Meningitis Case Study PDF

Meningitis HUNSUR ANANTH KUMAR ARSHITHA General data M.J Male DOB: 3 December,2020 Age: 3 years Nationality: Filipino Religion: catholic Address: sitio kawayan banawa Guadalupe, cebu city Admitted date : 09/ Feb /2024 Reliability: 80 Informant: father Chief...

Meningitis HUNSUR ANANTH KUMAR ARSHITHA General data M.J Male DOB: 3 December,2020 Age: 3 years Nationality: Filipino Religion: catholic Address: sitio kawayan banawa Guadalupe, cebu city Admitted date : 09/ Feb /2024 Reliability: 80 Informant: father Chief complaint: Motion Physical design seizures Computing  History of present illness 1 week prior to admission, patient’s mother noted sudden onset of weakness along with decreased appetite in the patient. No medication was given. No consultation was sought. 1 day prior to admission, weakness and decreased appetite persisted now associated with onset of non productive cough.No medication was given. No consultation was sought. 3 hours prior to admission, persistence of weaknesses & decreased appetite now associated with fever ( Tmax - 38.6C)., patient mother sought consultation at CCMC ER for further management. In the ER, patient had 2 episodes of tonic clonic movement with upward rolling of eyeballs which lasted for 10 - 15 minutes, thus subsequently admitted. Personal history prenatal history: Mother was 28 years old, OB score G3P3(3003), 1st prenatal checkup at 3 months AOG following every month. Folic acid, iron, multivitamins were taken no maternal illnesses during pregnancy. a Non smoker, non alcoholic. Natal history :Full term, via normal spontaneous vaginal delivery in private clinic assist by midwife.Good cry, with birth weight of 2800kg. Postnatal history : Newborn screening was normal. No jaundice.Discharged with good outcome. Feeding history: Exclusive breastfeeding until 6 months of age, 8-12 times a day for 10 - 15 minutes. Complementary feeding cerelac was introduced at 6 months of age. Developmental history: Past history: No previous medical illnesses or hospitalization. No food or drug allergies. No previous history of surgery. Family history : The grandfather had TB and bronchial asthma, and maternal grandmother had hypertension.There are no other diseases in family. No heredofamilial disease were reported. There is no family hospital of hepatitis A/B Personal and social history Father 40 years old utility worker in construction site. Smoker Mother 30 year old housewife, she never drinks or smoke. There are 8 members in the household. Birth rank: 3/3 Source of water: mineral water Garbage disposal: once in week Immunization history Review of system (+) Fever,(+) weakness, (+) seizure, (+) cough Physical examination General survey: awake, drowsy, febrile,not in respiratory distress. Vital signs: T - 38.6., RR- 30 cpm, , HR - 79 bpm, 02 sat - 98% BP- 90/60 mmhg Anthropometric measurements: Height: 86cm, below -3 z score Weight :9.5kg, below -3 z score Head circumference : 48.5 MUAC : 11cm  Physical examination Skin : warm to touch, good turgor, no lesions ,masses nor cyanosis HEENT: anicteric sclerae, pink palpebral conjunctiva ,no nasal discharge Neck : (+) stiffness ,(-) lymphadenopathy. Chest / lungs : inspection : no masses or lesions no retractions. Palpation: no tenderness, masses,lesions, equal chest expansion. Percussion: resonant on percussion. Auscultation: (+) rales on both lung field. Cardiovascular: Inspection: no lesions, no scars Palpation: no thrills Percussion: tympanic on percussion Auscultation: distinct heart sounds,(-)murmurs Physical examination Abdomen: Inspection: no scars, no bruise, globular in shape Auscultation: normoactive bowel sounds Percussion: no dullness Palpation: no mass, no pain during light and deep palpation Extremities: strong peripheral pulse ,normal range of motion, no clubbing or edema, CRT< 2 sec. Genitourinary: grossly male Anus /rectum: not done  Neurologic: Cerebral: Awake Cerebellar: Good posture Physical GCS: 10 ( E3V3M4) examina CN I :not accessed tion CNII & CN III: Pupils are reactive to light CN III, IV, VI: Eyes move together along with finger CN V: Able to feel light touch on face CN VII: intact facial expression CN VIII : Blinking of both eyes in response to loud noise CN IX, X: No deformity in swallowing, (+)gag reflex CN XI: Shoulders are symmetric CN XII: Moved tongue side by side  3 year old ,male Salient Anorexia (Decreased appetite ) Fatigue febrile features Irritability Drowsy 3 recurrent, tonic-clonic seizures,Duration 10 to 15 minutes; with upward rolling of eyes. Neck stiffness Rales on both lung fields Cough & coryza Exposure to TB  Working impression 1. TB meningitis 2. Severe acute malnutrition  Differential diagnosis Rule in Rule out Epilepsy (+) 2 or more recurrent seizing less than < (-)Unprovoked seizure 24 hours. (-)spasticity of upper & lower (+) convulsions extremities (-) photosensitivity Bacterial meningitis (+)high fever (-)sensitivity to light (+)cough (-)easily bruising (+) convulsions (-)rash (+)fever (-)sensitivity to light Encephalitis (+) fatigue (+) cough (+) seizures (-)agitation (-)altered sensorium (+) rales on both lung field (+) Cough (-) retraction PCAP (+) coryza (-)oxygen desaturation (+)Convulsions (-) dyspnea/tachypnea  СВС Blood culture Gram staining Lumbar puncture, C/s (color, leukocyte count, differential, glucose, Electrolytes PCR Coagulation profile Diagnostics liver and kidney function Chest x-ray CT/ MRI Blood gases EEG ECG Case study: meningitis  Meningitis is an inflammation (swelling) of the protective membranes (meninges) covering the brain and spinal cord. Meningitis can occur at all ages but it is commonest in infancy. While 95% of the cases take place between 1 month- 5 years of age. It is more common in males than females. Etiology Bacterial Cause Common cause: Neisseria meningitidis (In children 1 month to 12 month) Streptococcus pneumoniae and Haemophilus influenzae type b. less common pathogens such as Pseudomonas aeruginosa, Staphylococcus aureus, coagulase-negative staphylococci, Salmonella spp., and Listeria monocytogenes.  Viral cause Viral meningitis comprises most aseptic meningitis syndromes. The viral agents for aseptic meningitis include the following: Enterovirus (polio virus, Echovirus,Coxsackievirus ) Herpesvirus (Hsv-1,2, Varicella.Z,EBV) Paramyxovirus (Mumps, Measles) Togavirus (Rubella) Rhabdovirus (Rabies) Retrovirus (HIV) Fungal cause It's rare in healthy people, but is a higher risk in those who have AIDS, other forms of immunodeficiency or immunosuppression. The most common agents are Cryptococcus neoformans, Candida, H capsulatum. Epidemiology Major risk factor for meningitis- lack of immunity to specific pathogens associated with young age. Additional risks: recent colonization with pathogenic bacteria close contact (household, daycare centres) with individuals having invasive disease caused by N. meningitidis and H. influenzae type b, crowding, poverty Mode of transmission Probably person-to-person contact through respiratory tract secretions or droplets Defects of the complement system (C5-C8) have been associated with recurrent meningococcal infection. Splenic dysfunction (sickle cell anemia) or asplenia (due to trauma, or congenital defect) is associated with an increased risk of pneumococcal, H. influenzae type b (to some extent), and, rarely, meningococcal sepsis and meningitis. Pathogenesis Bacterial meningitis most commonly results from haematogenous dissemination of microorganisms from a distant site of infection; bacteremia usually precedes meningitis or occurs concomitantly. Usual source of bacteremia: bacterial colonisation of naso-pharynx with potentially pathogenic microorganism. Signs & symptoms Fever Anorexia Poor feeding Headache Symptoms of upper respiratory tract infection Myalgias Arthralgias Tachycardia Hypotension Various cutaneous signs, such as petechiae, purpura, or an erythematous macular rash Clinical manifestations Common presentation is sudden onset rapidly progressive manifestations of shock Purpura disseminated intravascular coagulation (DIC)reduced levels of consciousness often resulting in progression to coma or death within 24 hr. More often, meningitis is preceded by several days of fever accompanied by upper respiratory tract or gastrointestinal symptoms, followed by nonspecific signs of CNS infection such as increasing lethargy and irritability. Fever Anorexia Poor feeding Headache Symptoms of upper respiratory tract infection Myalgias Arthralgias Tachycardia Hypotension Various cutaneous signs, such as petechiae, purpura, or an erythematous macular rash Meningeal irritation is manifested as: Nuchal rigidity- impaired neck flexion resulting from muscle spasm (not actual rigidity) of the extensor muscles of the neck; usually attributed to meningeal irritation. Back pain Kernig sign (flexion of the hip 90 degrees with subsequent pain with extension of the leg), and Brudzinski sign (involuntary flexion of the knees and hips after passive flexion of the neck while supine) Alterations of mental status are common among patients with meningitis and may be the consequence of increased ICP, cerebritis, or hypotension; manifestations include irritability, lethargy, stupor, obtundation, and coma. Diagnostics CSF Study Confirmed by analysis of the CSF, which typically reveals microorganisms on Gram stain and culture. Lumbar Puncture is done for CSF collection. The CSF leukocyte count in bacterial meningitis usually is elevated to >1,000/mm3 and, typically, there is a neutrophilic predominance (75- 95%). Turbid CSF is present when the CSF leukocyte count exceeds 200-400/mm3. viral or bacterial meningitis have 1 mo of age can be treated with Chloramphenicol, 100 mg/kg/24 hr, given every 6 hr. Another option for patients with allergy to B-lactam antibiotics is a combination of Vancomycin and Rifampin. Corticosteroids Use of intravenous dexamethasone 0.15 mg/kg/ dose given every 6 hr for 2 days, in the treatment of children older than 6 wk with acute bacterial meningitis caused by H. influenzae type b. Among children with meningitis caused by H. influenzae type b, corticosteroid recipients have a shorter duration of fever (inflammation is reduced), lower CSF protein and lactate levels, and a reduction in sensorineural hearing loss (result of cochlear infection). Complications During the treatment of meningitis, acute CNS complications can include seizures, increased ICP, cranial nerve palsies, stroke. Subdural effusions are especially common in infants Prolonged fever (>10 days) is noted in approximately 10% of patients. Prolonged fever is usually caused by intercurrent viral infection, nosocomial or secondary bacterial infection, thrombophlebitis, or drug reaction. Prevention Vaccination and antibiotic prophylaxis of susceptible at-risk contacts represent the 2 available means of reducing the likelihood of bacterial meningitis. Haemophilus influenzae Type B All children should be immunized with H. influenzae type b conjugate vaccine beginning at 2 mo of age. Streptococcus pneumoniae Routine administration of conjugate vaccine against S. pneumoniae is recommended for children younger than 5 yr of age. The initial dose is given at about 2 mo of age. Prognosis Appropriate antibiotic therapy and supportive care have reduced the mortality of bacterial meningitis after the neonatal period to