MENINGITIS

Presenters

Shella Novita Wizni Nadra Lubis : dr. Tina C. L. Tobing, Sp. A (K)

Supervisor

Definisi
Meningitis is a disease caused by the inflammation of the protective membranes covering the brain and spinal cord known as the meninges.

Etiologi

Fungal

Viral

Parasitic

Bacterial

Meningitis

Non Infectious

Pathogenesis
causative agent Invasion of the central nervous system via the blood stream Migrate to Subarachnoid The inflammatory response in piamater, arachnoid, cerebrospinal fluid, and ventricular

Exudate spread across the cranial nerves and spinal nerves

neurological damage

Pathogenesis and Pathophysiology

Pathogenesis of Tuberculous Meningitis

BTA enter the body Common through inhalation, rare in the skin, gastrointestinal tract

Pulmonary infection / other focus of infection

multiplication

Spread homogeneous

Meningens

BTA is inactive / dormant

forming tubercles

When the immune system is weak

Rupture of meningeal tubercles

Meningitis

The release of BTA into the subarachnoid

Diagnosis Sign and Symptoms nonspecific findings Meningeal irritation

fever, anorexia and poor feeding, headache, symptoms of upper respiratory tract infection, myalgias, arthralgias, tachycardia, hypotension

nuchal rigidity, back pain, Kernig sign and Brudzinski sign

Lumbar Puncture Latex Agglutination Tests PCR sTREM-1 Blood Culture

Management

Antibiotic

Therapy
Glucocorticoid

MEDICAL RECORD
Name Age AK 14 years 7 months old

Sex
Address No.RM

Male
Namo Rambe 54.33.40 January 05th 2013

Date of hospital admission

History Taking
AK, 14 years 7 months old, male, weight 35 kg, height 158 cm, was admitted to Haji Adam Malik Hospital at the Infection Unit Pediatric Department on January 05th 2013 with main complaint altered level of consciousness at admission to the ER. It started seven days ago starting from seizure once, with duration less than 5 minute and frequency less than 3 times a day. Seizure generalized, with eyes rolling up, jerking extremities, and patient fall to sleep after seizure over. Patient experienced fever since three weeks ago. Fever is fluctuating without chills, and decreased with antipiretic drugs. Headache was found since three weeks ago. Cough was not found. History of contact with an infected person with chronic coughs was not found. No history of trauma was found. Theres no history of complete immunization and BCG scar.

History of Birth

Appropriate for gestation age (40 weeks), spontaneously, crying immediately and loudly, history of cyanotic (-), birth weight = 3700 gr

History of Development
History of Feeding History of Immunitation

6 months old : sitting 10 months old : standing 14 months old : walking 0-3 months old : breast milk 3-18 months old : breast milk + rice porridge 18 months old until now : family food DPT : (-) Polio : 1 times BCG : (-) Measles : (-) Hep. B : (-)

History of previous illness

Varicella at the age of 10 years old Thypoid fever 2 months ago Patient was treated for three day in RS Herna by neurologist and diagnosed as meningitis tuberculosis. Injection of Meropenem, Dexamethasone, Ranitidine and Dilantin

History of previous medication

Physical Examination
Presence Status Sensorium : GCS7 (E2V1M4), temperature: 37,8C. Anemic (-), dyspnea (-), cyanotic (-), edema (-), icteric (-). Body weight (BW): 35 kg, body length (BL): 158 cm, BW/BL : 97.8% Eye: Light reflexes (+/+), anisochoric pupil, right = 2 mm, left = 3 mm, pale inferior conj. palpebra (-/-). Ear/ mouth: normal. Nose: nasale canule and NGT (+) Lymph node enlargement (-), nuchal rigidity (+)

Head

Neck

Thorax

Symmetrical fusiform , retraction (-) HR: 90 bpm, regular, murmur (-) RR : 18 bpm, regular, rales (-)

Abdominal

Soepel, peristaltic (+), liver and spleen not palpable

Extremities

Genitalia

Pulse = 90 bpm, regular, adequate pressure/volume. Warm acral, CRT < 3 seconds. Physiologic Reflex : Right APR/KPR (+ /+), Left APR/KPR (+/+) Pathologic Reflex : Babinsky (-), Chaddock (-), Schuffner (-), Oppenheim (-/-) Meningeal Reflex : Brudzinsky I/II (-/-) Male, within normal limit

Laboratorium:
Test(03-1-2013) Complete Blood Count Hemoglobin (Hb) Erytrocyte (RBC) Leukocyte (WBC) Hematocrite Trombocyte (PLT) MCV MCH MCHC ESR Results 11.40 g % 5.09 x 106/mm3 19.80 x 103/mm3 35 % 217 x 103/mm3 70.00 fL 22.00 pg 31.00 g % 35 mm/h Normal Value 13.0 18.0 g % 4.5 6.5 x106/mm3 4.5 10.0 x103/mm3 38 - 52 % 150 450 x103/mm3 76 - 96 fL 27 - 32 pg 30 50 g % 0 10 mm/h

Cell Count: Neutrofil Limfosit Monosit Eosinophil Basophil

82 % 11 % 5% 1% 0%

40 60 % 20 40 % 48% 13% 01%

Renal Function Test: Ureum Creatinine Electrolyte: Na K Cl Serology: IgM Salmonella typhi

30 mg/dL 0.71 mg/dL 135 mEq/L 4.3 mEq/L 100 mEq/L +6

15-45 mg/dL 0.7-1.2 mg/dL 135-148 mEq/L 3.8-5.4 mEq/L 94-111 mEq/L 2 : Negative

Test (05-1-2013) Results ANALYSIS OF CEREBROSPINAL FLUID Color Clear LDH 200 U/L Total Protein 103.20 mg/dL Leukocyte Count 0.56 x 103/uL Erytocyte Count 0.002 x 106/uL
Glucose pH MN Cell PMN Cel 20.2 mg/dL 8 89.5 % 10.5 %

Normal Value
Clear < 200 U/L < 45 < 32 x103/uL 40 76 mg/dL 78

Working diagnose Management

Meningitis Serous Nasale canule oxygen 0.5-1 L/minute 30 Head elevation IVFD D5% NaCl 0,9% 25 gtt/minute microdrips Mannitol 20% injection 125cc/8 hours/IV (done within 1 hour) Dexamethasone injection 4mg/6 hours/IV Rifampicin 1x525 mg INH 1x350 mg Pyrazinamid 1x875 mg Ethambutol 1x525 mg Sonde voiding diet 1800 kkal with 70 gram protein

Investigation planning

Consult to neurology division Consult to respirology division

Chest X-ray (3-1-2013)

Conclusion : Normal chest x-ray

Head CT-Scan (3-1-2013)

Conclusion : Mild Dilatation Pan Ventricle

Brain MRI (3-1-2013)

Conclusion : Meningitis with inflamation process in dorsal midbrain and right portion of cerebellum and hydrocephalus and cerebral infarct in right basal ganglia

FOLLOW UP

Follow Up January 6th 2013 S : Altered level of consciousness (+) O: Sensorium : Head GCS 7 (E2V1M4), weight = 35 Kg, Temperature = 37,2 0C : Eye: Light reflexes (+/+), anisochoric pupil, right = 2 mm, left = 3 mm, pale inferior conj. palpebra (-/-). Ear/ mouth: normal. Nose: nasale canule and NGT (+) Neck : Lymph node enlargement (-), nuchal rigidity (+) Thorax : Symmetrical fusiform , retraction (-) HR: 90 bpm, regular, murmur (-) RR : 28 bpm, regular, rales (-) Abdominal : Extremities : Soepel, peristaltic (+), liver and spleen not palpable Pulse = 90 bpm, regular, adequate pressure/volume. Warm acral, CRT

< 3 seconds. Blood pressure = 90/40 mmHg

Physiologic Reflex : Right APR/KPR (+ /+), Left APR/KPR (+/+) Pathologic Reflex : Babinsky (-), Chaddock (-), Schuffner (-), Oppenheim (-/-) Meningeal Reflex : Brudzinsky I/II (-/-)

A : Meningitis Serous
P: Nasale canule oxygen 0.5-1 L/minute

30 Head elevation
IVFD D5% NaCl 0,9% 25 gtt/minute microdrips Ceftriaxone injection 1g/12 hours/IV (H2) Mannitol 20% injection 125cc/8 hours/IV (done within 1 hour) Dexamethasone injection 4mg/6 hours/IV Rifampicin 1x525 mg INH 1x350 mg

Pyrazinamid 1x875 mg
Ethambutol 1x525 mg Sonde voiding diet 1800 kkal with 70 gram protein

Follow Up January 7th 2012 Pediatric Neuorologist Consultation: Diagnose : Meningitis Serous Treatment : Phenytoin 700 mg injection in 70 cc NaCl (done within 20 minutes), for next 12 hours phenytoin 90 mg in 9 cc NaCl 0.9%/ 12 hours

Mantoux test done in left volar (lower arm). Read at Thursday, January 10th
2013. Ophtalmologist Consultation: Diagnose : Conjunctivitis OS Treatment : C. floxa 4x1 gtt (OS) C. lyteers 4x1 gtt (ODS) Eyes covered by wet (by RL) sterile gauze

Electrolyte Check Result: Hyponatremia (Na = 125 mEq/L).

Corrected by NaCl 3% 420 cc (105 gtt/minute microdrips) Balance : Input = 845cc Different = - 255cc Output = 1100cc

Follow Up January 8th 2013 S : Altered level of consciousness (+), Fever (+)

A : Meningitis Serous + Conunctivitis OS

P : Ceftriaxone injection 1g/12 hours/IV aff IVFD NaCl 3% 350cc/12 hours (done within 2 hours) electrolyte recheck Diamox pulvers 3x250 mg Ibuprofen pulvers 4x400 mg Phenytoin injection with maintenance dose 90 mg/12 hour/iv diluted in 9 cc NaCl 0.9%

is given over in 20 minute

Eyes cover with wet (RL) sterile gauze Balance : Input = 1440cc Urine Dipstic: LEU NIT URO PRO pH 0.2 6.0

Different = - 485cc

Output = 1925cc

BLO SG +++ 1.005

KET BIL GLU -

Test(8-1-2013) Electrolyte: Na K Cl Ca P Mg

Results

Normal Value

133 mEq/L 4.9 mEq/L 102 mEq/L 8.3 mEq/L 2.8 mEq/L 2.27 mEq/L

135-155 mEq/L 3.6-5.5 mEq/L 96-106 mEq/L 9.2-11 mEq/L 3.4-6.2 mEq/L 1,3-1,8 mEq/L

Follow Up January 9th 2013 S : Altered level of consciousness (+), Blood in NGT (+), Fever (-) A : Meningitis Serous + Conunctivitis OS P : Sonde voiding diet 1800 kkal with 70 gram protein fasting for cooling spooling Balance : Input = 775cc Urine Dipstic: LEU NIT URO PRO 0.2

Differernt = - 425cc

Output = 1250cc

pH BLO SG KET BIL GLU 7.0 ++ 1.005 -

Follow Up January 10th 2013 S : Altered level of consciousness (+), Clear NGT (+)

A : Meningitis Serous + Conunctivitis OS

P : Nebule of NaCl 0.9% 2.5cc + Ventolin Suction regularly every 2 hours Sonde voiding diet 1800 kkal with 70 gram protein Balance : Input = 1225cc

Differernt = - 425cc

Output = 1650cc

Urine Dipstic: LEU NIT URO PRO pH BLO SG KET BIL GLU 0.2 5.0 + 1.025 + -

Test(8-1-2013) Blood Gases: pH pCO2 pO2 HCO3 Total CO2 BE SaO2

Results

Normal Value

7.429 18.4 mmHg 107.3 mmHg 11.9 mmol/L 12.5 mmol/L -10.0 mmol/L 98%

7.35-7.45 38-42 mmHg 85-100 mmHg 22-26 mmol/L 19-25 mmol/L (-2) (+2) mmol/L 95-100%

Follow Up January 11th 2013 S : Altered level of consciousness (+) A : Meningitis Serous + Conunctivitis OS

Balance : Input = 1430cc Urine Dipstic: LEU NIT URO PRO 0.2 +

Differernt = 95cc

Output = 1325cc

pH BLO SG KET BIL GLU 6.0 - 1.015 -

Follow Up January 12th 2013 S : Altered level of consciousness (+) , vesicles on left side of neck (+), blood in urinary cathteter (+) O : Head : OFT (+) Neck : vesicle (+) multiple on left side of neck, ulcer (+) on back side of neck A : Meningitis Serous + Conjunctivitis OS + Susp. Herpes Zooster + Hematuria ec Susp. UTI + Pressure ulcer P : Zinc 1x10 mg Chest physiotherapy

Balance : Input = 1980cc

Differernt = 605cc

Output = 1375cc

Test(12-1-2013) Electrolyte: Na K Cl Ca P Mg

Results

Normal Value

132 mEq/L 4.0 mEq/L 107 mEq/L 7.5 mEq/L 3.6 mEq/L 1.95 mEq/L

135-155 mEq/L 3.6-5.5 mEq/L 96-106 mEq/L 9.2-11 mEq/L 3.4-6.2 mEq/L 1,3-1,8 mEq/L

Hypocalcemia Correction: 0.5xBB = 0.5x35 = 17.5 cc Ca gluconas in 17.5 cc Dextrose 5% (done within 20 minutes)

Test(12-1-2013) Urinalysis Color Glucose Bilirubin Keton SG pH Protein Urobilinogen Nitrit Blood Urine Sediment: Eritrocyte Leucocyte Epitel Cast Cristal

Results Yellow Negative Negative Negative 1.025 6.0 Negative Negative Negative Positive

Normal Value Yellow Negative Negative Negative 1.005-1.030 5-8 Negative Negative Negative

10-15 3-5 0-1 Negative Negative

<3 <6 Negative

Follow Up January 13th 2013

S : Altered level of consciousness (+), vesicles on left side of neck (+), blood in urinary
cathteter (+) A : Meningitis Serous + Conjunctivitis OS + Susp. Herpes Zooster + Hematuria ec Susp. UTI + Pressure ulcer

Balance : Input = 1950cc

Differernt = 225cc

Output = 1725cc

Urine Dipstic: LEU NIT URO PRO pH BLO SG 0.2 5.0 1.015

KET BIL GLU -

Follow Up January 14th 2013 S : Altered level of consciousness (+), vesicles on left side of neck (+), blood in urinary cathteter (+) A : Meningitis Serous + Conjunctivitis OS + Susp. Herpes Zooster + Hematuria ec Susp. UTI + Pressure ulcer

P :
Gentamycin cream Acyclovir cream Acyclovir 5x800 mg

Blood Cultur : No micoorganisme growth Balance : Input = 1400cc

Differernt = -100cc

Output = 1500cc

Urine Dipstic: LEU NIT URO PRO pH BLO SG 0.2 ++ 6.0 1.015

KET BIL GLU -

Follow Up January 15th 2013 S : Altered level of consciousness (+), vesicles on left side of neck (+), blood in urinary cathteter (-) A : Meningitis Serous + Conjunctivitis OS + Susp. Herpes Zooster + Susp. UTI + Pressure ulcer

Balance : Input = 1750cc

Differernt = 225cc

Output = 1525cc

Urine Dipstic: LEU NIT URO PRO pH BLO SG KET BIL GLU + 0.2 6.0 1.010 -

Test(14-1-2013) Urinalysis Color Glucose Bilirubin Keton SG pH Protein Urobilinogen Nitrit Blood Urine Sediment: Eritrocyte Leucocyte Epitel Cast Cristal Others

Results Yellow Negative Negative Negative 1.020 5.0 Negative Negative Negative Positive

Normal Value Yellow Negative Negative Negative 1.005-1.030 5-8 Negative Negative Negative

1-3 0-1 0-1 Negative Negative Yeast (+)

<3 <6 Negative

Nephrology Division Consultation : Repeat Urinalysis and urine cultur Medical Rehabilitation Consultation : Treatment every 3 days as IR, Chest FR and Body moving

Follow Up January 16th 2013 S : Altered level of consciousness (+), vesicles on left side of neck (+) A : Meningitis Serous + Conjunctivitis OS + Susp. Herpes Zooster + Susp. UTI + Pressure

ulcer

Balance : Input = 1450cc

Differernt = - 850cc

Output = 2300cc

Urine Dipstic: LEU NIT URO PRO pH BLO SG KET BIL GLU + 0.2 6.0 1.010 -

Test(16-1-2013) Complete Blood Count Hemoglobin (Hb) Erytrocyte (RBC) Leukocyte (WBC) Hematocrite Trombocyte (PLT) MCV MCH MCHC RDW MPV PCT PDW ESR Cell Count: Neutrofil Limfosit Monosit Eosinophil Basophil Neutrophil absolute Limfosit absolute Monosit absolute Eosinophil absolute Basophil absolute

Results 10.00 g % 4.31 x 106/mm3 18.07 x 103/mm3 31.70 % 378 x 103/mm3 73.50 fL 23.20 pg 31.50 g % 23.40 % 7.90 fL 0.30 % 7.6 fL 44 mm/h 86.80 % 5.30 % 4.10 % 3.70 % 0.100 % 15.68x103/L 0.96x103/L 0.74x103/L 0.67x103/L 0.02x103/L

Normal Value 12.0 14.4 g % 4.20 4.87 x106/mm3 4.5 11.0 x103/mm3 43 - 49 % 150 450 x103/mm3 85 - 95 fL 28 - 32 pg 33 35 g % 11,6 14,8 % 7,2 10,2 fL

< 15 mm/h 37 80 % 20 40 % 28% 16% 01% 2.4 7.3 x103/L 1.7 5.1 x103/L 0.2 0.6 x103/L 0.10 0.30 x103/L 0 0,1 x103/L

Liver Function: Total Bilirubin Direct Bilirubin ALP SGOT SGPT Renal Function: Ureum Creatinine Uric acid Electrolyte: Na K Cl Ca P Mg

0.56 mg/dL 0.19 mg/dL 96 U/L 43 U/L 45 U/L

< 1 mg/dL 0-0.2 mg/dL < 390 U/L < 38 U/L < 41 U/L

24.70 mg/dL 0.36 mg/dL 3.9 mg/dL 129 mEq/L 3.4 mEq/L 100 mEq/L 7.8 mEq/L 4.4 mEq/L 2.10 mEq/L

< 50 mg/dL 0.57-0.87 mg/dL < 7.0 mg/dL 135-148 mEq/L 3.8-5.4 mEq/L 94-111 mEq/L 9.2-11 mEq/L 3.4-6.2 mEq/L 1,3-1,8 mEq/L

Follow Up January 17th 2013 S : Altered level of consciousness (+), vesicles on left side of neck (+) A : Meningitis Serous + Conjunctivitis OS + Cristalina Miliaria + Susp. UTI + Pressure ulcer

P : Acyclovir cream 2x1 aff Acyclovir 5x800 mg aff Urine Cultur : Fungal (+)
Dermatologist Consultation : Diagnose : Cristalina Miliaria Treatment : Hydrocortisone 2.5% sue 2x1 Balance : Input = 2700cc

Differernt = -50cc

Output = 2750cc

Follow Up January 18th 2013 S : Altered level of consciousness (+), vesicles on left side of neck (+) A : Meningitis Serous + Conjunctivitis OS + Cristalina Miliaria + Susp. UTI + Pressure ulcer P : Hydrocortisone 2.5% cream 2x1

Balance : Input = 1350cc

Urine Dipstic: LEU NIT URO PRO + - 0.2 -

Differernt = 500cc

Output = 850cc

pH BLO SG KET BIL GLU 6.0 - 1.015 -

Test(18-1-2013) Electrolyte: Na K Cl Ca P Mg

Results

Normal Value

118 mEq/L 3.4 mEq/L 96 mEq/L 7.5 mEq/L 3.2 mEq/L 1.78 mEq/L

135-155 mEq/L 3.6-5.5 mEq/L 96-106 mEq/L 9.2-11 mEq/L 3.4-6.2 mEq/L 1,3-1,8 mEq/L

Hyponatremia Correction : (135-118) x 0.6 x 35 = 357 mEq/L Corrected by : NaCl 3% = (357/513) x 1000 = 695 L (done within 4 hours) 174 gtt/i microdrips = 56 gtt/i macrodrips
Hypocalcemia Correction : 0.5 x 35 = 17.5 cc Ca gluconas in 17.5 D5% IV Bolus (done within 20 minutes)

Test(18-1-2013) Urinalysis Color Glucose Bilirubin Keton SG pH Protein Urobilinogen Nitrit Blood

Results Yellow Negative Negative Negative 1.020 6.0 Negative Negative Negative Positive

Normal Value Yellow Negative Negative Negative 1.005-1.030 5-8 Negative Negative Negative

Urine Sediment: Eritrocyte Leucocyte Epitel Cast Cristal Others

5-10 10-15 0-1 Negative Oxalat 1-2 Yeast (+), hifa (+)

<3 <6

Negative

Follow Up January 19th 2013 S : Altered level of consciousness (+), vesicles on left side of neck (+) A : Meningitis Serous + Conjunctivitis OS + Cristalina Miliaria + Susp. UTI + Pressure ulcer P : Fluconazole injection loading dose 12 mg/kgBB/IV (400 mg IV) maintenance dose 6 mg/kgBB/IV (100 mg IV)

Balance : Input = 1650cc

Differernt = -375cc

Output = 2025cc

Follow Up January 20th 2013 S : Altered level of consciousness (+), vesicles on left side of neck (+) A : Meningitis Serous + Conjunctivitis OS + Cristalina Miliaria + Susp. UTI + Pressure ulcer

Balance : Input = 1550cc Urine Dipstic: LEU NIT URO PRO - 0.2 -

Differernt = 150cc

Output = 1400cc

pH 6.0

BLO SG ++ 1.030

KET BIL GLU -

Follow Up January 20th 2013 S : Altered level of consciousness (+), vesicles on left side of neck (+) A : Meningitis Serous + Conjunctivitis OS + Cristalina Miliaria + Susp. UTI + Pressure ulcer

Balance : Input = 2100cc

Differernt = 800cc

Output = 1700cc

Urine Dipstic: LEU NIT URO PRO pH BLO SG KET BIL GLU - 0.2 6.0 - 1.015 -

DISCUSSION

Theory
Symptoms often appear are fever, headache, and stiff neck and some accompanying symptoms such as nausea, vomiting, photophobia, impaired mental status, severe meningitis symptoms that may occur is a seizure until coma. Diagnosis is confirmed by examination of cerebrospinal fluid (CSF) and identification of bacteria, viruses or fungi, by culture or detection antigen.

Case
Some of the symptoms above can be found on the case, i.e., fever, headache, stiff neck accompanied by weight of the seizure symptoms of meningitis.

Lumbar puncture performed on the patient. Examination showed that there was no increase in the amount of protein CSF. CSF normal protein levels, a slight increase, or decrease can be found in meningitis viral. In this case, the patient show altered level of consciousness, seizure, recurrent fever and headache that indicates sign of central nervous system infection.

For tuberculous meningitis, the diagnosis is confirmed based on clinical feature and ziehl-neelsen gram staining.

Theory
On acute bacterial meningitis and the chronic decline in glucose levels (< 40 mg/dL) and high protein (usually 100500 mg/dL)8. In some studies, the analysis of culture fluid CSS with negative bacterial colonies are often caused because the patient has received antibiotic therapy before LP.

Case
CSF fluid analysis results of the patients showed clear color with a low in glucose levels (20.2 mg/dl normal value 40-76 mg / dl) and high protein levels (103.20 mg/dL normal <45 mg/dL).

Antibiotics is a therapeutic option for Patients is given antibiotics treatment of bacterial meningitis in the Ceftriaxone injection 1g/12 hours/IV at range 10-28 days old, depending on first, waiting for Tuberculosis drugs. the type of bacteria causing the infection.

Summary
Patients, M, a 14 days old baby was diagnosed with meningitis ec Staphylococcus epidermidis. A comprehensive treatment to

manage meningitis has been conducted to this patient. He has been stabilized, and then he discharge by his own request.