Acute bacterial meningitis

Clinical manifestations

Meningococcemia

Meningial irritation signs

Nuchal rigidity,

Brudzinski sign: Involuntary flexion of the knees and hips follows flexion of the neck in the supine child.

Increased intracranial pressure

Bulging anterior fontanel is a sign of Increased intracranial pressure

Seizures due to:

- Cerebritis 

- Infarction

-          Electrolyte disturbances

-           may be associated with poor prognosis

-          Diagnosis

-          Lumbar puncture: should be performed when bacterial meningitis is suspected.

-          - The microorganisms on gram stain and culture is positive in 70-90% of the cases.

-          - Neurtophilic pleocytosis (>1000/mm3) is present.

-          - Elevated CSF proteins

-          - Reduced glucose concentrations.

-          Treatment

-          Antibiotics

-          Initial antibiotic therapy

-          Cefotaxime 200-300 mg/kg/24hr for 10-14 days IV or ceftriaxone100mg/kg/24 hr is usually used. Vancomycin (60 mg/kg/24 hr, given every 6 hr) may be added in suspected resistant strain infection.

-          Chloramphenicol: 100mg/kg/24 hr in 4 divided doses IV is used in patients allergic to          β-lactam antibiotics.

-          · Penicillin 300,000 U/kg/24hr, IV in 4-6 divided doses is used for penicillin sensitive N. meningitides infection.

see the pictures

Nuchal rigidity

Brudzinski sign

Dialated pupil

Increased intracranial pressure (

Lumbar puncture

The child is seen in convulsion

Down’s syndrome

Down’s syndrome

    The classic phenotype of Down syndrome include a flattened occiput, midfacial hypoplasia, depressed nasal bridge, upward Slanting palpebral fissures, epicanthic folds , grayish speckling of the iris (Brushfield spots). Micrognathia excess nuchal skin, single palmer creases(simian creases), single flexion creases and incurving of the fifth fingers (clinodactyly) and increased distance between the first and second toes. Down syndrome may present with marked hypotonia ;congenital heart defects, duodenal atresia and tracheoesophageal fistula. However it is imperative that cytogenetic studies be done to confirm the diagnosis and to differentiate a nondisjunctional triosomy from translocation .In case of translocation Down syndrome karyotyping  is indicated for parents to detect balanced translocation carrier  

Recurrence  risk of Down syndrome

    The risk increases sharply when the mothers age is above 35 years for the non disjunction group (age-dependent) ,

 affected females who become pregnant have a high risk (30–50%) of having a Down syndrome child .

The translocation group is usually age independent specially if it is familial translocation.

However ,the recurrence risk of Down syndrome is high if the mother is a translocation carrier, such a condition there is one in three risk of having an effected child at any one pregnancy .

Headache and Migraine

•          Headache is a common problem in pediatrics.

•          Headache may occasionally indicate a severe underlying disorder (e.g. brain tumour) and thus careful evaluation of child with recurrent, severe or unconventional headache is mandatory.

•          Most toddlers cannot communicate the characteristics of headache but they become irritable, prefer a darkened room because of photophobia or repeatedly rub their eyes and head.

•          Causes of headache in children:

•          1- Migraine: is defined as recurrent headache with symptom-free intervals.

•          It manifests by: throbbing, bitemporal or unilateral pain associated with nausea, vomiting, abdominal pain, photophobia and commonly positive family history of migraine.

•          Treatment of migraine:

•             - Avoid stress, fatigue and anxiety.

•             - Elimination of certain foods as nuts, chocolate, and cola drinks, particularly if there is association between these foods and onset of migraine.

•             - Acute attacks: should be treated by analgesics (acetaminophen, Ibuprofen) and antiemeticsProphylaxis against recurrent attacks:•          By administration of propranolol, cyproheptadine or antiepileptic drugs, if the attacks are frequent and /or severe

•          2- Tension headache: dull aching, sharp pain, generalized or at the vertex. It is usually associated with difficult sleep, dizziness, family or school problems.

•          3- Increased intra-cranial tension: commonly bifrontal increases by coughing or sneezing, associated with persistent vomiting which increases in the morning and not responds to antiemetics.

•          4- Other causes

•           a- Hypertension, anemia.                                                             

•           b- Psychogenic factors or stress.   

•          c- Refractive errors and strabismus.                                          

•          d- Sinusitis and carries of teeth

•          Evaluation of headache by:

•             ● Blood pressure measurement.                          

•             ● Measuring head size & teeth examination.

•             ● Neurological examination.                   

•             ● Ophthalmologic evaluation for visual acuity & fundus examination.

•             ● E.N.T. examination.

•             ● Plain x ray of skull.

•             ● C.T. brain for exclusion of intracranial space occupying lesions.

Common anticonvulsant drugs

Treatment of acute convulsions:

Diazepan: it is used as an emergency treatment for acute seizures and for prophylaxis against febrile convulsions. Dosage is 0.2 to 0.3 mg/kg/dose I.V; observe respiration because it may cause respiratory depression

Phenytoin: is used in treatment of status epilepticus by I.V drip.

Phenobarbital: phenobarbital treats tonic-clonic and simple partial seizures in newborn infants.

Treatment of recurrent convulsions

 Epilepsy: is the main cause of recurrent convulsions. Epilepsy is suggested by presence of 2 unprovoked seizures within less than 24 hr. period.

Carbamazepine: is highly effective for all partial seizures; and is highly effective for generalized tonic-clonic seizures. Dosage is 10 to 30 mg/kg/day.

Valproate: it is a broad-spectrum anticonvulsant drug. It mainly used for generalized seizures.

It is especially useful for myoclonic and absence seizures. It is also used in partial seizures. It is given in a dose of 20 to 60 mg/kg/day.

Febrile convulsions

It is a very common convulsive disorder during childhood with uniformly excellent prognosis. However, it may signify a serious underlying acute infectious disease such as septicemia, so that each child must be carefully examined and appropriately investigated for the cause of the associated fever.

Clinical manifestations

· Age incidence: it occurs between 9 months and 5 years with a peak incidence between 14-18     months.

· There is a positive family history of febrile convulsions in up to 20% of cases.

· Febrile convulsions occur at the onset of rapid rise of body temperature (within 8-12 hours of rise of body temperature). Most affected children have a temperature above 39ºC at the time of convulsions.

•          The convulsive fit in simple febrile convulsions has the following characters: it is generalized tonic-clonic convulsion, brief and usually lasts for few seconds to less than 15 minutes, the post-ictal stupor is short, and there is usually one convulsive fit during the same illness.

· There are no clinical features suggesting CNS infection, meningeal irritation or increased intracranial pressure.

· There is an evidence of extracranial infection as pharyngitis, otitis media, pneumonia or gastroenteritis.

Investigations

1- Lumbar puncture and CSF analysis are not indicated in typical cases. CSF is normal.

2- EEG examination is normal after 2 weeks of the febrile seizure.

Management of febrile convulsions

· Reassurance of the parents.

· Careful search for, and treatment of the cause of fever.

· Active measures to control the fever including the use of antipyretics, cold fomentation and water bath.

· Control of seizures: anticonvulsants e.g. diazepam can be used for the immediate control of febrile convulsions in a dose of 0.2-0.3 mg/kg/dose IV.

Prophylaxis against recurrence of febrile convulsions

Prolonged anti-convulsant prophylaxis for the prevention of recurrent febrile convulsions is

Oral diazepam is an effective and safe method of reducing the risk of recurrence of febrile seizures. diazepam 0.3-mg/kg/8 hr (1mg/kg/24hr) is administered for the duration of illness (usually 2-3 days).

Prognosis of febrile convulsions

Febrile convulsions rarely develop into epilepsy, and usually they spontaneously disappear without specific therapy. The risk factors for development of epilepsy in children as a complication of febrile convulsions include:

a- Positive family history of epilepsy.        

b- Initial febrile seizure prior to 9 mo of age.

c- Prolonged or atypical febrile seizure.                   

d- Frequent seizures.

e- Motor or mental deficits.

Convulsions and seizures causes and treatment

Definition

•          They are defined as a paroxysmal involuntary disturbance of brain function that may be manifested as an impairment or loss of consciousness, abnormal motor activity, behavioralabnormalities, sensory disturbance or autonomic dysfunction. Convulsions are among the most common pediatric emergencies.

•          Convulsions which chronically recur may be due to primary epilepsy, or secondary epilepsy following some insult to brain as post-traumatic, post-anoxic and with some inborn errors of metabolism.

•          Causes of acute seizures in infants and children

•          1- Fever: febrile convulsions.

•          2- Intracranial infections: meningitis, encephalitis, brain abscesses.

•          3- Encephalopathies e.g. post-exanthem, post-immunization.

•          4- Metabolic and electrolyte disturbances: hypoglycemia, hypocalcemia, hypomagnesemia, hyponatremia, hypernatremia, alkalosis, pyridoxine deficiency.

•          5- Intoxications:

•            · Endogenous: uremia or hepatic encephalopathies.

•            · Exogenous: e.g. acute lead poisoning.

•            · Therapeutic: e.g theophylline, isoniazid.

•          6- Head trauma: subdural hematoma and intracranial hemorrhage.

•          7- Non-traumatic intracranial hemorrhage:arterio-venous malformations and bleeding disorders.

•          8- Hypertensive encephalopathy.

•          9- Cerebral ischemia:

•          a- Arterial spasm, thrombosis or embolism.             

•          b- Venous thrombosis.

•          c- Circulatory collapse.                                            

•          d- Brain anoxia.

•          Diagnosis 

•          The following investigations may help in diagnosis:

•           1- Urine analysis.

•          2- Tuberculin testing.

•           3- Blood gases and pH.                                                                

•          4- Blood picture.

•           5- CSF examination.                                                                                      

•          6- Serum Na, Ca and Mg.

•           7- Coagulation screen.                                                                 

•          8- Blood, urine and CSF cultures.

•          9- Blood glucose and blood urea/ creatinine.                      

•          10- Liver function tests.                                               

•          11-Skull x-ray and CT scan.

•          12- EEG.                                                                    

•          13- Search for toxins and drugs in serum and urine.

•          Treatment of recurrent convulsions

•           Epilepsy: is the main cause of recurrent convulsions. Epilepsy is suggested by presence of 2 unprovoked seizures within less than 24 hr. period.

•          Carbamazepine: is highly effective for all partial seizures; and is highly effective for generalized tonic-clonic seizures. Dosage is 10 to 30 mg/kg/day.

•          Valproate: it is a broad-spectrum anticonvulsant drug. It mainly used for generalized seizures.

•          It is especially useful for myoclonic and absence seizures. It is also used in partial seizures. It is given in a dose of 20 to 60 mg/kg/day.