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Extern conference. 4 OCT 2007. History . A 4-month-old boy Chief complaint: high-grade fever 1 day Present illness: 3 d PTA he had low grade fever with no other symptoms. 1 d PTA he had high grade fever with chill without URI symptoms, N/V, or diarrhea.

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history
History
  • A 4-month-old boy
  • Chief complaint: high-grade fever 1 day
  • Present illness:
    • 3 d PTA he had low grade fever with no other symptoms.
    • 1 d PTA he had high grade fever with chill without URI symptoms, N/V, or diarrhea.
    • He exhibited lethargy and food refusal. The bulging of his anterior fontanelle was observed. He had no seizure.
history1
History
  • Present illness:
    • He took only acetaminophen every 4 hours but his symptoms did not relieved.
    • On the day of admission, he sought for a doctor and was diagnosed as brain edema. He was suggested to go to a hospital.
    • He had no history of trauma. Nobody in his family had symptoms like him.
history2
History
  • Pertinent underlying disease: none
  • Significant medical history: none (healthy)
  • Significant neonatal history: none
  • Developmental history: normal
    • Smile, hold head up,crawl, localize sounds, glare
  • Dietary history: absolute breast feeding
history3
History
  • Immunization: BCG, 1OPV, 1DPT, 2HBV
  • Current medication: none
  • Significant family history:
      • Father - HBV carrier
      • Mother - Euthyroid goiter
physical examination
Physical examination

T 38.5oC, RR 50/min, HR 180/min, BP91/62mmHg

BW 8.1 kg , Ht 50 cm

GA: look sick, drowsiness, not pale, no jaundice, no edema, dry lips, slightly sunken eye ball, anterior fontanelle-bulging, 2x3 cm

HEENT: pharynx-not injected, normal TM both ears

physical examination1
Physical examination

RS: normal breath sound, no adventitious sound

CVS: normal S1&S2, no murmur

Abd: soft, not tender, liver and spleen-not palpable

Genitalia: WNL

physical examination2
Physical examination
  • CNS:
    • pupil 3 mm BRTL, no facial palsy
    • motor power grade IV+ all
    • DTR 3+ all
    • Stiff neck : positive
    • Brudzinski’s sign : positive
    • Kernig sign : positive
problem list
Problem list
  • Fever for 3 days
  • Drowsiness for 1 day
  • Bulging ant.fontanelle and presence of meningeal signs
  • Mild dehydration
differential diagnosis
Differential diagnosis
  • Meningitis
  • Sepsis
definition of fever
Definitionof fever
  • temperature -Rectal >38ºc

-Oral >37.6

-Axillary >37.3

  • Acute fever - fever with source

- fever without source

history taking
History taking
  • Fever : character, pattern, duration
  • Associate organ/systemic symptom

- RS : cough, rhinorrhea, dyspnea

- GI : nausea, vomiting, diarrhea,

- GU : abnormal urine

- NS : alteration of consciousness, seizure, severe headache

history taking1
History taking
  • Behavior activity e.g. drowsy, food/milk intolerance
  • Sick contact
  • Previous treatment, past medication
  • Underlying disease, recent immunization
physical examination3
Physical Examination
  • Vital signs :
  • GA : irritability, sign of dehydration, pale, jaundice
  • HEENT : TM, nasal discharge, tonsils & pharynx
  • Skin rash , sign of soft tissue infection
  • CVS : new onset of murmur, embolic phenomenon
physical examination4
Physical Examination
  • RS : breath sound, adventitious sound, percussion
  • Abdomen : BS, hepatosplenomegaly
  • NS : level of consciousness, fontanelle, motor system, meningeal irritation sign
  • Bone and joint system
investigation
Investigation
  • CBC ,UA
  • Indication for LP in children with fever

- alteration of consciousness

- age<18 months with first episode of febrile seizure or complex febrile seizure

- age<3 months with sepsis

- suspected meningitis

clinical presentation
Clinical presentation
  • Depend on the patient’s age

- newborn: nonspecific

- infancy: fever, vomiting, irritability, convulsion, tense& bulging fontanelle

- children: fever, chills, vomiting, severe headache

  • Meningococcemia: purpura fulminans
clinical presentation1
Clinical presentation
  • Meningeal irritation sign

- significantly less frequent in neonates

- Brudzinski sign, stiff neck, Kernig sign

slide24
Kernig’s signSevere stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees.
slide25
Brudzinski’s signSevere neck stiffness causes a patient's hips and knees to flex when the neck is flexed.
treatment
Treatment
  • Dexamethasone in Hib meningitis with in min after first dose of ATB can reduce risk for hearing and neurologic complication

- 0.15 mg/kg q 6hr for 4 days or

0.4 mg/kg q 12 hr for 2 days

diagnosis
Diagnosis
  • definite diagnosis: CSF examination and C/S
  • CSF gram stain
  • Rapid antigen testing:

GBS, E.coli K1, S.pneumoniae, Hib, N.meningitidis

  • Hemoculture
investigation admission d1
Investigation :admission D1
  • Blood for H/C , CBC , BUN , Cr , Electrolyte , BS
  • LP and CSF analysis, CSF culture, gram stain
  • UA ,MUC
lab admission day1
Lab : Admission day1
  • CBC : Hct 35.4, WBC 21160, N72.7, L 15.3,M11.9, Plt 371,000, MCV79.2
  • BUN7, Cr0.3 , Na133, K 4.3, Cl 97, HCO3 16,AG20, BS 137
  • U/A : pH 6.0 ,sp.gr1.015, WBC0-4, Glu3+, Protein -, Ketone -
  • CSF : Glu 56, TP 100, RBC 10,000, WBC 1,960 (correct WBC : 1,946)
  • CSF G/S : no bacteria was seen, few PMN
lab admission day2
Lab : Admission Day2
  • Bacterial Ag profile: Hib, N. Meningitidis A, B/Ecoli, C, Y/W, Strep. Agalactiae, Strep. Pneumo : All Negative
csf profile1
CSF profile

Nelson Textbook of Pediatrics 16th ed.

diagnosis1
Diagnosis

Bacterial

meningitis

treatment1
Treatment1
  • 1.Empirical antibiotics
  • Cefotaxime (300mg/kg/day) 300mg iv q 6hr
  • Gentamicin (5mg/kg/day) 15mg iv q 8hr
  • 2.supportive treatments
  • Paracetamol(120mg/5ml)4ml oral prn for fever q4-6 hr
  • IV fluid
treatment2
Treatment2
  • 3.monitoring
  • Record v/s q 4hr
  • Record neuro sign q4hr
  • HC,BW OD
  • Record I/O
lab admission day21
Lab : Admission Day2
  • H/C : gram –ve rod
  • MUC : no growth
  • Bacterial Ag profile: Hib, N. MeningitidisA, B/Ecoli, C, Y/W, Strep. Agalactiae, Strep. Pneumo : All Negative
treatment3
Treatment3
  • Ciprofloxacin <40 MKD>

sig 110 mg iv q 8 hr

treatment4
Treatment
  • Add ciprofloxacin in Salmonella meningitis to prevent relapse
  • Change ATB to PGS in mennigococcal meningitis if sensitive
lab admission day3
Lab : Admission Day3
  • CSF culture : Salmonella groupD
  • H/C :Salmonella groupD
  • Drug sensitivity : Cefotaxime, Ciprofloxacin
repeated lp
Repeated LP
  • For diagnosis : in questionable caserepeated LP in 24 hrs
  • For evaluate response of treatment(48-72hrs after treatment)

- cases with poor response

- resistant organism

- neonatal meningitis

-those received steroid

complication
Complication
  • Seizure
  • Subdural effusion 20-30%,subdural empyema 1%
  • SIADH
  • Hearing loss (require hearing evaluation at the end of treatment)
  • Hydrocephalus
  • brain abscess
slide51
Plan
  • Continue ATB 28 days
special thanks
Special thanks

A. Kulkanya Chokephaibulkit,

A. Jeeranda Santiprapob

A. Panjama