NEONATAL MENINGITIS

 

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–Meningitis is the most frequent and serious infection of the CNS and affects the pia matter, arachnoids (leptomeninges) and subarachnoid space.

–Early onset –Early onset infection with streptococcus Agalactiae generally presents at or within 24 hours of birth but can occur through day 6 of life.

–Late onset Late onset has been variably defined for epidemiological purposes as occurring from 1^st week to 5 year age after birth. Late onset infections with Streptococcus Agalactiae usually occur within four to five weeks of age.

–Despite advances in the early diagnosis and the treatment of new meningitis, it still causes high morbidity and frequent neurological sequelae in survivors. The development of meningitis is described in approx. 15% of new born diagnosed with bacteriaemia. Pre-term birth, low birth weight, pre-mature rupture of the membranes and maternal Peri-Partum infections are the major factors of neonatal meningitis and sepsis.

–CAUSE –The leading causative bacteria for meningitis in this age group area

–GBS (group B streptococcus)

–Escherichia Coli

–Gram negative bacteria

EPIDEMIOLOGY

–Due to the progress of medicine in developed countries, the incidence of neonatal meningitis is estimated to be 0.3 per 1000 live births.

PROGNOSIS Survivors of neonatal meningitis are at significant risk for moderate to severe disability. Some 25-50% have significant problems with language, motor function, hearing, vision, and cognition; 5-20% have future epilepsy. Survivors are also more likely to have subtle problems, including visual deficits, middle-ear disease, and behavioral problems. As many as 20% of children identified as normal at 5-year follow-up may have significant educational difficulties lasting into late adolescence

CLINICAL CASE PRESENTATION

–A 3 year old male child was admitted on the first day of acute illness. Initially the child presented to the emergency with the history of two hours of fever, irritability and focal seizures. Previously he was healthy full-term neonate born to a 23 year old multi-gravida mother. Despite fever upto 39.8  ̊C and to lose stools the child had to other symptoms. Soon after the admission the child clinical condition worsened and lumber puncture was performed. The diagnosis was based on cell count in CSF which shows negative gram stain result. The patient was febrile and ill-appearing. Cerebral edema changes were observed in cranial ultrasound.

SIGNS AND SYMPTOMS

–Headache, fever, vomiting, and rigidity of the neck are the most common symptoms that present with the onset of meningitis.

Early symptoms include nausea, drowsiness and confusion. Pain in the posterior thigh or lumbar region may also be noted.

Later symptoms can include seizures, photophobia and rapid breathing rate.

Meningitis causes inflammation of the meningeal membranes; as a result nerve roots may endure tension as they pass through these inflamed membranes.

Passive ROM of the neck into flexion will gradually become painful and limited.

Also, neck extension and rotation may be painful as well, however not to the extent of flexion.

In severe cases, Brudzinki’s sign, or Kernig’s may be presented

PATHOPHYSIOLOGY

Newborns are specially vulnerable to infection thus cellular and humoral immunities are immature including the phagocytic function. A full-term newborn has a distinct immunity system i.e. biased towards T-helper type II and anti-inflammatory cytokines production. The deficient expressions of complement and anti-microbial proteins and peptides likely contributes to a newborns susceptibility pyogenic bacteria.

PATHOLOGICAL SYSTEMIC INVOLVMENT

–Nervous –Inflammation of subarachnoid space –Spread of inflammation to parenchyma –Focal ischemic lesions –Hydrocephaly/microcephaly –Impaired consciousness –Stages include irritability, confusion, drowsiness, stupor, and coma –Hemiparesis –Seizures –Cranial nerve palsy –Hypothalamic dysfunction in children

–Vascular –Inflammation of small subarachnoid vessels (especially veins) –Thrombotic obstruction of vessels

–Musculoskeletal –Opisthotonic posture –Infectious spread to joints

–Sensory –Impaired hearing –Loss of vision

–Metabolic –Dehydration –Hyponatremia(low sodium level)

–Gastrointestinal –Vomiting

–Integumentary –Petechial rash of skin (usually associated with bacterial meningitis)

TREATMENT

–Early initiation of antimicrobial drugs is essential. –Aggressive anti-microbial is life-saving in neonates meningitis because distinguishing viral from meningitis is difficult early in the clinical course a combination of agents is often necessary providing coverage for both type of infection. –The duration of therapy for bacterial meningitis within appropriate aging is typically 14 to 21 days. The patient makes full recovery following the surgical drainage of abscess and a 6 weeks total course of antibiotics – vaccination with pneumococcal, and meningococcal vaccines

PREVENTION

–The use of intrapartum antibiotic prophylaxis (penicillin) in pregnant mothers who are positive for group B streptococcal (GBS) colonization on screening or have risk factors for GBS colonization has reduced the incidence of neonatal early-onset GBS meningitis from approximately 1.8 cases to 0.3 cases per 1000 live births. Screening and risk factor assessment should be included universally in routine prenatal care. –Cesarean delivery decreases, but does not eliminate, transmission of Herpes Simplex Virus from the mother’s genital tract to the neonate in cases of known infection. Suppressive antiviral therapy for HSV-infected women during the third trimester may prevent recurrent infectious episodes and thereby minimize the infant’s exposure to the virus during delivery.

–Long-Term Monitoring –Because of the potential for hearing loss, neonates with meningitis should undergo brainstem auditory evoked response (BAER) testing at 4-6 weeks after discharge. Survivors of neonatal meningitis require long-term surveillance not only for disorders of hearing but also for disorders of vision, motor, or cognitive function. –Developmental delay is a frequent complication of neonatal meningitis. Early intervention services should be employed to maximize developmental gains.

COMPLICATIONS

–Despite advances in antimicrobial therapy, mortality and morbidity remains high in neonatal meningitis. In infants that have unsatisfactory responses to antibiotic treatment, there are a number of complicated manifestations that arise.

Clinical presentation of complications includes

–Prolonged or secondary fever –Uncontrollable/refractory seizures –Late seizures –Depressed level of consciousness –Prolonged disturbance of consciousness –Persistent focal signs –Frontal bulging –Syndrome of inappropriate antidiuretic hormone (SIADH) –Brain infarction

PHYSICAL THERAPY MANAGEMENT

–Physiotherapy treatment is often needed for the secondary complications to Meningitis such as: muscle weakness, poor balance and co-ordination.

Treatment can include:

–Strengthening exercises to help improve muscle function. This can be in the form of simple exercises such as sit to stand or walking. Your child may find these tasks difficult after having Meningitis.

–Stretching exercises as your child may experience a stiff neck.

–Balance exercises such as standing with their eyes closed, standing on a wobble board or standing on one leg. This is important as they need balance for tasks such as walking, running and cycling.

–Co-ordination exercises such as catching balls, juggling and kicking a football.