Purulent Meningitis
in Children
Jiang Li
Department of Neurology
Children’s Hospital
Chongqing University of Medical Sciences
? Acute infection of central nervous system(CNS),
90% of cases occur in the age of 1mo-5yr,
? The inflammation of meninges caused by
various bacteria.Common features in clinical
practices include,fever,increased intracranial
pressure,meningeal irritation.
? One of the most potentially serious infections,
associated with high mortality (about 10%) and
morbidity,
Purulent Meningitis
1.Etiology
1.1 Pathogens:
? Main pathogens,Neissria meningitidis,streptoccus
pneumoniae,Haemophilus influenzae,(2/3 of
purulent meningitis are caused by these pathogens)
? Pathogens in special populations (neonate & <3mo
infants,malnutrition,immunodeficiency),
gramnegative enteric bacilli,group B streptococci,
staphlococcus aureus
1.2 Major risk factors for meningitis
? Immature immunologic function and attenuated
immunologic response to pathogens
? Low level of immunoglobulin,defects of
complement and properdin system
? Immature or impaired blood-brain-barrier (BBB)
? Immature BBB function,maturation at about 1yr
? Impaired BBB,Congenial or acquired defects
across mucocutaneous barrier
1.3 Access of bacteria invasion
? Typical access---hematogenous dissemination
? Bacteria colonizing the mucous membranes of
the nasopharynx ?invasion into local tissue ?
bacteremia ? hematogenous seeding to the
subarachnoid space
? Mode of transmission,Person to person contact
through respiratory tract secretions or droplets
? Bacteria spread to the meninges directly,
through anatomic defects in the skull or
head trauma
? Invasion from parameningeal organs:
such as paranasal sinuses or middle ear
Access of bacteria invasion
2,Pathology
? Structure of meninges
? Characterized by leptomeningeal and
perivascular infiltration with
polymorphonuclear leukocytes and an
inflammatory exudate.
?Exudate which may be distributed from
convexity of brain to basal region of cranium.
? Exudate is more thickness due to
streptococcus pneumoniae than other
pathogens.
Pathology
3,Clinical manifestations
? The younger the child is,the higher incidence of
meningitis will be,?-2/3 of cases occur less than
1yr of age.
? Mode of presentation:
? Acute or fulminant onset,symptoms and signs
of sepsis; meningitis evolve rapidly over a few
hours and death within 24 hours; usually
infected with Neissria meningitides
(N,meningitides).
? Subacute onset,
Precede by several days of upper respiratory
tract or gastrointestinal symptoms; difficult to
pinpoint the exact onset of meningitis; usually
with meningitis due to Haemophilus influenzae
(H influenzae) and streptoccus pneumococcus
(S pneumococcus).
Mode of presentation
? Common features of meningitis:
? signs of systemic infection, fever(90-95%),
anorexia,shock,alteration of mental status
and consciousness
? neurological signs:
? increased intracranial pressure,headache,
vomiting(82%),herniation
? meningeal irritation,nuchal rigidity(77%),
kernig sign,brudzinski sign
Clinical manifestations
brudzinski sign
? Seizure (20-30%)
? Focal or generalized
? Due to cerebritis,infarction,electrolyte
disturbances
? Frequently noted with H influenzae &
S pneumococcal meningitis
? Persist after 4th day and difficult to treat with
poor prognosis
Clinical manifestations
Clinical manifestations
? Alteration of mental status and consciousness
? Including,irritability,lethargy,stupor
obtundation,coma
? Due to increased intracranial pressure,
cerebritis,hypotension
? Often with pneumococcal or meningococcal
meningitis
? Comatose patients with a poor prognosis
? The symptoms and signs are not evident in
neonates and infants younger than 3mo of
age; and patients already received irregular
antibiotic therapy.
Clinical manifestations
Signs of systemic
infection
Increased
intracranial
pressure
meningeal
irritation
Typical
(older
children)
Fever,
altered consciousness,
seizure
Headache,
vomiting,
herniation
nuchal rigidity,
back pain,kernig
sign,brudzinski
sign
Atypical
(neonate &
<3mo
infant )
Fever,normal
temperature or
hypothermia; minim or
subtle seizure; poor
feeding;less activity
Scream,frown;
bulging or full
fontanel;
widening of the
sutures
Not evident
Comparison of the manifestations of meningitis
between different age groups
Clinical manifestations
4,Diagnosis
? Earlier diagnosis and prompt initiation of effective
antibiotic treatment is critical for minimizing
sequelae of purulent meningitis.
? Suspected cases,febrile infants with seizure,
meningeal irritability,increased intracranial
pressure,altered mental status
? Pay attention to the atypical symptoms and
signs in neonate,infant and patient already
received irregular antibiotic therapy
? Diagnosis is confirmed by analysis of cerebrospinal
fluid ( CSF)
? Suggestion bacterial meningitis
? Increased pressure (90%)
? Appearance,slightly cloudy to purulent
? Raised white blood cells,consisting chiefly of
polymorphonuclear leukocytes
? Raised protein concentration,decreased
glucose concentration (80%)
Diagnosis
? Confirmation of the diagnosis,isolation from the
CSF of a specific bacterial pathogen by
microscopy or a positive culture or rapid antigen-
detection test of CSF
? Gram-stained smear of CSF,identify the
causative organism in 70-90% of cases
? CSF culture,positive in about 80% of cases.
definitive diagnosis,determination of antibiotic
sensitivity.
? PCR,amplifies bacterial DNA (H influenzae,N,
meningitidis)
Diagnosis
5,Differential diagnosis
? Purulent meningitis caused by different pathogens
? Neissria meningitidis:
? Occur in epidemics (type A,C),which is more
common in spring,or sporadic all the year
(type B,C,Y)
? Sudden onset with various cutaneous signs
( petechiae,purpura,or an erythematous
macular rash)
? Streptococcus pneumoniae:
? Young infants ( <1yr) are most susceptible
population
? Peak season,spring and winter
? Easier to have subdural effusion and
hydrocephalus
? Easily have a protracted course and relapse
Differential diagnosis
? Haemophilus influenzae
? Occurs predominantly in infants 2mo to 2yr
of age
? Many cases are in winter
? Higher incidence of subdural effusion
? Others pathogens,staphylococcus aureus,
gramnegative enteric bacilli
? Special susceptible population,neonate,
<3mo infants,malnutrition,immunodeficiency
? Severe infection,difficult to treat
Differential diagnosis
? Meningitis caused by other microorganisms
? Viral meningitis/encephalitis,
? Less severe systemic infectious symptoms
? Usually not develop after 2-3weeks
? CSF,normal glucose
Differential diagnosis
? Tuberculous meningitis
? Subacute onset and progress
? A history of close contact with known
cases of tuberculosis
? Evidence of acute or healed tubercular
infection on chest x-ray
? Tuberculin skin test, OT,PPD
? CSF
Differential diagnosis
Disease Pressure
(Kpa)
aspect Total
WBC
(x106/L)
Protein
(g/L)
Glucose
(mmol/L)
smears cultures
normal 0.69-1.96
(0.29-
0.78)
clear 0-5
(0-20)
0.2-0.4
(0.2-1.2)
2.2-4.4 - -
Purulent
meningitis
? cloudy ??
(PMN)
??
(1-5)
??
(<2.2)
Gram’s
stain +
+
Tuberculous
meningitis
? Normal
or
cloudy
?
(MN)
? ? AFB
stain +
?
Viral
meningitis/
encephalitis
Normal
or ?
Normal Normal or
?
(MN)
Normal
or ?
(<1)
normal - ?
Fungal
meningitis
Normal
or ?
Normal
or
cloudy
?
(MN)
? ? India
ink prep
+
?
Cerebrospinal fluid in neurologic infection
6,Complications and sequelae
6.1 Subdural effusion
? Definitive diagnosis,volume of fluid in subdural
space >2ml,protein>0.4g/L,
? Incidence,develop in 10-30% of patients,
asymptomatic in 85-90% of patients; especially
common in infants 4-6 month of age ( rare in
children over 1yr);
? Causative organisms,45% of cases of
meningitis caused by H influenzae,30% by
S pneumoniae,9% by N meningitidis
subdural effusion
? Indications,
? No response to a sensitive antibiotic therapy
? Prolonged fever or fever reoccurring after an
afebrile interval with effective treatment
? Bulging fontanel,widening of sutures,
enlarging head circumference,emesis,seizure,
altered consciousness.
? Improved CSF profile with more serious clinical
manifestations
subdural effusion
? Diagnosis methods:
? Cranial translucent test
? B ultrasonic examination and CT
? Subdural space puncture
subdural effusion
normal subdural effusion
6.2 Ventriculitis
6.3 hydrocephalus
Complications
Circulation of cerebrospinal fluid(CSF)
6.2 Ventriculitis
? Usually occurs in neonates and infants (<1yr),
with severe prognosis
? The main cause is delayed diagnosis and
treatment of meningitis.
Complications
? Diagnosis:
? B ultrasonic examination or neuroimaging
studies( CT,MRI),enlarged lateral ventricle
? Lateral ventricle puncture,bacteria and
inflammatory cells in ventricular fluid,
WBC>50x106/L,Glucose<1.6mmol/L,
or protein>400mg/L.
Ventriculitis
Circulation of cerebrospinal fluid(CSF)
6.3 hydrocephalus,
? Communicating hydrocephalus,adhered or
destroyed arachnoid granulation around the
cistern at the base of the brain
? Obstructive hydrocephalus,following
obstructed of the cerebral aqueduct,or the
foramina of Magendie and Luschka
6.4 others:
Deafness,blindness,paralysis,epilepsy,
mental retardation
Complications
7,Treatment
7.1 Antibacterial therapy
? Therapy principles,early treatment,antibiotics
susceptible to pathogens and with high
permeability through BBB,given intraveninously,
enough dose,enough course of antibiotic
therapy
? Susceptible to pathogens
? First choice,Cefotaxime,Ceftriaxone (3dr
generation of cephalosporins,high permeability
through BBB,products of metabolism also has
effect,CSF sterilization within 24h)
? Other choice,Penicillin,Chloromycin,Cefuroxime,
Ceftazidime ( delayed effect to make CSF sterile,
high incidence of relapse and deafness)
Antibacterial therapy
Etiology Standard antibiotics of choice Duration of
therapy
H.influenzae Cefotaxime /Ceftriaxone 7-10days
N.meningitidis Cefotaxime /Ceftriaxone 7days
S.pneumoniae Cefotaxime /Ceftriaxone 2-3weeks
Staphlococcus
aureus
Semisynthetic penicillins (Oxacillin
sodium,Cloxacillin
sodium),Norvancomycin
>3weeks
E.coli Cefotaxime /Ceftriaxone
(or + ampicillin)
> 3weeks
Unknown Cefotaxime/Ceftriaxone + ampicillin >2-3weeks
Antibiotic therapy of bacterial meningitis
? Maintenance fluid and thermal energy supplement:
? Fluid administration,60-80ml/kg/day
? Fluid infusion with dehydration therapy
7.2 Supportive care
Treatment
? increased intracranial pressure
? Osmotic therapy,intravenous mannitol 0.5-
1g/kg/every time,q4-6h
? Combination with intravenous dexamethasone,
0.3-0.5mg/kg/day
? Endotracheal intubation and hyperventilation
Treatment
? Subdural effusion
? Few volume could be absorbed with treatment
spontaneously
? Subdural puncture,take out 15ml/each time
(unilateral puncture),less than 30ml/each time
( bilateral puncture),everyday or every other
day
? Stripping operation,for the cases not cure after
3-4weeks
Treatment
? Others:
? Ventriculitis, lateral ventricle puncture and
injection of antibiotics locally
? Epilepsy,AEDs
Treatment
in Children
Jiang Li
Department of Neurology
Children’s Hospital
Chongqing University of Medical Sciences
? Acute infection of central nervous system(CNS),
90% of cases occur in the age of 1mo-5yr,
? The inflammation of meninges caused by
various bacteria.Common features in clinical
practices include,fever,increased intracranial
pressure,meningeal irritation.
? One of the most potentially serious infections,
associated with high mortality (about 10%) and
morbidity,
Purulent Meningitis
1.Etiology
1.1 Pathogens:
? Main pathogens,Neissria meningitidis,streptoccus
pneumoniae,Haemophilus influenzae,(2/3 of
purulent meningitis are caused by these pathogens)
? Pathogens in special populations (neonate & <3mo
infants,malnutrition,immunodeficiency),
gramnegative enteric bacilli,group B streptococci,
staphlococcus aureus
1.2 Major risk factors for meningitis
? Immature immunologic function and attenuated
immunologic response to pathogens
? Low level of immunoglobulin,defects of
complement and properdin system
? Immature or impaired blood-brain-barrier (BBB)
? Immature BBB function,maturation at about 1yr
? Impaired BBB,Congenial or acquired defects
across mucocutaneous barrier
1.3 Access of bacteria invasion
? Typical access---hematogenous dissemination
? Bacteria colonizing the mucous membranes of
the nasopharynx ?invasion into local tissue ?
bacteremia ? hematogenous seeding to the
subarachnoid space
? Mode of transmission,Person to person contact
through respiratory tract secretions or droplets
? Bacteria spread to the meninges directly,
through anatomic defects in the skull or
head trauma
? Invasion from parameningeal organs:
such as paranasal sinuses or middle ear
Access of bacteria invasion
2,Pathology
? Structure of meninges
? Characterized by leptomeningeal and
perivascular infiltration with
polymorphonuclear leukocytes and an
inflammatory exudate.
?Exudate which may be distributed from
convexity of brain to basal region of cranium.
? Exudate is more thickness due to
streptococcus pneumoniae than other
pathogens.
Pathology
3,Clinical manifestations
? The younger the child is,the higher incidence of
meningitis will be,?-2/3 of cases occur less than
1yr of age.
? Mode of presentation:
? Acute or fulminant onset,symptoms and signs
of sepsis; meningitis evolve rapidly over a few
hours and death within 24 hours; usually
infected with Neissria meningitides
(N,meningitides).
? Subacute onset,
Precede by several days of upper respiratory
tract or gastrointestinal symptoms; difficult to
pinpoint the exact onset of meningitis; usually
with meningitis due to Haemophilus influenzae
(H influenzae) and streptoccus pneumococcus
(S pneumococcus).
Mode of presentation
? Common features of meningitis:
? signs of systemic infection, fever(90-95%),
anorexia,shock,alteration of mental status
and consciousness
? neurological signs:
? increased intracranial pressure,headache,
vomiting(82%),herniation
? meningeal irritation,nuchal rigidity(77%),
kernig sign,brudzinski sign
Clinical manifestations
brudzinski sign
? Seizure (20-30%)
? Focal or generalized
? Due to cerebritis,infarction,electrolyte
disturbances
? Frequently noted with H influenzae &
S pneumococcal meningitis
? Persist after 4th day and difficult to treat with
poor prognosis
Clinical manifestations
Clinical manifestations
? Alteration of mental status and consciousness
? Including,irritability,lethargy,stupor
obtundation,coma
? Due to increased intracranial pressure,
cerebritis,hypotension
? Often with pneumococcal or meningococcal
meningitis
? Comatose patients with a poor prognosis
? The symptoms and signs are not evident in
neonates and infants younger than 3mo of
age; and patients already received irregular
antibiotic therapy.
Clinical manifestations
Signs of systemic
infection
Increased
intracranial
pressure
meningeal
irritation
Typical
(older
children)
Fever,
altered consciousness,
seizure
Headache,
vomiting,
herniation
nuchal rigidity,
back pain,kernig
sign,brudzinski
sign
Atypical
(neonate &
<3mo
infant )
Fever,normal
temperature or
hypothermia; minim or
subtle seizure; poor
feeding;less activity
Scream,frown;
bulging or full
fontanel;
widening of the
sutures
Not evident
Comparison of the manifestations of meningitis
between different age groups
Clinical manifestations
4,Diagnosis
? Earlier diagnosis and prompt initiation of effective
antibiotic treatment is critical for minimizing
sequelae of purulent meningitis.
? Suspected cases,febrile infants with seizure,
meningeal irritability,increased intracranial
pressure,altered mental status
? Pay attention to the atypical symptoms and
signs in neonate,infant and patient already
received irregular antibiotic therapy
? Diagnosis is confirmed by analysis of cerebrospinal
fluid ( CSF)
? Suggestion bacterial meningitis
? Increased pressure (90%)
? Appearance,slightly cloudy to purulent
? Raised white blood cells,consisting chiefly of
polymorphonuclear leukocytes
? Raised protein concentration,decreased
glucose concentration (80%)
Diagnosis
? Confirmation of the diagnosis,isolation from the
CSF of a specific bacterial pathogen by
microscopy or a positive culture or rapid antigen-
detection test of CSF
? Gram-stained smear of CSF,identify the
causative organism in 70-90% of cases
? CSF culture,positive in about 80% of cases.
definitive diagnosis,determination of antibiotic
sensitivity.
? PCR,amplifies bacterial DNA (H influenzae,N,
meningitidis)
Diagnosis
5,Differential diagnosis
? Purulent meningitis caused by different pathogens
? Neissria meningitidis:
? Occur in epidemics (type A,C),which is more
common in spring,or sporadic all the year
(type B,C,Y)
? Sudden onset with various cutaneous signs
( petechiae,purpura,or an erythematous
macular rash)
? Streptococcus pneumoniae:
? Young infants ( <1yr) are most susceptible
population
? Peak season,spring and winter
? Easier to have subdural effusion and
hydrocephalus
? Easily have a protracted course and relapse
Differential diagnosis
? Haemophilus influenzae
? Occurs predominantly in infants 2mo to 2yr
of age
? Many cases are in winter
? Higher incidence of subdural effusion
? Others pathogens,staphylococcus aureus,
gramnegative enteric bacilli
? Special susceptible population,neonate,
<3mo infants,malnutrition,immunodeficiency
? Severe infection,difficult to treat
Differential diagnosis
? Meningitis caused by other microorganisms
? Viral meningitis/encephalitis,
? Less severe systemic infectious symptoms
? Usually not develop after 2-3weeks
? CSF,normal glucose
Differential diagnosis
? Tuberculous meningitis
? Subacute onset and progress
? A history of close contact with known
cases of tuberculosis
? Evidence of acute or healed tubercular
infection on chest x-ray
? Tuberculin skin test, OT,PPD
? CSF
Differential diagnosis
Disease Pressure
(Kpa)
aspect Total
WBC
(x106/L)
Protein
(g/L)
Glucose
(mmol/L)
smears cultures
normal 0.69-1.96
(0.29-
0.78)
clear 0-5
(0-20)
0.2-0.4
(0.2-1.2)
2.2-4.4 - -
Purulent
meningitis
? cloudy ??
(PMN)
??
(1-5)
??
(<2.2)
Gram’s
stain +
+
Tuberculous
meningitis
? Normal
or
cloudy
?
(MN)
? ? AFB
stain +
?
Viral
meningitis/
encephalitis
Normal
or ?
Normal Normal or
?
(MN)
Normal
or ?
(<1)
normal - ?
Fungal
meningitis
Normal
or ?
Normal
or
cloudy
?
(MN)
? ? India
ink prep
+
?
Cerebrospinal fluid in neurologic infection
6,Complications and sequelae
6.1 Subdural effusion
? Definitive diagnosis,volume of fluid in subdural
space >2ml,protein>0.4g/L,
? Incidence,develop in 10-30% of patients,
asymptomatic in 85-90% of patients; especially
common in infants 4-6 month of age ( rare in
children over 1yr);
? Causative organisms,45% of cases of
meningitis caused by H influenzae,30% by
S pneumoniae,9% by N meningitidis
subdural effusion
? Indications,
? No response to a sensitive antibiotic therapy
? Prolonged fever or fever reoccurring after an
afebrile interval with effective treatment
? Bulging fontanel,widening of sutures,
enlarging head circumference,emesis,seizure,
altered consciousness.
? Improved CSF profile with more serious clinical
manifestations
subdural effusion
? Diagnosis methods:
? Cranial translucent test
? B ultrasonic examination and CT
? Subdural space puncture
subdural effusion
normal subdural effusion
6.2 Ventriculitis
6.3 hydrocephalus
Complications
Circulation of cerebrospinal fluid(CSF)
6.2 Ventriculitis
? Usually occurs in neonates and infants (<1yr),
with severe prognosis
? The main cause is delayed diagnosis and
treatment of meningitis.
Complications
? Diagnosis:
? B ultrasonic examination or neuroimaging
studies( CT,MRI),enlarged lateral ventricle
? Lateral ventricle puncture,bacteria and
inflammatory cells in ventricular fluid,
WBC>50x106/L,Glucose<1.6mmol/L,
or protein>400mg/L.
Ventriculitis
Circulation of cerebrospinal fluid(CSF)
6.3 hydrocephalus,
? Communicating hydrocephalus,adhered or
destroyed arachnoid granulation around the
cistern at the base of the brain
? Obstructive hydrocephalus,following
obstructed of the cerebral aqueduct,or the
foramina of Magendie and Luschka
6.4 others:
Deafness,blindness,paralysis,epilepsy,
mental retardation
Complications
7,Treatment
7.1 Antibacterial therapy
? Therapy principles,early treatment,antibiotics
susceptible to pathogens and with high
permeability through BBB,given intraveninously,
enough dose,enough course of antibiotic
therapy
? Susceptible to pathogens
? First choice,Cefotaxime,Ceftriaxone (3dr
generation of cephalosporins,high permeability
through BBB,products of metabolism also has
effect,CSF sterilization within 24h)
? Other choice,Penicillin,Chloromycin,Cefuroxime,
Ceftazidime ( delayed effect to make CSF sterile,
high incidence of relapse and deafness)
Antibacterial therapy
Etiology Standard antibiotics of choice Duration of
therapy
H.influenzae Cefotaxime /Ceftriaxone 7-10days
N.meningitidis Cefotaxime /Ceftriaxone 7days
S.pneumoniae Cefotaxime /Ceftriaxone 2-3weeks
Staphlococcus
aureus
Semisynthetic penicillins (Oxacillin
sodium,Cloxacillin
sodium),Norvancomycin
>3weeks
E.coli Cefotaxime /Ceftriaxone
(or + ampicillin)
> 3weeks
Unknown Cefotaxime/Ceftriaxone + ampicillin >2-3weeks
Antibiotic therapy of bacterial meningitis
? Maintenance fluid and thermal energy supplement:
? Fluid administration,60-80ml/kg/day
? Fluid infusion with dehydration therapy
7.2 Supportive care
Treatment
? increased intracranial pressure
? Osmotic therapy,intravenous mannitol 0.5-
1g/kg/every time,q4-6h
? Combination with intravenous dexamethasone,
0.3-0.5mg/kg/day
? Endotracheal intubation and hyperventilation
Treatment
? Subdural effusion
? Few volume could be absorbed with treatment
spontaneously
? Subdural puncture,take out 15ml/each time
(unilateral puncture),less than 30ml/each time
( bilateral puncture),everyday or every other
day
? Stripping operation,for the cases not cure after
3-4weeks
Treatment
? Others:
? Ventriculitis, lateral ventricle puncture and
injection of antibiotics locally
? Epilepsy,AEDs
Treatment
