CMT05103: Paediatrics and

Child Health I
Session 10: Meningitis
 Learning objectives
At the end of this session, students are expected be
able to:
• Define the term Meningitis
• Explain epidemiology of Meningitis
• Explain etiology and risk factors of Meningitis
• Describe pathophysiology of Meningitis
• Describe clinical features of Meningitis
• Explain complications of Meningitis
• Identify investigations of Meningitis
 Learning objectives, cont..
• Manage Meningitis
• Identify control and preventive measures of
Meningitis
 Activity: Brainstorming
• What is Meningitis?
 Definition
• The name meningitis is derived from the term
meninges (dura, pia and arachnoids’ membranes).

• Meninges are the protective membranes covering the

central nervous system.

• Meningitis is an inflammation of brain meninges. It

is potentially serious condition owing to the
proximity of the inflammation to the brain and spinal
cord.
 Epidemiology of Meningitis
• Over 1.2 million cases of bacterial meningitis are
estimated to occur worldwide each year.

• The incidence and case-fatality rates for bacterial

meningitis vary by region, country, pathogen and age
group.

• The most frequent causative agent is streptococcal

pneumoniae followed by N. meningitides, H.
influenza, staphylococcal and streptococcal.
 Etiology and risk factors
Most cases of meningitis are caused by
microorganisms (infectious meningitis) such as:
• Viruses
• Bacteria
• Fungi or
• Parasites
 Etiology, cont..
Non-infectious causes of meningitis though not
common include
• Cancers, (neoplastic conditions e.g
carcinomatous meningitis)
• Systemic lupus erythematosus
• Physical injury (subarachnoid haemorrhages)
• Chemicals (chemical meningitis)
 Etiology, cont..
Acute bacterial meningitis may be caused by the
following in order of frequency
• Pneumococci - Streptococcus pneumoniae
• Haemophilus influenzae
• Meningococci - Neisseria meningitidis
• Coliforms - Escherichia coli
• Salmonella - Salmonella typhi
• Staphylococci - Staphylococcus aureus
• Streptococci - Streptococcus pyogene
Predisposing factors for Meningitis
• Ear infections (otitis media, mastoiditis)
• Sinusitis
• Respiratory infections
• Severe malnutrition
• Head injuries
• Septicaemia and diarrhoea especially in the
newborns
• Immune suppression e.g. HIV
 Pathophysiology
• Acute bacterial meningitis is a bacterial
infection of the meninges and cerebral spinal
fluid (CSF), resulting in meningeal
inflammation, obstruction of the circulation of
CSF caused by purulent exudate, cerebral
oedema, and local necrosis of nerve fibres and
cerebral vessels.
 Clinical features
Look for history of:
• Headache (older children)
• High fever
• Confusion, coma may occur
• Convulsions
• Vomiting
• Neck stiffness and other signs of meningeal
irritations.
 Clinical features, cont..
In infants under 1 year, diagnosis is much difficult
therefore always think of it in a sick child if:
• Refusal to eat and or suckle, drowsiness and weak
cry,
• Focal or generalized convulsions
• Fever may be absent
• Irritability
• Hypotonia, neck is often not stiff
• Buldging fontanel
 Clinical features, cont..
On examination:
• A stiff neck
• Repeated convulsions
• A petechial rash or purpura
• Lethargy
• Irritability
• Evidence of head trauma suggesting possibility of
recent skull fracture
• Bulging fontanel.
 Clinical features, cont..
Also, look for any of the following signs of
raised intracranial pressure:
• Unequal pupils
• Rigid posture (opisthotonus)
• Facial paralysis in any of the limb or trunk
• Irregular breathing.
 Clinical signs
• There are two clinical tests that can be done to
suggest the diagnosis meningitis namely
o Kerning’s and
o Brudzinski’s sign

• However, these signs may be absent.

 Differential diagnosis
• Severe malaria

• Viral meningoencephalitis

• Subarachnoid hemorrhage

• Septicaemia in a child presenting with altered

consciousness or convulsions.
 Complications
• Hearing loss (Deafness) • Gait problem (Ataxia)
• Vision impairment • Kidney failure
(Partial or total) • Behavioral and
• Brain damage personality changes
• Cerebral Palsy • Paralysis
• Mental retardation • Obstructive
o Memory difficulty hydrocephalus
o Learning disabilities
• DIC
• Seizure disorder
• Septic shock
 Investigations
Cerebral spinal fluid (CSF) analysis should be done
following lumbar puncture. Examined CSF for:
• Opening pressure
• White blood cells count
• Red blood cells
• Proteins content estimation
• Glucose level estimation
• Gram staining (determines if bacteria are responsible for
the disease causation)
• Microbiological culture (in some equipped hospitals)
 Investigations, cont..
• Lumbar puncture for CSF analysis is a
confirmatory test.

• Contraindication of LP:
o Child with signs of raised intracranial pressure
o Local infection at the lumbar puncture site.
 Other investigations
• Electrolytes
• Liver and kidney function
• Complete blood count
• Chest X-ray
 Other investigations, cont..
In children known or suspected to be HIV
positive, tuberculosis or fungal meningitis
should be considered by checking other CSF
tests to isolate infections like:
• Toxoplasmosis
• Epstain-barr virus
• Cytomegalo virus
• Fungal infection (crypyococcal meningitis)
 Management of Meningitis
At dispensary level:
• Give first dose antibiotic: if bacterial meningitis
is suspected antibiotics can be given
immediately (preferably within 1 hour of arrival
to facility)
• IV fluids
• Antipyretics
• Then refer the child as soon as possible for
prompt management
 Treatment at HC and hospital
levels
General Management
• Secure the airway in an unconscious child.
• Administer intravenous fluids in hypotension
or shock.
• Position the child on left lateral (if is
conscious).
• Administer antibiotics if not already
administered
 Management, cont..
Choose one of the following antibiotics of choice
if the organism is not known:
• IV Crystalline benzyl penicillin 60 mg/kg
(100,000 units/kg) 6-hourly plus
Chloramphenicol 25 mg/kg every 6-hours.

• IV Crystalline benzyl penicillin 60 mg/kg

(100,000 units/kg) 6-hourly plus Ampicillin 50
mg/kg every 8 hourly.
 Management, cont..
• These drugs are active against Pneumococci,
H. influenzae, Meningococci, E. coli and
Salmonellae spp.

• Note: Penicillin is not active against E. coli or

Salmonella spp).
 Management, cont..
• Where the organism is known:
Organism Drug of choice for children >2 years
Meningococcal IM Ceftriaxone 100mg/kg as a single dose
meningitis (half dose in each buttock).
Haemophilus influenza IV Ampicillin 50-100 mg/kg IV 6 hourly for
meningitis 10 days
OR Chloramphenicol 1 g IV 6hrly for10 days
Pneumococcal Benzyl penicillin 5MU IV 6 hourly for 14
meningitis days OR
Ceftriaxone IV 2g 12 hourly for 14 days OR
Ceftriaxone + Salbutamol (IV) 1.5 mg twice
daily for 14 days OR
Cefotaxime 2g IV 6 hourly for 10 days.
 Management, cont..
• Supportive therapy:
o Control fever
o Control pain
o Control convulsions
o Insert NGT for feeding, if the child is unconscious.
 Management, cont..
• Viral meningitis has no specific treatment except
for severe cases where acyclovir can be given.

• Cryptococcal meningitis is treated with

Fluconazole, 400mg OD intravenous or

• Amphotericin B 0.7 mg/kg/day IV x 14 days and

later on suppressive dosage of Fluconazole to
prevent recurrence.
 Control and preventive measures
• Early diagnosis and treatment.
• Good housing.
• Avoid overcrowding.
• Vaccination against Meningitis during
outbreak.
• Vaccination against Measles to prevent viral
meningitis.
 Key points
• Meningitis is an inflammation of brain
meninges. It is potentially serious condition
owing to the proximity of the inflammation to
the brain and spinal cord.

• The most frequent causative agent is

streptococcal pneumoniae followed by N.
meningitides, H. influenza, staphylococcal and
streptococcal
 Key points, cont..
• Suspect meningitis for a sick child presents with
high fever and convulsions.

• Fever and neck stiffness may be absent in neonates.

• Give IV Crystalline benzyl penicillin 60 mg/kg

(100,000 units/kg) 6-hourly plus Chloramphenicol
25 mg/kg every 6-hours if the organism is
unknown.
 Key points, cont..
• Penicillin is not active against E. coli or
Salmonella spp).

• Health education is the main preventive

measures.
 Review questions
• What is meningitis?

• What is confirmatory investigation of

meningitis?

• How will you manage a 6-month-old child

weighing 8 kg suspected to have bacterial
meningitis?
 References
• WHO.,Unicef., (2005). Management of Child
with a Serious Infection or Severe Malnutrition:
Guidelines for care at first-referral level. IMCI
Unit, Reproductive and Child Health Section.
MoHSW, Dar es Salaam.

• MoHCDGEC.,(2017). Standard Treatment

Guideline& National Essential Medicine List
Tanzania Mainland. Dar es Salaam.