Meningitis in Pediatrics (Detailed Discussion)
Definition
Meningitis is inflammation of the meninges (pia mater, arachnoid mater, and dura mater)
surrounding the brain and spinal cord. It is a medical emergency because delayed diagnosis
and treatment can lead to death or permanent neurological damage.
Anatomy of the Meninges
The brain and spinal cord are covered by three layers:
* Dura mater – outer tough layer
* Arachnoid mater – middle layer
* Pia mater – inner delicate layer
The subarachnoid space contains cerebrospinal fluid (CSF). In meningitis, infection causes
inflammation of this space.
Types of Meningitis
1. Bacterial Meningitis (Most serious)
Common organisms according to age:
Neonates (0–28 days)
* Group B Streptococcus (GBS)
* Escherichia coli
* Listeria monocytogenes
Infants (1–3 months)
* GBS
* E. coli
* Streptococcus pneumoniae
* Neisseria meningitidis
Children (>3 months)
* Streptococcus pneumoniae (most common)
* Neisseria meningitidis
* Haemophilus influenzae type b (Hib) (reduced due to vaccination)
2. Viral (Aseptic) Meningitis
Common causes:
* Enteroviruses (most common)
* Coxsackie virus
* Echovirus
* Mumps virus
* HSV
* Varicella-zoster virus
Usually has a better prognosis than bacterial meningitis.
Pathophysiology
* Organism enters bloodstream.
* Crosses the blood–brain barrier.
* Multiplies in CSF.
* Triggers inflammatory response.
* Increased intracranial pressure (ICP), cerebral edema, reduced cerebral perfusion.
* Neuronal injury and neurological complications.
Clinical Features
Neonates
Symptoms are often nonspecific:
* Poor feeding
* Weak cry
* Fever or hypothermia
* Irritability
* Lethargy
* Vomiting
* Apnea
* Seizures
* Bulging fontanelle
* Jaundice
Older Infants and Children
General symptoms
* Fever
* Headache
* Vomiting
* Poor feeding
* Irritability
* Drowsiness
Classical signs
* Neck stiffness
* Photophobia
* Altered consciousness
* Seizures
Examination
* Vital signs
* Level of consciousness (Glasgow Coma Scale)
* Neck stiffness
* Rash
* Cranial nerve examination
* Fontanelle (infants)
Investigations
Blood Tests
* CBC
* CRP
* ESR
* Blood culture
* Electrolytes
* Blood glucose
Diagnosis
History
* Fever
* Headache
* Seizures
* Vaccination history
* Sick contacts
* TB exposure
* Recent ear or sinus infection
Examination
* Vital signs
* Level of consciousness (Glasgow Coma Scale)
* Neck stiffness
Signs of raised ICP
* Bulging fontanelle
* Bradycardia
* Hypertension
* Irregular respiration
* Papilledema (late)
Meningococcal meningitis
* Petechial or purpuric rash
* Septic shock
* Disseminated intravascular coagulation (DIC)
CSF Findings
| Feature | Bacterial |
|---|---|
| Appearance | Turbid |
| Cells | Neutrophils \uparrow |
| Protein | High |
| Glucose | Low |
| Opening pressure | High |
Management
Emergency Stabilization
* Airway
* Breathing
* Circulation (ABC)
* Oxygen
* IV access
* Correct hypoglycemia
* Control seizures
Antibiotic Therapy
Neonates
* Ampicillin + Gentamicin or
* Ampicillin + Cefotaxime
Infants (>1 month) and children
* Ceftriaxone or Cefotaxime + Vancomycin
Modify antibiotics according to culture and sensitivity.
Corticosteroids
Dexamethasone
* Given before or with the first dose of antibiotics.
* Reduces hearing loss, especially in Hib meningitis.
Supportive Care
* IV fluids
* Antipyretics
* Analgesics
* Nutrition
* Monitor urine output
Supportive Care
* IV fluids
* Antipyretics
* Analgesics
* Nutrition
* Monitor urine output
* Monitor neurological status
Seizure Management
* Diazepam or Lorazepam (acute)
* Levetiracetam or Phenytoin if recurrent
Late
* Hearing loss (most common)
* Hydrocephalus
* Cranial nerve palsy
* Cerebral infarction
* Cognitive impairment
* Developmental delay
* Epilepsy
* Vision problems
Prevention
* Vaccination: Hib, Pneumococcal (PCV), Meningococcal vaccines
* Early treatment of ear and sinus
Prognosis
* Viral meningitis: Excellent recovery in most children.
* Bacterial meningitis: Mortality 5–15%; survivors may have neurological sequelae.
* Tuberculous meningitis: Often associated with long-term neurological deficits if treatment
is delayed.
Exam Pearls
* In neonates, meningitis often presents with poor feeding, lethargy, temperature instability,
and seizures rather than classic neck stiffness.
* Petechial or purpuric rash strongly suggests meningococcal meningitis.
* Always assess for contraindications to lumbar puncture before performing the procedure.
* Early diagnosis and prompt treatment significantly reduce mortality and neurological
complications.
Prevention
* Vaccination: Hib, Pneumococcal (PCV), Meningococcal vaccines
* Early treatment of ear and sinus infections
* Chemoprophylaxis for close contacts of meningococcal meningitis (e.g., rifampicin,
ciprofloxacin, or ceftriaxone)
Complications
Early
* Septic shock
* DIC
* Status epilepticus
* Raised ICP
* Brain edema
Late
* Hearing loss (most common)
* Hydrocephalus
* Cranial nerve palsy
* Cerebral infarction
* Cognitive impairment
* First-line empiric antibiotic (>1 month): Ceftriaxone/Cefotaxime + Vancomycin.
* Drug used to reduce hearing loss: Dexamethasone.
* Most common long-term complication: Sensorineural hearing loss.
* Classic triad of meningitis: Fever + Neck stiffness + Altered mental status (may not be
present in infants).
* Medical emergency: Suspected bacterial meningitis requires immediate antibiotics—do not
delay treatment while awaiting investigations if the child is critically ill.
Exam Pearls
Important Pediatric MCQs
* Most common cause of bacterial meningitis in children: Streptococcus pneumoniae.
* Most common cause of viral meningitis: Enteroviruses.
* Gold standard investigation: Lumbar puncture with CSF analysis.
* CSF in bacterial meningitis: High neutrophils, high protein, low glucose.
* CSF in viral meningitis: Lymphocytic predominance, normal glucose, mildly elevated protein.
* First-line empiric antibiotic (>1
CSF Findings
| Feature | Viral | TB |
|---|---|---|
| Appearance | Clear | Slightly cloudy |
| Cells | Lymphocytes \uparrow | Lymphocytes \uparrow |
| Protein | Mild \uparrow | Very high |
| Glucose | Normal | Low |
| Opening pressure | Normal/slightly \uparrow | High |
Seizure Management
* Diazepam or Lorazepam (acute)
* Levetiracetam or Phenytoin if recurrent
Raised Intracranial Pressure
* Elevate head 30°
* Mannitol or hypertonic saline (if indicated)
* Mechanical ventilation if required
Neuroimaging (CT/MRI)
Indications:
* Focal neurological deficits
* Suspected brain abscess
* Hydrocephalus
* Raised ICP
* Persistent seizures
Meningeal Signs
Neck stiffness
Pain on neck flexion.
Kernig's Sign
Pain/resistance when extending the knee with the hip flexed.
Brudzinski's Sign
Passive neck flexion causes involuntary hip and knee flexion.
Lumbar Puncture (Gold Standard)
CSF analysis:
* Opening pressure
* Cell count
* Protein
* Glucose
* Gram stain
* Culture
* PCR (viral causes)
Contraindications to Lumbar Puncture
Do not perform LP if:
* Signs of raised intracranial pressure
* Papilledema
* Focal neurological deficit
* Severe cardiorespiratory instability
* Shock
* Coagulopathy
* Local skin infection at puncture site
Risk Factors
* Age <5 years
* Prematurity
* Lack of Hib or pneumococcal vaccination
* Immunodeficiency
* Malnutrition
* CSF leak
* Head trauma
* Cochlear implants
* Close contact with meningococcal infection
3. Tuberculous Meningitis (TBM)
* Caused by Mycobacterium tuberculosis
* Common in developing countries
* Subacute onset
* Serious complications (hydrocephalus, cranial nerve palsies)
4. Fungal Meningitis
* Rare
* Seen in immunocompromised children