                                                                                                                     paediatrician, infectious
                                                                                                                                                                                     diseases physician, consultant
                                                                                                                                                                                     in emergency medicine,




                Meningitis
                                                                                                                                                                                     and director of paediatric
                                                                                                                                                                                     physician training, Royal
                                                                                                                                                                                     Children’s Hospital,
                                                                                                                                                                                     Parkville, Victoria.




 Background
                in children                                                                                                                                                             Clarification
                                                                                                                                                                                       The How to Treat article,
                                                                                                                                                                                       ‘Cervical Cancer Screening’
                                                                                                                                                                                       (July 28th), stated that only
                                                                                                                                                                                       women who have been
                                                                                                                                                                                       treated for a high-grade
                                                                                                                                                                                       lesion within the past two
                                                                                                                                                                                       years would be eligible for a
MENINGITIS is inflammation of the         which may also occur in conjunction     meningitis is a source of great anxi-       the consequences of overlooking a                        Medicare benefit for HPV
meninges that surround the brain          with inflammation of the meninges       ety for both parents and doctors.           treatable and potentially lethal con-                    testing. However, women
and spinal cord. During meningitis,       (meningo-encephalitis) or spinal cord      To add to this anxiety, children         dition may be devastating.                               who are already undergoing
inflammatory cells spill into the cere-   (encephalomyelitis).                    with meningitis may present in a               Up to 58% of children with                            annual cytological review for
brospinal fluid (CSF) from the               Bacterial meningitis is a medical    non-specific manner, and distin-            meningitis have received prior anti-                     the follow-up of a previously
meninges and increase the cell count.     emergency that requires prompt          guishing a child with meningitis from       biotics, which can modify the clinical                   treated HSIL are also
   Encephalitis refers to inflamma-       assessment and treatment. The pos-      those with other less serious infec-        presentation and make reaching the                       eligible.
tion affecting the brain parenchyma,      sibility of encountering a child with   tions can be very difficult. However,                                       cont’d page 31




                                                                                                             Home improvement
                                                                                                          Studies suggest that self-measured                  you make more informed therapeutic
                                                                                                          blood pressure levels correlate more                decisions – helping to reduce the risk
                                                                                                          closely than in-clinic readings with                of cardiovascular events.
                                                                                                          target-organ damage. Furthermore,
                                                                                                          the National Heart Foundation believes              So when it comes to improving
                                                                                                          that patient self-measured blood                    cardiovascular health, it appears there’s
                                                                                                          pressure levels can help give you a                 no place like home.
                                                                                                          more complete, accurate picture of
                                                                                                                                                                                                                  OMR104 CVATE




                                                                                                          the patient’s blood pressure, and help

                                                                                                                          http://www.heartfoundation.com.au/downloads/SelfMeasurement_BP_HP.pdf




                                                                                    www.australiandoctor.com.au                                                         15 September 2006 | Australian Doctor |             29
from page 29                                                                                                                                                                       maternal genital tract pre-           Most cases of bacterial
correct diagnosis more diffi-                                                                                                                                                      dominate: group B strepto-         meningitis arise sporadically;
cult. It is therefore important                                                                                                                                                    cocci, Escherichia coli and        only meningococcal infec-
to consider the possibility of                                                                                                                                                     Listeria monocytogenes.            tions can occur in epidemic
meningitis in any sick infant                                                                                                                                                         In older children and adults    form. Meningococci are
or child, particularly if they                                                                                                                                                     the most common causes are         transmitted from person to
are already taking antibi-                                                                                                                                                         Neisseria meningitidis (men-       person by nasopharyngeal
otics.                                                                                                                                                                             ingococci) and S pneumoniae        secretions from a patient or
                                                                                                                                                                                   (pneumococci). Other causes,       carrier, and transmission
Epidemiology                                                                                                                                                                       including Staphylococcus           requires close contact.
The annual incidence of bac-                                                                                                                                                       species and Gram-negative             Major epidemics have
terial meningitis is 30-50                                                                                                                                                         bacilli, are occasionally seen     occurred in South America,
cases per 100,000 children                                                                                                                                                         in immunocompromised               Finland, Mongolia and sub-
aged under five years. Rates                                                                                                                                                       patients or after trauma or        Saharan Africa, and out-
are highest in infants, Indige-                                                                                                                                                    neurosurgery.                      breaks have been noted in
nous populations, and                                                                                                                                                                 Haemophilus influenzae          students living in dormito-
during late winter and                                                                                                                                                             type b (Hib) rarely causes         ries.
spring. Viral meningitis is                                                                                                                                                        meningitis now because of             Age is a major determi-
more common in older chil-                                                                                                                                                         widespread immunisation.           nant of susceptibility to
dren and occurs more often                                                                                                                                                         Mycobacterium tuberculosis         meningococcal disease. The
in summer and autumn.                                                                                                                                                              meningitis is rare, other than     age-specific incidence of
                                                                                                                                                                                   in children who have spent         meningococcal disease is
Pathogenesis                                                                                                                                                                       prolonged periods in regions       highest in young children,
Meningitis usually follows                                                                                                                                                         of high prevalence (eg,            although maternal anti-
invasion of the bloodstream                                                                                                                                                        South-East Asia, the Pacific       bodies usually protect
by organisms that have                                                                                                                                                             and Africa, India, China,          infants in the first few
colonised mucosal surfaces.                                                                                                                                                        Indonesia and Vietnam).            months of life. Teenagers
In the neonatal period,                                                                                                                                                               Meningococci are divided        and the elderly also have
pathogens are mainly              Pneumococcal meningitis.                                                                                                                         into serogroups on the basis       increased risk.
acquired by contact with,                                                                                                                                                          of antigenic differences in           Other risk factors include
and aspiration of, intestinal                                                                                                                                                      their capsular polysaccha-         crowding, low socioeco-
and genital tract secretions                                                                                                                                                       rides (A, B, C, D, X, Y, Z,        nomic status, exposure to
from the mother during                                                Serotypes responsible for invasive pneumococcal disease                                                      W-135 and 29-E).                   tobacco smoke and certain
birth. Neonates can also be                                                   in children aged <5 year, Australia, 2003                                                               Groups B, C, Y and W-           immune defects (eg, comple-
exposed to multiple nosoco-                                                                                                                                                        135 are the predominant            ment deficiency).
mial pathogens in neonatal                                                             Communicable Diseases Intelligence 2004; 28:455-64.                                         serogroups associated with
units.                                                                                                                                                                             invasive disease in developed      Viruses
   In infants and children,                                                                                                                            Cumulative percentage       countries, whereas the group       Enteroviruses, including cox-
meningitis usually develops                                          250                                                                                                      90   A strain accounts for epi-         sackie and echoviruses, cause
when encapsulated bacteria                                                                                                                                                    80   demic disease in many other        85–95% of cases of viral
that have colonised the                                                                                                                                  84%                       countries, especially sub-         meningitis. Herpes simplex
                                    Number of isolates




                                                                     200                                                                        79.9                          70
nasopharynx are dissemi-                                                                                                69.3
                                                                                                                                     75.7
                                                                                                                                                                              60
                                                                                                                                                                                   Saharan Africa.                    viruses 1 (HSV-1) and 2
nated in the blood. Although                                         150                                       62.5                                                                   In Australia, the most          (HSV-2) and other herpes
                                                                                                                                                                              50
viral infections of the upper                                                                    49.2                                                                              common N meningitidis              viruses (human herpes
                                                                                                                                                                              40
respiratory tract commonly                                           100                                                                                                           serogroup causing invasive         viruses 6, 7 and 8, varicella-
                                                                                34.6                                                                                          30
precede meningitis, invasion                                                                                                                                                       disease in children under 15       zoster virus, cytomegalovirus
                                                                     50                                                                                                       20
is a rare occurrence, given                                                                                                                                                        is serogroup B (77%), fol-         and Epstein-Barr virus) tend
the frequency of viral respi-                                                                                                                                                 10   lowed by serogroup C               to cause meningo-encephali-
ratory infections in children.                                        0                                                                                                       0    (19%). The predominance of         tis.
                                                                               14           6B           19F          18C        4            23F       9V       Non-
   Factors that may increase                                                                                                                                    vaccine            serogroup B declines in chil-         However, HSV-1 and
this chance include exposure                                                                                           Serotype                                                    dren aged 15-19 (serogroup         HSV-2 are possibly the most
to some bacteria that have                                                                                                                                                         B 54%; serogroup C 40%).           important causes to con-
virulence factors that pro-                                                                                                                                                           Although more than 90           sider, as meningo-encephali-
mote penetration of the res-                                                                                                                                                       serotypes of pneumococci           tis caused by these viruses is
piratory epithelium, com-                                                                                                                                                          have been identified on the        associated with high mor-
promise of host defences,                                                  Penicillin-resistant S pneumoniae, bloodstream isolates                                                 basis of their capsular poly-      bidity and mortality, which
(eg, reduced ciliary function                                                   Communicable Diseases Intelligence 2003; 27 Suppl:S61-S66.                                         saccharides, only a few are        may be reduced with early
or reduced mucosal IgA) and                                                                                                                                                        commonly associated with           treatment.
certain environmental fac-                                                                                                                                                         invasive disease and menin-           Enterovirus 71 (EV 71)
tors (particularly exposure                                            80                                                                                                          gitis.                             emerged as a significant ner-
to cigarette smoke).                                                                        Mean inhibitory concentration > 1mg/L*                                                    The most common pneu-           vous system pathogen in
   Organisms may then pen-                                             70                                                                                                          mococcal serotypes causing         Asia after outbreaks in
etrate vulnerable sites of the                                                              Mean inhibitory concentration 0.125-1mg/L*                                             invasive disease (14, 6B,          Sarawak (1997), Taiwan
                                         Penicillin resistance (%)




                                                                       60
blood-brain barrier (eg, the                                                                                                                                                       18C, 19F, 4, 23F and 9V)           (1998) and more recently in
choroid plexus and cerebral                                            50                                                                                                          are contained in the seven-        Perth (1999). EV 71 is
capillaries) and reach the                                                                                                                                                         valent conjugate pneumo-           related to the coxsackie A16
subarachnoid space. Inflam-                                            40                                                                                                          coccal vaccine, which is now       virus and both can cause
matory mediators, produced                                                                                                                                                         a component of the immu-           hand, foot and mouth dis-
in response to the presence                                            30                                                                                                          nisation schedule in Aus-          ease in young children.
of bacteria, are believed to                                                                                                                                                       tralia.                               In the 1998 outbreak in
                                                                       20
enhance the permeability of                                                                                                                                                           In the US, where use of         Taiwan, 78 patients died
the blood-brain barrier and                                            10                                                                                                          conjugate pneumococcal             and another 405 had severe
facilitate bacterial invasion                                                                                                                                                      vaccine has been routine           complications, including
of the CSF.                                                                0                                                                                                       since 2000, rates of invasive      brainstem encephalitis,
   Meningitis can also                                                                                                                                                             disease have fallen in both        poliomyelitis-like paralysis,
                                                                                Australia    Japan         Taiwan       China        Hong    Philippines Singapore   South
develop by direct extension                                                    1998-2001      (15)           (0)         (1)         Kong         (7)       (17)     Africa        vaccinated children and            myocarditis and pulmonary
of infection from a paranasal                                                    (324)                                                (21)                            (20)         unvaccinated elderly people        oedema.
sinus or from the middle ear                                                                                                                                                       because of improved herd              In Hong Kong, 427
                                                                                                        Country (number of isolates)
through the mastoid to the                                                                                                                                                         immunity.                          patients were admitted to
meninges. Severe head               *Susceptible ≤ 0.06mg/L; intermediate susceptibility 0.1-1mg/L; resistant ≥ 2mg/L.                                                                It is too early to judge the    hospital with hand, foot and
trauma with skull fracture,                                                                                                                                                        impact of universal meningo-       mouth disease in 1998, four
CSF rhinorrhoea, or both,                                                                               ing wounds or extension                  the result of a localised or      coccal and pneumococcal            of whom were identified
can lead to meningitis,                                                                                 from a suppurative para-                 systemic insult, but is most      vaccination in Australia.          with meningo-encephalitis
which is usually caused by                                                                              meningeal focus.                         commonly caused by viruses        However, the pneumococcal          secondary to EV 71.
Streptococcus pneumoniae.                                                                                                                        or fungi.                         serotypes contained in the
   Bacteria can be directly                                                                             Aetiology                                                                  conjugate vaccine include a        Fungi
inoculated into the CSF by                                                                              Meningitis is usually broadly            Bacteria                          high proportion of those that      Cryptococcus neoformans
congenital dural defects                                                                                classified as bacterial or               The bacterial causes of           are resistant to penicillin and,   is the most common fungal
(dermal sinus or meningo-                                                                               aseptic. Bacterial meningitis            meningitis vary with the age      in Victoria at least, it appears   cause of meningitis but
myelocele), neurosurgical                                                                               is still a major cause of death          of the child. In infants less     that rates of penicillin-resis-    occurs almost exclusively
procedures (such as CSF                                                                                 and disability in children.              than 2–3 months old, organ-       tant pneumococcal meningitis       in immunocompromised
diversion shunts), penetrat-                                                                            Aseptic meningitis may be                isms acquired from the            are decreasing.                    patients.

                                                                                                                                www.australiandoctor.com.au                                                 15 September 2006 | Australian Doctor |   31
 How to treat – meningitis in children


     History and examination
 OBTAINING a careful history                   sign in this age group.                                                                  threshold for referral to an emer-          ■ Presentation in summer or autumn,
 about prodromal symptoms, tempo                  The clinical presentation of                                                          gency department for a lumbar                 particularly in clusters.
 of the illness and accompanying               meningitis is often non-specific in                                                      puncture should be lowered. This is         ■ Gradual onset of non-specific con-

 symptoms may provide clues to the             infants and young children. Mani-                                                        one of the reasons why antibiotics            stitutional symptoms including
 aetiology of a child’s meningitis.            festations may merely include                                                            should be avoided in children                 diarrhoea, cough and myalgia.
 Important points to consider include:         fever, irritability, lethargy and                                                        unless there is clear evidence of a         ■ Low-grade fever.

 ■ Maternal obstetric history —                poor feeding.                                                                            bacterial infection.                           It is very difficult to predict which
   were swabs taken for group B                   If the fontanelle is still open, it                                                                                               of the innumerable children seen in
   streptococci? Was the labour pro-           may bulge in an infant with menin-                                                       Rash                                        general practice with probable viral
   longed or complicated in some               gitis, but this may occur as a result                                                    Rash may occur with any bacterial           RTIs will be ‘the one with meningi-
   other way? Were intrapartum                 of any cause of raised intracranial                                                      meningitis but is less common with          tis’. However, it is essential to do
   antibiotics given?                          pressure. The fontanelle must be                                                         pneumococcal infection. Although            so, because a short period between
 ■ Perinatal complications — was the           palpated with the infant sitting                                                         petechiae or purpura are sugges-            onset of disease and admission has
   baby unwell at birth or shortly             upright quietly; if the infant is lying   Meningococcal sepsis with extensive            tive of meningococcal sepsis, they          been shown to improve outcome.
                                                                                         purpuric lesions of the arm.
   afterwards?                                 prone and/or crying when exam-                                                           occur more often in children with              Looking for features that suggest
 ■ Immunisation status.                        ined, the fontanelle may falsely          Partially treated meningitis                   viral meningitis (eg, enteroviral           that the child has more than just an
 ■ Infectious contacts.                        appear to bulge.                          Children who have recently been                meningitis).                                RTI is very important. These may
 ■ Recent use of antibiotics.                     Photophobia is difficult to ascer-     treated with oral antibiotics may                 Meningococcal infection may also         include:
                                               tain in young children, and other         present in an even more insidious              present with other rashes, including        ■ Drowsiness on history or exami-

 Clinical findings                             signs of meningeal irritation may be      fashion with subtle clinical findings.         blanching maculopapular spots, but            nation.
 The classic clinical features of              absent or difficult to elicit.            It is not uncommon in clinical prac-           up to half of cases may present with        ■ Decreased activity.

 meningitis include:                              In adults with meningitis,             tice to be faced with a child who is           no rash. Unfortunately, the type of         ■ Pallor on history or examination.

 ■ Headache.                                   Kernig’s sign (inability to extend        already receiving an oral penicillin           rash does not predict the severity of       ■ Breathing difficulty or chest wall

 ■ Vomiting.                                   the knee when the leg is flexed at        or cephalosporin for otitis media or           the disease, although a rapidly evolv-        recession.
 ■ Neck stiffness.                             the hip), Brudzinski sign (bending        an RTI, and who presents with fever            ing petechial or purpuric rash is a         ■ Temperature >38°C or <36.4°C.

 ■ Photophobia.                                the head forward produces flexion         and irritability.                              sign of very poor prognosis.                ■ Feeding less than 50% of the

 ■ Altered conscious state.                    movements of the legs) and nuchal            Although these symptoms may be                 It is impossible to reliably differen-     normal amount for the infant.
    However, young children may                rigidity have been shown to have          attributable to the underlying infec-          tiate between bacterial and viral           ■ More than five vomits in the pre-

 not (or may not be able to) com-              low positive and negative predic-         tion, it is often impossible to reli-          meningitis on clinical grounds. How-          vious 24 hours.
 plain of headache or photophobia,             tive value; in children these signs       ably exclude meningitis on clinical            ever, features that are more suggestive     ■ Fewer than four wet nappies in the

 and neck stiffness is not a reliable          are often not present at all.             grounds. In this situation the                 of (entero)viral meningitis include:          previous 24 hours.



     Investigations
 DEFINITIVE diagnosis of                                                                                                                               children and those with             specificity are high, particu-
 meningitis relies on bio-                  Serotypes of pneumococcal isolates with reduced susceptibility to                                          meningitis. However, results        larly for N meningitidis,
 chemical analysis, micros-                                                                                                                            should always be interpreted        HSV and enterovirus. PCR
                                               penicillin in children aged <5 years, Australia, 2003 (n=71)
 copy and culture of the CSF.                                                                                                                          in the context of the clinical      for N meningitidis is partic-
 Children with suspected                                   Communicable Diseases Intelligence 2004; 28:455–64.                                         picture. For example, in            ularly useful in patients with
 meningitis should have a                                                                                                                              early bacterial meningitis the      a clinical picture consistent
 lumbar puncture performed,                                                                                                                            CSF cell count may be               with meningococcal menin-
 unless there is a contra-             Serotype             19F       9V        14       6B       23F        19A      6A         33F       Total       normal, while in enteroviral        gitis but who have already
 indication. The only absolute         No of isolates       19        16        16       8        1          6        4          1         71          meningitis there is typically       received antibiotics.
 contraindication is raised                                                                                                                            an early neutrophil predom-            Latex agglutination allows
 intracranial pressure.                                                                                                                                inance that may remain for          rapid detection of bacterial
    It may be difficult to            (Mauve = serotypes in vaccine)                                                                                   more than 24 hours.                 antigens in CSF and urine but
 determine whether intracra-                                                                                                                              Organisms are seen on            lacks sensitivity and specificity,
 nial pressure is raised, but                                                                                                                          CSF Gram stain in 60–80%            other than for Hib, and is
 the following signs may be                    Table 1: Typical CSF profiles in normal children and those with meningitis                              of cases of meningitis, pro-        therefore rarely used.
 indicative:                                                                                                                                           vided that prior antibiotics
 ■ Coma (absent or non-pur-                                           White cell count                       Biochemistry                              have not been given. The            Other investigations
   poseful response to painful                              Neutrophils         Lymphocytes       Protein                 Glucose                      sensitivity is highest in           Other investigations include:
   stimulus).                                                     6                  6                                                                 patients with pneumococcal          ■ Culture of blood, throat
                                                            (10 cells/L)        (10 cells/L)      (g/L)                   (CSF:blood ratio)
 ■ Abnormal pupillary res-                                                                                                                             meningitis. Prior antibiotics         swab or swab of skin lesions
   ponses.                            Normal                0                   ≤5                <0.4                    ≥ 0.6 (or ≥2.5mmol/L)        may preclude culture of the           may yield a causative organ-
 ■ Abnormal posturing.
                                      (age >1 month)                                                                                                   causative organism, but the           ism if lumbar puncture
 ■ Focal neurological signs or        Normal                0                   ≤10               <1.0                    ≥ 0.6 (or ≥2.1mmol/L)        biochemistry and white cell           cannot be performed (or
   seizures.                          term neonate                                                                                                     count remain abnormal for             will be delayed until after
 ■ Recent (within 30 min-                                                                                                                              several days after treatment          antibiotics are given).
                                      Bacterial             ↑                   ↑                 ↑                       ↓
   utes), prolonged (>30 min-         meningitis                                                                                                       has begun.                            Knowledge of the causative
   utes) or tonic seizures.                                                                                                                               A traumatic tap occurs in          organism and its antibiotic
                                      Viral meningitis      ↑                   ↑                 0.4-1.0                 Usually normal
 ■ Papilloedema — although                                                                                                                             15-20% of lumbar punctures            susceptibility may alter the
   this is an unreliable and                                                                                                                           in children. Several formulae         choice and duration of
   late sign.                                                              should certainly not delay            cells/L will cause CSF to             have been devised for inter-          antibiotics.
    Lumbar puncture may                                                    ongoing management: raised            appear turbid. The CSF pro-           preting CSF contaminated            ■ Gram stain on blood smear

 need to be delayed if there                                               intracranial pressure cannot          file may help differentiate           with blood, but the safest            may be positive.
 is cardiovascular compro-                                                 be excluded with CT.                  between bacterial and viral           practice if meningitis is sus-      ■ Blood glucose should be

 mise or shock, respiratory                                                   In a prospective study of          meningitis, but findings vary.        pected is to disregard the red        measured at the same time
 compromise, coagulopathy                                                  children with bacterial menin-           The white blood cell differ-       cell count and begin treatment        as CSF glucose (see ‘DEFG’
 or thrombocytopenia. The                                                  gitis, CT findings obtained           ential may be misleading early        for meningitis. If the clinical       page 33).
 following are not con-                                                    during the acute stages of            in the course of meningitis:          course is not as expected,          ■ Baseline serum sodium

 traindications to performing                                              meningitis failed to reveal any       more than 10% of patients             another diagnosis such as             should be measured.
 a lumbar puncture:                                                        significant abnormalities that        with bacterial infection will         cerebral haemorrhage should           Hyponatraemia occurs in
 ■ Drowsiness or irritability.                                             were not suspected on neuro-          have an initial lymphocytic           be suspected.                         about one-third of children
                                                                                                 1
 ■ Vomiting.                                                               logical examination.                  predominance, while the pat-             A repeat lumbar puncture           with meningitis and may
 ■ Bulging fontanelle in the                                                  Moreover, cerebral herni-          tern in patients with viral           showing a persistently high           be due to increased antidi-
   absence of other signs of                                               ation can occur with a                meningitis may initially be           red cell count would be sug-          uretic hormone secretion,
   raised intracranial pres-                                               normal CT. CT scans should            dominated by neutrophils.             gestive and require further           increased urine sodium
   sure.                             Meningococcal sepsis with             be reserved for children with            Culture is the gold stan-          investigation with cerebral           losses, or excessive elec-
 ■ Seizures, per se.
                                     extensive purpuric lesions of         focal neurological signs,             dard for determining the              CT.                                   trolyte-free water intake or
                                     the hand.
 ■ Suspected meningococcal                                                 focal seizures or signs of            causative organism in                    Seizures do not cause an           administration.
   disease.                                                                raised intracranial pressure.         meningitis. However, PCR is           increased CSF cell count in         ■ FBC and acute-phase reac-

    Cerebral CT should not be                                                                                    much faster and more sensi-           the absence of meningitis.            tants (eg, C-reactive pro-
 used to decide if it is safe to                                           Examination of the CSF                tive in some circumstances               Bacterial or viral DNA             tein) may provide support-
 proceed with lumbar punc-                                                 Normal CSF is clear and con-          (see later).                          can be detected in blood              ive information.
 ture in patients suspected of                                             tains few cells (and no neu-             Table 1 indicates the typi-        and/or CSF using PCR                ■ Enterovirus may be isolated
                                                                                                        6
 having meningitis, and                                                    trophils). As few as 200 × 10         cal CSF profiles in normal            analysis. Sensitivity and             from throat swab or stool.

32   | Australian Doctor | 15 September 2006                                                   www.australiandoctor.com.au
 Management
Initial management                                                                                        A recent large European       important in treating menin-      incidence of bacterial menin-
ABC                                                                                                    trial in adults with meningi-    gitis. Over- or under-hydra-      gitis.
CHECK airway, breathing                                                                                tis showed a reduction in        tion is associated with
and circulation and manage                                                                             mortality and severe mor-        adverse outcomes. Many            Chemoprophylaxis
appropriately. Children with                                                                           bidity with pneumococcal         children with meningitis          Contacts of patients with
clinical signs of shock or                                                                             meningitis when subjects         have increased antidiuretic       meningococcal meningitis
hypovolaemia should be                                                                                 were treated with adjunctive     hormone secretion, and            may require chemoprophy-
given 0.9% (normal) saline                                                                             steroids either with, or 15-     some will have dehydration        laxis to prevent secondary
at 20mL/kg.                                                                                            20 minutes before, the first     due to vomiting, poor fluid       spread. Those who should
                                                                                                       dose of antibiotic, then every   intake or septic shock.           receive chemoprophylaxis
                                                                                                                                 2
DEFG (‘don’t ever forget                                                                               six hours for four days.            Initial fluid resuscitation    include:
glucose’)                                                                                                 A recent Cochrane meta-       to treat shock should be          ■ The index case if treated

This is particularly true for a                                                                        analysis including adult and     given as required with iso-         only with penicillin (does
child who is fitting with (or                                                                          paediatric trials concluded      tonic saline. Thereafter, iso-      not eradicate carriage).
without) fever. The child                                                                              that adjuvant steroids are       tonic fluids should be given      ■ All intimate, household or

may have meningitis, but fit-                                                                          beneficial for children with     to maintain systemic blood          day-care contacts who have
                                                                                                                             3
ting may also be secondary                                                                             bacterial meningitis.            pressure (and thereby cere-         been exposed to the index
to hypoglycaemia associated                                                                               However, evidence from        bral blood flow).                   case within 10 days of
                                  Typical raised purpuric lesion of meningococcal disease.
with serious illness and                                                                               animal studies shows that           The optimal ongoing fluid        onset of symptoms.
reduced glucose intake.                                                                                dexamethasone reduces pen-       requirement for children          ■ Any    person who had
Check the blood sugar level                                                                            etration of vancomycin into      with meningitis is not clearly      mouth-to-mouth resuscita-
and treat if low.                                                                                      infected CSF. Thus there is      established. Previous guide-        tion or direct airway secre-
                                                                                                       concern that use of dexam-       lines have suggested the            tion contact with the index
Antibiotics                                                                                            ethasone with vancomycin         importance of fluid restric-        case.
After initial fluid resuscita-                                                                         could compromise the effi-       tion but more recent studies         One of the following
tion, the emphasis is on                                                                               cacy of vancomycin in third-     have questioned this              antibiotics should be pre-
starting parenteral antibi-                                                                            generation cephalosporin-        approach.                         scribed for chemoprophy-
otics promptly (see table                                                                              resistant strains.                  Assessment of the clinical     laxis:
page 34). Delay in antibiotic                                                                             Fortunately, most cases of    signs of hydration, including     ■ Rifampicin        10mg/kg
therapy has been associated                                                                            pneumococcal meningitis are      weight, measurement of              (5mg/kg in babies less than
with adverse clinical out-                                                                             still caused by strains that     serum sodium, documenta-            one month old) orally 12-
come in adults with bacterial                                                                          are susceptible to penicillin    tion of urine output and            hourly (maximum 600mg)
meningitis.                                                                                            and third-generation ceph-       clinical assessment of the          for two days, or
                                                                                                       alosporins. Accordingly,         neurological state should be      ■ Ceftriaxone 125mg (chil-

Age <2 months. Benzylpeni-                                                                             children older than four         monitored closely, and the          dren ≤12 years old) or
cillin plus cefotaxime is the                                                                          weeks who are being treated      total fluid intake adjusted         250mg (>12 years) IM as a
treatment of choice. Because                                                                           for possible meningitis (but     accordingly.                        single dose, or
of the morbidity associated       Child with suspected meningitis awaiting lumbar puncture, with       who have not yet received           Although it may be neces-      ■ Ciprofloxacin 500mg orally

with neonatal Gram-nega-          topical anaesthetic applied to the lumbar region.                    parenteral antibiotics, or       sary to restrict fluids if the      as a single dose.
tive meningitis, and the high                                                                          who have received their first    serum sodium concentration           Rifampicin and cipro-
rates of recrudescence, many                                                                           dose less than one hour pre-     is <130mmol/L or if there         floxacin should not be used
neonatologists also add gen-                                                                           viously) should be given IV      are signs of fluid overload,      in pregnant women.
tamicin.                                                                                               dexamethasone 0.15mg/kg          fluid restriction does not
                                                                                                       six-hourly.                      generally improve outcome         Complications
Age >2 months. Use cefo-                                                                                  Steroids should preferably    and has even been associated      Bacterial meningitis is asso-
taxime alone. Note that van-                                                                           be given 15-30 minutes           with worse neurological out-      ciated with an overall 4.5%
comycin is added in many                                                                               before antibiotics, although     comes.                            mortality rate; this may be
centres for suspected pneu-                                                                            antibiotic administration           Treatment of viral menin-      as low as 2% in infants and
mococcal meningitis; how-                                                                              should not be delayed for        gitis is generally sympto-        children and as high as 20-
ever, rates of resistance to                                                                           more than 30 minutes.            matic, but meningitis caused      30% in neonates. Mortality
penicillin and cephalosporin                                                                              If a GP sees a child with     by HSV and other herpes           is generally higher for pneu-
among pneumococci appear                                                                               suspected meningitis in the      group viruses is usually          mococcal meningitis.
to be decreasing in Australia                                                                          surgery or on a home visit,      treated with high-dose aci-          Morbidity, including intel-
since the introduction of                                                                              the decision about whether       clovir. In immunocompro-          lectual, cognitive and audi-
conjugate pneumococcal                                                                                 to administer antibiotics will   mised children, IV im-            tory impairments, occurs in
vaccine into the routine                                                                               depend on the distance from      munoglobulin may also be          10-20% of survivors. The
schedule, and this may not                                                                             the nearest emergency            considered.                       risk for sequelae is greatest
be necessary.                                                                                          department.                                                        in those who experience
                                  Infant with severe meningococcal sepsis in the ICU.                     If there is any doubt about   Notification                      acute neurological complica-
Duration of antibiotic treat-                                                                          how quickly the child will be    All cases of presumed or          tions at the time of their ill-
ment. The duration of                                                  After entry into the CSF,       investigated and treated, IM     confirmed N meningitidis          ness. Use of antibiotics has
antibiotic therapy depends                                          the bacteria replicate rapidly     or IV antibiotics should be      (or Hib) disease should be        had a profound effect on the
on the organism isolated.                                           and liberate active cell-wall      given immediately. If a third-   urgently notified to the          clinical course and prognosis
For S pneumoniae and                                                or membrane-associated             generation cephalosporin is      appropriate health authority      of meningitis.
H influenzae, 10-14 days’                                           components. Antibiotics that       available, this would be the     which varies from state to
treatment is generally rec-                                         act on cell walls (eg,             preferred choice, although       state. Invasive S pneumoniae      Pitfalls
ommended, while for                                                 cephalosporins and peni-           early administration of peni-    infections must also be noti-     Partially treated meningitis
N meningitidis a seven-day                                          cillins) cause rapid lysis of      cillin has been shown to         fied, although only written       As mentioned previously, the
course is generally recom-                                          bacteria, which can initially      reduce mortality.                notification within five days     child who has recently been
mended. Even shorter                                                cause enhanced release of             The only absolute con-        of diagnosis is required.         treated with oral antibiotics
courses have been suc-                                              these active bacterial prod-       traindication is known                                             may present in a more
cessfully used in New Zea-                                          ucts into the CSF.                 severe penicillin anaphylaxis.   Prevention                        insidious fashion, resulting
land.                                                                  If steroids are given before    When a history of brief          Immunisation                      in subtle clinical findings.
  In L monocytogenes and                                            antibiotics, this process may      rashes or illness (not requir-   With the introduction of          The threshold for a CSF
group B streptococcal menin-                                        be diminished, but routine         ing treatment) after adminis-    effective conjugated vaccines     examination may need to
gitis, antibiotics should be                                        administration of steroids as      tration of penicillin is         against Hib, the incidence of     be varied accordingly, par-
given for 14-21 days. For                                           adjunctive therapy has been        reported, the benefit from       bacterial meningitis caused       ticularly in the younger child
Gram-negative bacilli a mini-                                       controversial. The evidence        administration of penicillin     by this pathogen has              or if the possibility of par-
mum of three weeks is                                               that steroids protect against      will outweigh any side           declined by more than 99%         tially treated meningitis
needed.                                                             neurological (particularly         effects and administration       in countries such as Aus-         exists.
                                                                    audiological) complications        should be continued. The         tralia that have adopted uni-
Steroids                                                            of childhood meningitis is         administration of steroids       versal immunisation.              Apparent improvement with
Neurological damage in                                              strongest in cases of Hib          can be delayed in this              Conjugate serogroup C          paracetamol
patients with meningitis is                                         meningitis, if dexamethasone       instance.                        meningococcal vaccine and         Clinical improvement with
caused by intense inflamma-                                         is given before the first dose                                      conjugate seven-valent pneu-      reduction of fever may occur
tion secondary to activation                                        of antibiotics, and when a         Ongoing management               mococcal vaccine are now          in children with serious bac-
of inflammatory pathways                                            third-generation cephalo-          Fluids                           also part of the routine          terial infection. However,
by the bacteria or bacterial                                        sporin such as ceftriaxone is      Careful management of fluid      schedule for all children and     this is less likely in children
products.                                                           used.                              and electrolyte balance is       should further reduce the         with bacterial meningitis.

                                                                                        www.australiandoctor.com.au                                             15 September 2006 | Australian Doctor |   33
 How to treat – meningitis in children


     Author’s case studies
 Clinical signs of                                                                              Drugs used in meningitis                                                            Management
 meningitis in a fully                                                                                                                                                              This girl sounds as if she has
 vaccinated infant                    Drug name                Brand name                                 Dosage                                   Duration of treatment            had a simple febrile convul-
 A 13-MONTH-old previ-                                                                                                                                                              sion secondary to otitis
 ously well infant presented to       Aciclovir                Aciclovir, Acihexal, Acyclo-V,             ■ < 3 months of age: 20mg/kg/dose        3 weeks                          media. If meningitis is not
 a peripheral hospital with a                                  Lovir, Zovirax, Zyclir                       8-hourly                                                                suspected, she does not
                                                                                                                                       2
                                                                                                          ■ 3 months-12 years: 500mg/m /dose
 24-hour history of fever and                                                                                                                                                       require any investigations,
 lethargy. His immunisations                                                                                8-hourly                                                                but a period of observation
                                                                                                          ■ >12 years: 10mg/kg/dose 8-hourly
 were up to date for his age                                                                                                                                                        until she is less drowsy
 (he had previously had three                                                                                                                                                       would be sensible.
                                      Benzylpenicillin         Benpen                                     50mg/kg/dose (max 3g), IV 4-hourly       7 days for meningococci,
 doses of Hib-containing vac-                                                                                                                                                          Otitis media does not nec-
                                                                                                                                                   10 days for pneumococci
 cine, three doses of conjugate                                                                                                                                                     essarily require antibiotic
 pneumococcal vaccine and             Cefotaxime               Cefotaxime                                 50mg/kg (max 2g) IV 6-hourly             7 days for meningococci,         treatment. It would be rea-
 one dose of conjugate                                                                                                                             10 days for pneumococci          sonable to give her paraceta-
 meningococcal vaccine).                                                                                                                                                            mol and review her the next
    He was initially admitted         Ceftriaxone              Ceftriaxone, Rocephin                      100mg/kg (max 2g) IV daily               Single dose                      day, with instructions to the
 for     observation        but                                                                           For prophylaxis: 125mg (<12 years)                                        parents to contact you if she
 remained drowsy and had                                                                                  250mg (>12 years) IM                                                      worsens. The parents will
 two generalised tonic-clonic                                                                                                                                                       need to be educated about
 convulsions the next day.            Ciprofloxacin            C-Flox, Ciprol, Ciproxin,                  500mg orally                             Single dose                      febrile convulsions and
 Ceftriaxone and aciclovir                                     Ciprofloxacin, Profloxin, Proquin                                                                                    appropriate management of
 were started and he was              Dexamethasone            Dexamethasone                              0.15mg/kg IV 6-hourly                    4 days
                                                                                                                                                                                    a potential subsequent con-
 transferred to the Royal                                                                                                                                                           vulsion.
 Children’s Hospital.                 Gentamicin               Gentamicin, Septopal                       ■ Up to 10 years: 7.5mg/kg/dose          Adjunctive treatment of
    At hospital he was noted                                                                                (max 240mg) IV or IM 24-hourly         Gram-negative meningitis for     Viral meningitis
 to have clinical signs consis-                                                                           ■ Over 10 years: 6mg/kg/dose             first 48 hours                   A 14-year-old girl reports
 tent with meningitis. He was                                                                               (max 360mg) IV or IM 24 hourly                                          abdominal pain, diarrhoea
 haemodynamically stable                                                                                                                                                            and headache for three days.
 and there were no signs of           Rifampicin               Rifadin, Rimycin                           10mg/kg orally 12-hourly (max 600mg)     2 days                           Her headache has worsened
 raised intracranial pressure.                                                                                                                                                      today and she has developed
                                      Vancomycin               Vancocin, Vancomycin                       15mg/kg (max 500mg) IV 6-hourly          10 days (for resistant
 A lumbar puncture was per-                                                                                                                                                         a painful neck and vomited
                                                                                                                                                   pneumococci)
 formed and initial CSF                                                                                                                                                             once.
 analysis revealed:                                                                                                                                                                    On examination she has a
                        6
 ■ Neutrophils 220 × 10 cells/L.                                                                                                                                                    temperature of 37.8°C but
                        6             Practice points
 ■ Lymphocytes 30 × 10 cells/L.                                                                                                                                                     does not look too unwell.
 ■ Protein 3g/L.                      ■   Bacterial meningitis can                                                                                                                  She has neck stiffness and
 ■ Glucose 2.1mmol/L (serum               be rapidly progressive and                                                                                                                photophobia and a gener-
   glucose 4.6mmol/L).                    result in substantial                                                                                                                     alised macular rash. She is
 ■ Gram stain: no bacteria                morbidity and mortality.                                                                                                                  neurologically normal.
   seen.
                                      ■   A high index of suspicion
 ■ Antibiotic activity detected.                                                                                                                                                    Management
                                          of the possibility of
                                                                                                                                                                                    This girl probably has
                                          meningitis must be
 Management                                                                                                                                                                         enteroviral meningitis. She
                                          maintained in any sick
 It was felt that the cause of                                                                                                                                                      needs a lumbar puncture to
                                          infant or child.
 the infant’s meningitis was                                                                                                                                                        confirm the diagnosis, and a
 more likely to be meningo-           ■   Symptoms and signs are                                                                                                                    stool sample may be helpful.
 coccal than pneumococcal.                frequently non-specific,                                                                                                                  If the CSF demonstrates
 His three doses of conjugate             particularly with younger                                                                                                                 pleocytosis, it should be sent
 pneumococcal           vaccine           age, and in children who                                                                                                                  for viral culture and
 should have protected him                have already begun treat-                                                                                                                 enteroviral PCR.
 against the most likely                  ment with antibiotics.                                                                                                                      Treatment is supportive.
 serotypes to cause meningi-                                                                                                                                                        She should be told that the
                                      ■   Antibiotic treatment must
 tis, and conjugate meningo-                                                                                                                                                        headache of viral meningitis
                                          not be delayed.
 coccal vaccine should pro-                                                                                                                                                         may persist for many days.
 tect him against serogroup           ■   Steroids may improve
 C disease, but serogroup B               outcome if given before             Toddler with early purpuric rash
 was a more likely cause in               the first dose of antibiotic.       typical of meningococcal infection.                                                                    References
 this age group.                                                                                                                                                                     1. Cabral D, et al. Prospective
                                      ■   Careful management of
    The third-generation                                                      ture are negative), menin-          he has felt hot, been off his    with the child if there is any    study of computed
                                          fluid and electrolyte
 cephalosporin was continued                                                  gitis can be confirmed, as          food and spent the morning       deterioration.                    tomography in acute bacterial
                                          balance is critical.
 and aciclovir and van-                                                       pleocytosis (presence of            lying on the couch.                 It would be preferable to      meningitis. Journal of
 comycin added (just in case          ■   Conjugate meningococcal             more cells than normal)                On examination he has an      avoid antibiotics unless there    Pediatrics 1987; 111:201-05.
 this was a case of resistant             and pneumococcal                    persists for at least several       aural temperature of 40°C.       is an obvious bacterial focus.    2. De Gans J, van de Beek
 pneumococcal meningitis).                vaccines may affect                 days.                               He looks flushed and miser-      If there is any doubt, it         D. European Dexametha-
 The infant’s presumed                    the epidemiology of               ■ Newer molecular tests may           able but not too sick. He is     would be sensible to send         sone in Adulthood Bacterial
 meningococcal infection was              meningitis in children.             yield the aetiology.                lying quietly in his mother’s    the child to an emergency         Meningitis Study
 notified to the Department                                                 ■ Although the infant had             arms and is well hydrated.       department (paediatric if         Investigators.
                                      ■   Viral meningitis cannot be                                                                                                                 Dexamethasone in adults
 of Human Services and the                                                    been given three doses of           He has red tympanic mem-         possible) for assessment.
                                          reliably differentiated on                                                                                                                 with bacterial
 family was given rifampicin                                                  conjugate pneumococcal              branes and pharyngitis but
                                          clinical grounds from                                                                                                                      meningitis. New England
 prophylaxis.                                                                 vaccine, there are more             does not have neck stiffness.    A febrile convulsion in an
                                          bacterial meningitis.                                                                                                                      Journal of Medicine 2002;
    As the CSF culture was                                                    than 90 serotypes alto-             There are no other clinical      infant with otitis media
 antibiotic affected, CSF was                                                 gether, and several types           findings.                        A three-year-old girl is          347:1549-56.
 sent for meningococcal PCR.                                                  can cause invasive disease.                                          brought in by her mother          3. van de Beek D, et al.
 Pneumococcal PCR (a new                                                    ■ Despite routine immunisa-           Management                       after a two-minute gener-         Corticosteroids in acute
 test not routinely offered and                                               tion with conjugate pneu-           It is more difficult to know     alised tonic-clonic convul-       bacterial meningitis.
 mainly used in research cen-                                                 mococcal and meningococ-            how to deal with this child      sion that occurred 15 min-        Cochrane Database of
 tres) was also performed.                                                    cal vaccines, it is important       than the previous one. He        utes ago at home. She had         Systematic Reviews 2003;
 The meningococcal PCR                                                        to consider these organ-            probably has a viral URTI,       woken with a slightly runny       CD004405.
 was negative but pneumo-                                                     isms as potential causes of         but his presentation would       nose but was otherwise well
 coccal PCR was positive.                                                     serious bacterial infection         not be inconsistent with         and had been playing hap-         Online resources
                                                                                                                                                                                     ■   Royal Children’s Hospital
    This case illustrates several                                             in children.                        meningitis.                      pily all morning.
                                                                                                                                                                                         Melbourne. Meningitis
 principles:                                                                                                         The most appropriate             On examination she was
                                                                                                                                                                                         guideline:
 ■ Always treat empirically                                                 The child who probably                management will depend on        slightly drowsy but oriented
                                                                                                                                                                                         www.rch.org.au/
   with antibiotics that will                                               only has a viral URTI                 how sick you feel the child      and interactive, with a tem-
                                                                                                                                                                                         clinicalguide/cpg.cfm?
   cover the most common                                                    A child aged two and a half           is. If he is not particularly    perature of 38.5°C. She had
                                                                                                                                                                                         doc_id=5179
   causes of meningitis.                                                    is brought in to see you by           unwell, it would be reason-      a unilateral red bulging tym-
                                                                                                                                                                                     ■   Meningitis Research
 ■ Although prior antibiotics                                               his mother. He has been               able to review him later in      panic membrane but no
                                                                                                                                                                                         Foundation:
   may sterilise the CSF (so                                                unwell for three days with            the day, with clear instruc-     neck stiffness or other neu-
                                                                                                                                                                                         www.meningitis.org
   that Gram stain and cul-                                                 coryza and cough and today            tions for the parent to return   rological abnormalities.

34   | Australian Doctor | 15 September 2006                                                       www.australiandoctor.com.au
 How to treat – meningitis in children


     GP’s contribution
                                                                Case study                                                                                                                                                                                         without access to immediate                  meningococcal disease. Myal-
                                                                JASON is a five-month-old                                                                                                                                                                          lumbar puncture, would it                    gia and arthralgia may also be
                                                                child I saw late one evening.                                                                                                                                                                      have been preferable to treat                seen with meningococcal dis-
                                                                His mum was concerned, as                                                                                                                                                                          Jason with cefotaxime IM                     ease (and viral meningitis) and
                                                                he was unwell with a cold and                                                                                                                                                                      injections and dexamethasone                 might be misinterpreted as
                                                                he was her first child.                                                                                                                                                                            IM injections simultaneously?                bone pain.
                                                                   Jason was a little pale, with                                                                                                                                                                   If so, what are the doses?
                                                                a respiratory rate of 28                                                                                                                                                                              I think it would be very rea-             If there are no definite symp-
       DR ASHLEY BERRY
                                                                breaths/minute and aural tem-                                                                                                                                                                      sonable to treat a five-month-               toms and signs of meningitis
               Lugarno, NSW
                                                                perature 37.1°C. His chest was                                                                                                                                                                     old like this with IM or IV                  (headache, vomiting, neck
                                                                clear, he had mildly hyper-                                                                                                                                                                        antibiotics in the situation                 stiffness, photophobia) and if
                                                                aemic tympanic membranes                                                                                                                                                                           you describe. Ceftriaxone                    there is no definite source of
                                                                and his pharynx was normal.                                                                                                                                                                        100mg/kg would be the best                   infection, would you advise
                                                                His abdomen was soft and                                                                                                                                                                           choice, although cefotaxime                  lumbar puncture for all chil-
                                                                both testes had descended.                                       ness or photophobia. In view                                       Meningitis is not common                                       50mg/kg or penicillin 50mg/kg                dren aged under two years
                                                                   As I could not find a spe-                                    of his irritability and because                                  although it’s quite possible                                     would be good alternatives. It               with irritability? Alternatively,
                                                                cific cause for his low-grade                                    there was no definite source                                     that a small number of chil-                                     would be fine to give dexam-                 for children in the ‘grey zone’,
                                                                temperature, I kept him in the                                   of infection, I referred him to                                  dren we presume to have non-                                     ethasone 0.15mg/kg although I                what are your criteria for
                                                                surgery while I saw my last                                      accident and emergency.                                          specific viral illnesses may                                     would definitely not delay the               lumbar puncture?
                                                                two patients. Mum attempted                                      There he immediately under-                                      have viral meningitis.                                           antibiotics.                                    It is mainly younger infants
                                                                to breastfeed him. He seemed                                     went lumbar puncture and                                                                                                                                                       in the ‘grey zone’, as you put it,
                                                                to feed a little and looked                                      was found to have viral                                          Given Jason had already had                                      What is the role of an urgent                that really need a lumbar punc-
                                                                better, so I let them go home,                                   meningitis, with raised CSF                                      his first two immunisations,                                     CT scan in this case?                        ture to exclude meningitis.
                                                                warning Mum to ring me if                                        lymphocytes and protein, and                                     how likely was this to be bac-                                      There is no role for a CT in              Febrile or ‘sick’ babies under
                                                                she had any concerns. My                                         reduced glucose level.                                           terial rather than viral?                                        this situation. CT scans should              one month of age must have a
                                                                diagnosis was a non-specific                                       He was observed in hos-                                           The first two lots of immu-                                   be reserved for children with                lumbar puncture (as well as
                                                                viral illness.                                                   pital for two days, improved                                     nisations provide some pro-                                      focal neurological signs, focal              culture of blood and urine).
                                                                   The next morning Jason                                        and was subsequently dis-                                        tection (not complete) against                                   seizures or signs of raised                     From 1-3 months of age I
                                                                was brought back to the                                          charged. I saw him six days                                      Hib and seven pneumococcal                                       intracranial pressure.                       would err on the side of cau-
                                                                surgery at 8am. He had been                                      after his initial presentation                                   serotypes (as well as hepatitis                                                                               tion, although it may be rea-
                                                                restless through the night —                                     and he was back to his                                           B, DTP and polio). And of                                        General questions for the                    sonable to do other tests first
                                                                unusual for him. His tempera-                                    normal self.                                                     course, viral infections are                                     author                                       and await the results of these
                                                                ture had risen to 37.3°C and                                                                                                      much more common than                                            I’ve heard that severe bone                  before proceeding to lumbar
                                                                he seemed a little irritable. He                                 Questions for the author                                         bacterial infections. All in all,                                pain may be an indicator of                  puncture. After three months
                                                                refused to feed through the                                      As a GP of 25 years, this was                                    this was more likely to be a                                     meningitis in older children.                of age the decision about
                                                                night.                                                           my first case of meningitis.                                     viral illness.                                                   Is this your experience?                     doing a lumbar puncture
                                                                   Again when I examined                                         How common is this in a gen-                                                                                                         Ankle pain is certainly often             would depend on how sick
                                                                him there was no neck stiff-                                     eral practice setting?                                           If I was in an isolated town                                     seen in adolescents with                     the child was.


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     1. Which TWO statements about meningitis                                                     ❏     a) Neck stiffness                                                                         ❏     a) Mark’s presentation in winter                                                      ❏ c) Mark’s grandmother, who last cared for
     are correct?                                                                                 ❏     b) Fever                                                                                  ❏     b) Petechial rash                                                                       Mark three weeks ago
     ❏ a) Distinguishing a child with meningitis from                                             ❏     c) Positive Kernig sign                                                                   ❏     c) Low-grade fever                                                                    ❏ d) Mark’s mother
        one with a less serious infection is usually                                              ❏     d) Irritability                                                                           ❏     d) Systolic murmur
        easy                                                                                                                                                                                                                                                                                  9. What role do steroids play in the
     ❏ b) Children with meningitis have often                                                     4. Which TWO actions are most important to                                                      7. You send Mark to hospital. Soon after                                                    treatment of meningitis (choose TWO)?
        received prior antibiotics                                                                take if you suspect meningitis and Kyle has                                                     arrival he deteriorates and has a seizure.                                                  ❏ a) Adjunctive steroids benefit adults with
     ❏ c) Rates of bacterial meningitis are highest in                                            not had any prior antibiotics?                                                                  After stabilisation an urgent lumbar puncture                                                  bacterial meningitis, but not children
        infants, Indigenous populations and during                                                ❏ a) Start antibiotics                                                                          shows neutrophils and red cells. Which ONE                                                  ❏ b) If steroids are given, antibiotic
        late winter and spring                                                                    ❏ b) Refer for urgent lumbar puncture                                                           conclusion can you reach?                                                                      administration should not be delayed for
     ❏ d) Meningitis related to skull fracture is                                                 ❏ c) Order brain CT                                                                             ❏ a) Mark’s meningitis must be bacterial                                                       more than 30 minutes
        usually caused by Neisseria meningitidis                                                  ❏ d) Order a white cell count to exclude                                                        ❏ b) The presence of red cells in the CSF                                                   ❏ c) Steroids can be used in children who have
                                                                                                     infection                                                                                       should not delay starting treatment for                                                     received oral antibiotics as long as the first
     2. Crystal attends with her three-week-old                                                                                                                                                      suspected meningitis                                                                        dose was given less than one hour earlier
     son, Kyle. He has been feeding poorly for                                                    5. Paul attends with his three-year-old son,                                                    ❏ c) Seizures, not meningitis, may have caused                                              ❏ d) Steroids have no role in suspected, but
     one day. Which THREE questions about                                                         Mark. He has been lethargic and irritable for                                                      Mark’s raised neutrophil level                                                              unproven, meningitis
     Crystal’s labour may be significant in Kyle’s                                                two days and has had diarrhoea once.                                                            ❏ d) Hypoglycaemia could not be the cause of
     illness?                                                                                     Which ONE factor in Mark’s history is LEAST                                                        his seizure                                                                              10. Which ONE statement about the
     ❏ a) Were swabs taken for group B strepto-                                                   important in establishing the diagnosis?                                                                                                                                                    epidemiology of meningitis is correct?
         cocci?                                                                                   ❏ a) Infectious contacts                                                                        8. Mark is proven to have meningococcal                                                     ❏ a) Group A meningococcus is the serotype
     ❏ b) Did Crystal have an epidural?                                                           ❏ b) Hearing loss                                                                               meningitis. His mother is six months pregnant.                                                 most likely to cause meningitis in Australia
     ❏ c) Were intrapartum antibiotics given?                                                     ❏ c) Recent use of antibiotics                                                                  Treatment of which of Mark’s contacts would                                                 ❏ b) The predominance of infection with
     ❏ d) Was the labour prolonged or                                                             ❏ d) Immunisation status                                                                        be appropriate (choose TWO)?                                                                   serogroup B meningococcus declines in
         complicated?                                                                                                                                                                             ❏ a) Any day-care contacts, if they have been                                                  children aged 15-19 years
                                                                                                  6. After examination you are concerned that                                                        exposed to Mark within 10 days of symptom                                                ❏ c) Most cases of bacterial meningitis occur in
     3. Which TWO signs are you most likely to                                                    Mark may have viral meningitis. Which TWO                                                          onset                                                                                       epidemics
     find in Kyle’s examination if he has                                                         factors or findings would support, but not                                                      ❏ b) All staff in the emergency department                                                  ❏ d) Meningococci are transmitted by the
     meningitis?                                                                                  prove, your diagnosis?                                                                             where Mark was admitted                                                                     faecal-oral route

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                                                                                                                                                                                                                                                                                              HOW TO TREAT Editor: Dr Lynn Buglar
                                                                                                                                                                                                                                                                                              Co-ordinator: Julian McAllan
                                                                                                                                                                                                                                                                                              Quiz: Dr Lynn Buglar
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           The mark required to obtain points is 80%. Please note that some questions have more than one correct answer. Your CPD activity will be updated on your RACGP records every January, April, July and October.

     NEXT WEEK Significant changes have occurred in the delivery of palliative care, due to recognition of a wider role for GPs, and a shift from management of largely acute care to largely chronic disease.
     The next How To Treat presents an update on palliative care in the home. The author is Dr Geoffrey Mitchell, principal research fellow, discipline of general practice,
     University of Queensland.


36    | Australian Doctor | 15 September 2006                                                                                                                         www.australiandoctor.com.au

								
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