Shake Shake Shake

Shake…Shake….Shake Neurology Module PEDIATRICS II

Salient Points: ES, 16 months old, admitted because of convulsions Five days PTA  cough and fever Two days later  grand mal seizures for 10 minutes Birth, neonatal, developmental history unremarkable First attack of febrile seizures at 6 months of age Father and cousins with febrile seizures

Salient Points: Pertinent Physical Examination Findings: Febrile, awake, with mild dehydration Congested pharyngeal wall, no exudates, (+) crackles on both lungs

Neurological Examination Findings: Essentially normal No meningeal signs

Is there a neurologic disease? The description of event appears to be a seizure. Seizures refer to excessive neuronal discharge with change in motor activity or behavior.

Is there a neurologic disease? Causes of seizure: Non-neurologic Metabolic disorders Electrolyte imbalance Hypoglycemia Hypoxia Fever Systemic infections Toxins Drug-related

Neurologic Tumors CNS malformation Vascular disorders Idiopathic epilepsy

What is the neurologic disease? In this patient, the seizures are ushered in by fever and respiratory infection.

Benign Febrile Seizures should be ruled out. The typical benign FS is characterized by: 1. Grand mal lasting for <15 min 2. Occurring once in the same illness 3. Age incidence: 3 months to 5 years 4. Occurs at temperature 380 C and

Complex Febrile Seizure Atypical - May occur more than once in an illness, focal seizure, more than15 minutes May need investigation to rule out epilepsy With focal manifestations

Diagnostic possibilities: Benign febrile seizures In the presence of fever, pneumonia and seizure, a CNS infection should be considered. An infant may not show any meningeal signs even in the presence of meningitis.

Management of BFC: Search for cause of fever No anticonvulsants needed Antipyretics Education of parents Oral diazepam at onset of febrile episode (1 mg/kg/24 hrs) for 2-3 days

Laboratory Tests: Not necessary if clear-cut BFC Tests mainly to determine cause of fever and rule out meningitis If done, CSF examination is normal EEG - Normal and not useful in BFC Neuroimaging - No role Blood tests / chest X-ray, etc

Diagnosis: Tests are usually directed towards ruling out meningitis especially in infants where meningeal signs are often lacking. Do lumbar puncture and CSF examination

Patient E.S. While in the hospital, he developed another seizure. Fever persisted. On examination, he was illlooking, irritable, with some resistance on neck flexion.

Differential Diagnosis: Fever with Seizures

CNS Infections

CNS Infections Forms: Meningitis Encephalitis Brain Abscess

Etiology Viral Bacterial (Acute Suppurative) Tuberculous Fungal

Acute MeningitisCauses: Bacterial 0 - 2 months: Grp B and D strep gram-negative enteric bacilli Listeria 2 mo – 2 yrs: S. pneumoniae N. meningitis H. influenza B Older children: S. pneumoniae N. meningitides

Bacterial Meningitis Acute Route of Infection Hematogenous Contiguous focus of infection CSF leak (trauma, congenital defect) Neurosurgical procedure

Clinical Features: Signs and symptoms

Neonates

Older infants and children

Nonspecific

Fever or hypothermia, abnormally sleepy or lethargic, disinterest in feeding, poor feeding, cyanosis, grunting, apneic episodes, vomiting

Fever, anorexia, confusion, irritability, photophobia, nausea, vomiting, headache, seizure

Meningeal inflammation

+/- Neck rigidity

Neck rigidity, Kernig and Brudzinski sign

Increased intracranial pressure

Bulging fontanel, diastasis of sutures, convulsions, opisthotonus

Headache, bulging fontanel, diastasis of sutures in infants, papilledema, mental confusion, altered state of consciousness

Focal neurologic signs

Hemiparesis, ptosis, facial nerve palsy

Hemiparesis, ptosis, deafness, facial nerve palsy, optic neuritis

Laboratory Diagnosis: 1.Lumbar Puncture Contraindications Skin infection over site Increased ICP with papilledema Focal neurologic deficits Suspected mass lesion Hematologic problems Significant cardiopulmonary compromise and shock

CSF Findings

Pressure (mm H20)

Cell Count (white blood cells/mm3)

Glucose (mg/100 ml)

Protein (mg/100 ml)

Normal values

90-180

0-5 lymphocytes

50-75 (at least 50% of simultaneous serum glucose)

15-40

Bacterial meningitis

200-300

100-5,000; neutrophils usually >80%

Reduced, < 40

100-1,000

Tuberculous meningitis

180-300

Usually < 500 lymphocytes

Reduced, < 40

100-200, but up to 1,000 if CSF block is present

Cryptococcal meningitis

180-300

10-200 lymphocytes

Reduced, <40

50-200

Viral meningitis

90-200

10-300 lymphocytes; may be >1,000 in echoviral and mumps meningitis and in lymphocytic choriomeningitis; early echoviral meningitis may show up to 80% neutrophilic predominance

Normal; occasionally slightly reduced in mumps meningitis and LCM

50-100

Viral encephalitis

180-300

0-500 lymphocytes

Normal

50-100

Laboratory Diagnosis: 2. Neuroimaging

Contrast enhanced CT image of a 3-month-old baby brain show brain edema and subdural empyema

Subdural effusion, cerebritis and developing abscess formation in a patient with bacterial meningitis

Patient’s laboratory results: CSF Analysis: Clear, colorless fluid OP 130 WBC = 320/cumm, all neutrophils RBC = 0 Protein = 90 Sugar = 40% of blood sugar Gram stain = (+) gram-negative coccobacilli Culture (-)

CBC: Hgb 11, RBC 4.3, WBC 12,000 with lymphocytic predominance

Diagnosis: Acute Bacterial Meningitis (Hemophilus) Pneumonia

Treatment: Bacterial meningitis is a medical emergency; delay in treatment may lead to increased sequelae or death Drug of choice must be bactericidal for pathogen involved Must achieve adequate levels in the CSF Initial regimen should cover most likely pathogens for specific age groups, and reach bactericidal levels in the CSF

Treatment:

Knowledge of local susceptibility patterns is essential Antibiotics should be guided by the bacteriologic results Duration of treatment: 10 -14 days

Empiric Therapy for Bacterial Meningitis: Patient group

Likely etiology

Antimicrobial choice Primary

Alternative

0-2 mos

E. coli Gram (-) bacilli S. pneumoniae

Ampicillin or Penicillin + Aminoglycoside

2mos – 5 yrs

H. influenzae S. pneumoniae N. meningitidis S. pneumoniae N. meningitidis

Ampicillin or Cefotaxime or Chloramphenico Ceftriaxone l

>5 yrs

Penicillin G

Ampicillin + Cefotaxime or Ceftriaxone

Chloramphenico l Task Force on Meningitis

Philippine Society of Microbiology and Infectious Diseases

Tuberculous Meningitis Subacute to chronic Staging of symptoms Stage I: early nonspecific Stage II: altered consciousness, minor focal signs, meningism, abnormal involuntary movements Stage III: stupor or coma, seizures, severe neurologic deficits and/or abnormal movements

Prognosis is related directly to the clinical stage of diagnosis

CSF Findings

Pressure (mm H20)

Cell Count (white blood cells/mm3)

Glucose (mg/100 ml)

Protein (mg/100 ml)

Normal values

90-180

0-5 lymphocytes

50-75 (at least 50% of simultaneous serum glucose)

15-40

Bacterial meningitis

200-300

100-5,000; neutrophils usually >80%

Reduced, < 40

100-1,000

Tuberculous meningitis

180-300

Usually < 500 lymphocytes

Reduced, < 40

100-200, but up to 1,000 if CSF block is present

Cryptococcal meningitis

180-300

10-200 lymphocytes

Reduced, <40

50-200

Viral meningitis

90-200

10-300 lymphocytes; may be >1,000 in echoviral and mumps meningitis and in lymphocytic choriomeningitis; early echoviral meningitis may show up to 80% neutrophilic predominance

Normal; occasionally slightly reduced in mumps meningitis and LCM

50-100

Viral encephalitis

180-300

0-500 lymphocytes

Normal

50-100

Late Neurologic Sequelae: Visual impairment Strabismus Hearing loss or impairment Locomotion/neuromotor deficits Epilepsy Mental or psychomotor retardation Hydrocephalus Microcephaly

Hydrocephalu s

Microcephaly

Cerebral Atrophy

Viral Meningitis Majority due to enteroviruses Higher incidence during summer to fall months Other viruses associated with meningitis in children: HSV types 1 and 2 Mumps Adenoviruses Polioviruses Lymphocytic choriomeningitis virus Epstein-Barr virus HIV St. Louis encephalitis virus Tick-borne encephalitis virus

CSF Findings

Pressure (mm H20)

Cell Count (white blood cells/mm3)

Glucose (mg/100 ml)

Protein (mg/100 ml)

Normal values

90-180

0-5 lymphocytes

50-75 (at least 50% of simultaneous serum glucose)

15-40

Bacterial meningitis

200-300

100-5,000; neutrophils usually >80%

Reduced, < 40

100-1,000

Tuberculous meningitis

180-300

Usually < 500 lymphocytes

Reduced, < 40

100-200, but up to 1,000 if CSF block is present

Cryptococcal meningitis

180-300

10-200 lymphocytes

Reduced, <40

50-200

Viral meningitis

90-200

10-300 lymphocytes; may be >1,000 in echoviral and mumps meningitis and in lymphocytic choriomeningitis; early echoviral meningitis may show up to 80% neutrophilic predominance

Normal; occasionally slightly reduced in mumps meningitis and LCM

50-100

Viral encephalitis

180-300

0-500 lymphocytes

Normal

50-100

Viral Meningitis Management: – – –

No specific antiviral therapy necessary Treatment is supportive with IV fluids Outcome is usually a full recovery

Viral Encephalitis Distinguished from viral meningitis by the extent and severity of cerebral dysfunction Two clinical presentations: Fever and malaise without meningeal signs With meningeal signs plus cerebral dysfunction (altered consciousness, personality changes, seizures, and paresis) and cranial nerve abnormalities

Viral Encephalitis Causes: Epidemic Arbovirus Poliovirus Echovirus Coxsakie virus

Sporadic Herpes simplex Varicella-Zoster Mumps

CSF Findings

Pressure (mm H20)

Cell Count (white blood cells/mm3)

Glucose (mg/100 ml)

Protein (mg/100 ml)

Normal values

90-180

0-5 lymphocytes

50-75 (at least 50% of simultaneous serum glucose)

15-40

Bacterial meningitis

200-300

100-5,000; neutrophils usually >80%

Reduced, < 40

100-1,000

Tuberculous meningitis

180-300

Usually < 500 lymphocytes

Reduced, < 40

100-200, but up to 1,000 if CSF block is present

Cryptococcal meningitis

180-300

10-200 lymphocytes

Reduced, <40

50-200

Viral meningitis

90-200

10-300 lymphocytes; may be >1,000 in echoviral and mumps meningitis and in lymphocytic choriomeningitis; early echoviral meningitis may show up to 80% neutrophilic predominance

Normal; occasionally slightly reduced in mumps meningitis and LCM

50-100

Viral encephalitis

180-300

0-500 lymphocytes

Normal

50-100

Viral Encephalitis Treatment: Acyclovir 10 mg/kg IV infusion every 8 hours for at least 10 days Supportive therapy

Prognosis: Mortality rate varies with etiology Permanent cerebral sequelae more likely in infants

Thank you!