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Meningitis In Meningitis In children children Harim Mohsin Harim Mohsin 02-13 02-13

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Page 1: Meningitis  In Children

Meningitis In childrenMeningitis In children

Harim MohsinHarim Mohsin

02-1302-13

Page 2: Meningitis  In Children

DefinitionDefinition

MeningitisMeningitis is the inflammation of the is the inflammation of the membranes surrounding the brain & spinal membranes surrounding the brain & spinal cord, including the dura, arachinoid & pia cord, including the dura, arachinoid & pia matter. matter.

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IncidenceIncidence

Meningitis can occur at all ages but it is Meningitis can occur at all ages but it is commonest in infancy. While 95% of the commonest in infancy. While 95% of the cases take place between 1 month- 5 cases take place between 1 month- 5 years of age. years of age.

It is more common in males than females. It is more common in males than females.

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TransmissionTransmission

The bacteria are transmitted from person to The bacteria are transmitted from person to person through droplets of respiratory or throat person through droplets of respiratory or throat secretions.secretions.

Close and prolonged contact (e.g. sneezing and Close and prolonged contact (e.g. sneezing and coughing on someone, living in close quarters or coughing on someone, living in close quarters or dormitories (military recruits, students), sharing dormitories (military recruits, students), sharing eating or drinking utensils, etc.) eating or drinking utensils, etc.)

The incubation period ranges between 2 -10 The incubation period ranges between 2 -10 days. days.

Page 5: Meningitis  In Children

Routes of InfectionNasopharynxNasopharynxBlood streamBlood streamDirect spread (skull fracture, meningo and Direct spread (skull fracture, meningo and

encephalocele)encephalocele)Middle ear infectionMiddle ear infectionInfected Ventriculoperitoneal shunts.Infected Ventriculoperitoneal shunts.Congenital defectsCongenital defectsSinusitisSinusitis

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Signs & SymptomsSigns & SymptomsThe symptoms of meningitis vary and depend on the age of the The symptoms of meningitis vary and depend on the age of the

child and cause of the infection. Common symptoms are:child and cause of the infection. Common symptoms are:

Flu-like symptomsFlu-like symptoms fever fever lethargy lethargy Altered consciousnessAltered consciousness irritability irritability headache headache photophobia photophobia stiff neck stiff neck Brudzinski signBrudzinski sign Kernig sign Kernig sign skin rashes skin rashes seizures seizures

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Signs & symptomsSigns & symptoms

Other symptoms of meningitis in Neonates/infants Other symptoms of meningitis in Neonates/infants can include:can include:

ApneaApnea jaundicejaundice neck rigidity neck rigidity Abnormal temperature (hypo/hyperthermia)Abnormal temperature (hypo/hyperthermia) poor feeding /weak sucking poor feeding /weak sucking a high-pitched cry a high-pitched cry bulging fontanellesbulging fontanelles Poor reflexes Poor reflexes

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TypesTypes

BacterialBacterial Viral (aseptic)Viral (aseptic) FungalFungal ParasiticParasitic Non-infectiousNon-infectious

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Pyogenic Meningitis Pyogenic Meningitis ETIOLOGY ‘Meningococcal’ meningitis- N. meningitidis. A, B, C and W135)

are recognized to cause epidemics

The commonest organisms according to age groups are:The commonest organisms according to age groups are:

0-2 months0-2 months E.ColiE.Coli, Group B streptococci, S.Aureus, Listeria , Group B streptococci, S.Aureus, Listeria MonotocytogenesMonotocytogenes

2 months- 2yrs 2 months- 2yrs H.Influenzae type bH.Influenzae type b, S.Pneumoniae, , S.Pneumoniae,

N.Meningitides.N.Meningitides. 2 yrs – 15+yrs2 yrs – 15+yrs N.MeningitidesN.Meningitides (serotypes A,B,C, Y & W135) (serotypes A,B,C, Y & W135)

S.PneumoniaeS.Pneumoniae (serotypes 1,3, 6,7) (serotypes 1,3, 6,7)

H.InfluenzaeH.Influenzae

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Bacterial MeningitisBacterial Meningitis

Pathogenesis: Pathogenesis: Entry of organism through blood brain barrierEntry of organism through blood brain barrier release of cell wall & membrane products release of cell wall & membrane products Outpouring of polymorphs & fibrinOutpouring of polymorphs & fibrin cytokines & chemokines cytokines & chemokines Inflammatory mediatorsInflammatory mediators Inflamed meninges covered with exudate (most Inflamed meninges covered with exudate (most

marked in pneumoccocal meningitis). marked in pneumoccocal meningitis).

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PathogenesisPathogenesis Meningeal irritation signs: inflammation of the spinal Meningeal irritation signs: inflammation of the spinal

nerves & roots. nerves & roots.

Hydrocephalus: Adhesive thickening of the arachinoid in Hydrocephalus: Adhesive thickening of the arachinoid in basal cistern or fibrosis of aqueduct or Foramina of Lushka basal cistern or fibrosis of aqueduct or Foramina of Lushka or Magendieor Magendie

Cerebral atrophy: thrombosis of small cortical veins Cerebral atrophy: thrombosis of small cortical veins resulting in necrosis of the cerebral cortex. resulting in necrosis of the cerebral cortex.

Seizures: depolarisation of neuronal membranes as a Seizures: depolarisation of neuronal membranes as a result of cellular electrolyte imbalance. result of cellular electrolyte imbalance.

Hypoglycorhachia: decreased transport of glucose across Hypoglycorhachia: decreased transport of glucose across inflammed choroid plexus & increased usage by host. inflammed choroid plexus & increased usage by host.

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NeonatesNeonates

Suspect meningitis with temperature more than Suspect meningitis with temperature more than 100.7 ‘F(38.2’C).100.7 ‘F(38.2’C).

Risk factors:Risk factors: Infective illness in motherInfective illness in mother PROMPROM Difficult deliveryDifficult delivery Premature babiesPremature babies Spina bifidaSpina bifida

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D/D:D/D:

Tuberculous Meningitis Tuberculous Meningitis Viral /aseptic MeningitisViral /aseptic MeningitisBrain AbscessBrain AbscessBrain tumorBrain tumorCerebral malariaCerebral malaria

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Viral meningitisViral meningitis

Viral meningitis comprises most aseptic Viral meningitis comprises most aseptic meningitis syndromes. The viral agents for meningitis syndromes. The viral agents for aseptic meningitis include the following:aseptic meningitis include the following:

Enterovirus (polio virus, Echovirus, Enterovirus (polio virus, Echovirus, Coxsackievirus )Coxsackievirus )

Herpesvirus (Hsv-1,2, Varicella.Z,EBV )Herpesvirus (Hsv-1,2, Varicella.Z,EBV ) Paramyxovirus (Mumps, Measles)Paramyxovirus (Mumps, Measles) Togavirus (Rubella)Togavirus (Rubella) Rhabdovirus (Rabies)Rhabdovirus (Rabies) Retrovirus (HIV)Retrovirus (HIV)

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Fungal MeningitisFungal Meningitis

It’s rare in healthy people, but is a higher It’s rare in healthy people, but is a higher risk in those who have AIDS, other forms risk in those who have AIDS, other forms of immunodeficiency or of immunodeficiency or immunosuppression. immunosuppression.

The most common agents are The most common agents are Cryptococcus neoformans, Candida, H Cryptococcus neoformans, Candida, H capsulatum. capsulatum.

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Parasitic MeningitisParasitic Meningitis

Infection with free-living amoebas is an infrequent Infection with free-living amoebas is an infrequent but often life-threatening human illness.but often life-threatening human illness.

It’s more common in underdeveloped countries It’s more common in underdeveloped countries and usually is caused by parasites found in and usually is caused by parasites found in contaminated water, food, and soil. contaminated water, food, and soil.

The most common causative agents are:The most common causative agents are:Free-living amoebas (ie, Free-living amoebas (ie, Acanthamoeba, Acanthamoeba,

Balamuthia, Naegleria)Balamuthia, Naegleria)Helminthic eosinophilic meningitisHelminthic eosinophilic meningitis

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Non-infectious meningitisNon-infectious meningitis

Rarely, meningitis can be caused by exposure to certain Rarely, meningitis can be caused by exposure to certain medications, such as the following: medications, such as the following:

Immune globulinImmune globulin

Levamisole Levamisole

MetronidazoleMetronidazole

Mumps and rubella vaccinesMumps and rubella vaccines

Nonsteroidal anti-inflammatory drugs (e.g., ibuprofen, Nonsteroidal anti-inflammatory drugs (e.g., ibuprofen, diclofenac, naproxen)diclofenac, naproxen)

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Tuberculous meningitisTuberculous meningitis

It’s a complication of Childhood It’s a complication of Childhood tuberculosis & common cause of tuberculosis & common cause of prolonged morbidity, handicap & prolonged morbidity, handicap & death.death.

Children below 5 years are specially Children below 5 years are specially prone.prone.

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CLINICAL FEATURES

Always sec. to primary tuberculosis.Always sec. to primary tuberculosis.

First PhaseFirst Phase:: Vague symptoms. Vague symptoms. Child doesn’t play, is irritable, restless or Child doesn’t play, is irritable, restless or

drowsy.drowsy.Anorexia & vomiting may be presentAnorexia & vomiting may be presentOlder child may complain of headache.Older child may complain of headache.Possibly preceding history of Measles or Possibly preceding history of Measles or

another illness with incompletely recoveryanother illness with incompletely recovery

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SECOND PHASESECOND PHASE:: Child is drowsy with neck stiffness, & Child is drowsy with neck stiffness, &

rigidity.rigidity.Kernig & Brudzinski sign may become Kernig & Brudzinski sign may become

positive, anterior fontanels bulgespositive, anterior fontanels bulgesTwitching of muscles, convulsions, raised Twitching of muscles, convulsions, raised

temperature.temperature.strabismus, nystagmus, and papilloedema strabismus, nystagmus, and papilloedema

may be present.may be present.Fundoscopy:Fundoscopy: Choroidal TB may be seen Choroidal TB may be seen

Page 21: Meningitis  In Children

TERMINAL PHASETERMINAL PHASE

Child is characteristically comatose Child is characteristically comatose with opisthotonus, & multiple focal with opisthotonus, & multiple focal paresis.paresis.

Cranial nerve palsies are present.Cranial nerve palsies are present.High grade fever often occurs High grade fever often occurs

terminally.terminally.

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DiagnosisDiagnosis

Lumbar PunctureLumbar Puncture:: pressure usually raised, pressure usually raised, 10-500 PMNs early but later lymphocytes 10-500 PMNs early but later lymphocytes

predominatepredominate Protein- 100-500,raisedProtein- 100-500,raised Glucose less than 50mg/dl in most casesGlucose less than 50mg/dl in most cases Culture for tubercle bacilli.Culture for tubercle bacilli. Presence of tuberculous focus elsewhere in the Presence of tuberculous focus elsewhere in the

body is strong supportive diagnosis.body is strong supportive diagnosis. CXR.CXR. Tuberculin skin testTuberculin skin test..

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TreatmentTreatmentAntituberculous Therapy:Antituberculous Therapy: Includes Includes

simultaneous administration of 4 drugs simultaneous administration of 4 drugs (Isoniazid, rifampicin,streptomycin , (Isoniazid, rifampicin,streptomycin , pyrazinamide) for first 3 months, followed pyrazinamide) for first 3 months, followed by 2 drugs for another 15 months usually by 2 drugs for another 15 months usually Rifampicin & INH.Rifampicin & INH.

Total period:Total period: 18 months. 18 months.

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TreatmentTreatmentSTEROIDS:STEROIDS: to reduce cerebral edema and to reduce cerebral edema and

to prevent subsequent fibrosis & to prevent subsequent fibrosis & subsequent obstruction to CSFsubsequent obstruction to CSF

2mg/kg/24 hours of prednisolone for 6-8 2mg/kg/24 hours of prednisolone for 6-8 weeks at the start of treatment starting 3 weeks at the start of treatment starting 3 days after initiation of anti tuberculous days after initiation of anti tuberculous therapy.therapy.

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D/D D/D

Partially treated bacterial meningitisPartially treated bacterial meningitis Viral meningitisViral meningitis Cerebral malariaCerebral malaria Viral encephalitisViral encephalitis

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Chronic MeningitisChronic Meningitis

Chronic meningitis Chronic meningitis is a constellation is a constellation of signs and of signs and symptoms of symptoms of meningeal meningeal irritation irritation associated with associated with CSF pleocytosis CSF pleocytosis that persists for that persists for longer than 4 longer than 4 weeks. weeks.

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ExaminationExamination General physical- General physical- Check for Consciousness level according to GCS

scoring, jaundice or irritability.

Resuscitation:Resuscitation: incase of septic shock, or DIC. incase of septic shock, or DIC.

Vitals:Vitals: temperature , HR, B.P., R/R. temperature , HR, B.P., R/R.

Signs of Increased ICP-Signs of Increased ICP- Bulging fontanelle, headache, nausea, Bulging fontanelle, headache, nausea, vomiting, ocular palsies, altered level of consciousness, and vomiting, ocular palsies, altered level of consciousness, and papilledema papilledema

Fundus:Fundus: papilloedema papilloedema

CN palsies:CN palsies: (esp. occulomotor, facial, and auditory) (esp. occulomotor, facial, and auditory)

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ExaminationExamination Meningismus - check for nuchal rigidity with passive Meningismus - check for nuchal rigidity with passive

neck flexion (gives 'involuntary resistance).neck flexion (gives 'involuntary resistance).

Brudzinski sign (hip & knee flexion with neck Brudzinski sign (hip & knee flexion with neck movement) movement)

Kernig sign (extend knee with hip flexed)Kernig sign (extend knee with hip flexed)

Hemiparesis.Hemiparesis.

Rash:Rash: petechial or purpuric rash (not only in petechial or purpuric rash (not only in meningococcal but also pneumococcal bacteremia).meningococcal but also pneumococcal bacteremia).

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InvestigationsInvestigations CBCCBC Blood cultureBlood culture Gram stainingGram staining LP- D/r, C/s (color, leukocyte count, differential, glucose, LP- D/r, C/s (color, leukocyte count, differential, glucose,

protein) protein) ElectrolytesElectrolytes PCRPCR Coagulation profile Coagulation profile liver and kidney function liver and kidney function Chest X-rayChest X-ray CT/ MRICT/ MRI Blood gasesBlood gases EEGEEG ECGECG

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DiagnosisDiagnosis

CSF picture is quite diagnostic of the kind of CSF picture is quite diagnostic of the kind of meningitis present. meningitis present.

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Contraindication for LPContraindication for LP

.Increase intracranial pressure. .Unstable patient. .Skin infection at site of LP. .Thrombocytopenia. .Papilloedema.

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DiagnosisDiagnosis Latex particle agglutination: Latex particle agglutination: detects presence of detects presence of

bacterial antigen in the spinal fluid. useful for detection bacterial antigen in the spinal fluid. useful for detection of H.influenzae type b, S.Pnemoniae, N.Meningitidis, of H.influenzae type b, S.Pnemoniae, N.Meningitidis, E.ColiE.Coli

Concurrent immuno-electrophoresis (CIE)-used for Concurrent immuno-electrophoresis (CIE)-used for rapid detection of H.influenza, S.pneumoniae & rapid detection of H.influenza, S.pneumoniae & N.meningitides. N.meningitides.

Smears:Smears: taken from purpuric spots may show taken from purpuric spots may show meningococci in Meningococcaemiameningococci in Meningococcaemia

DNA sequences :DNA sequences : are helpful in identifying bacteria are helpful in identifying bacteria

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TreatmentTreatment

Supportive therapy:Supportive therapy: Maintain fluid & electrolyte balance as Maintain fluid & electrolyte balance as

requiredrequired Transfuse whole blood, PRC, FFP or Transfuse whole blood, PRC, FFP or

platelets as required.platelets as required. Maintain temperature controlMaintain temperature control Monitor OFCMonitor OFC

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TreatmentTreatment

SteroidsSteroids::

Dexamethasone useful for H.influenzae type b, Dexamethasone useful for H.influenzae type b, First dose should be given 1 hr prior to starting First dose should be given 1 hr prior to starting antibiotics.antibiotics.

Antibiotics IVAntibiotics IV..

Duration:1-3 weeks depending on age & type of Duration:1-3 weeks depending on age & type of organisms.organisms.

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TreatmentTreatment

Initial till results of Initial till results of C/S are knownC/S are known

Probable/Proved Probable/Proved MeningococciMeningococci

Ampicillin Ampicillin 300mg/kg/day+300mg/kg/day+

ChloramphenicolChloramphenicol

75-100mg.kg/day75-100mg.kg/day

Penicillins Penicillins

2-5 lac units /kg/day2-5 lac units /kg/day

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TreatmentTreatment Probable Probable

H.InfluenzaeH.Influenzae

Probable E.ColiProbable E.Coli

Ampicillin + Ampicillin + chloramphenicol or chloramphenicol or

33rdrd generation generation cephalosporincephalosporin

(cefotaxime (cefotaxime 200mg/kg/day)200mg/kg/day)

Ampicillin + Ampicillin + gentamycingentamycin

200mg/kg+2.5-4 mg/kg 200mg/kg+2.5-4 mg/kg IV 12hrlyIV 12hrly

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TreatmentTreatment

Probable group B Probable group B streptococcistreptococci

Penicillin Penicillin 50,000i.u/kgI.V/4 50,000i.u/kgI.V/4 hourly.hourly.

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Other Drugs availableOther Drugs available

Anti-microbialsAnti-microbials CeftriaxoneCeftriaxone CefotaximeCefotaxime Penicillin G Penicillin G VancomycinVancomycin AmpicillinAmpicillin Gentamicin Gentamicin

Anti-ViralsAnti-Virals Acyclovir Ganciclovir (>3mths)Ganciclovir (>3mths)

Anti-fungals

Amphotericin B

Fluconazole

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PreventionPrevention

The vaccines against Hib, measles, mumps, polio, The vaccines against Hib, measles, mumps, polio, meningococcus, and pneumococcus can protect against meningococcus, and pneumococcus can protect against meningitismeningitis

Hib vaccine: Hib vaccine: all infants should receive at 2,4,6 months of all infants should receive at 2,4,6 months of age & booster 1 year later.age & booster 1 year later.

After 1 year 1 dose is given till the age of 5 years.After 1 year 1 dose is given till the age of 5 years.

Pneumococcal vaccine: Pneumococcal vaccine: 0.5 ml is given IM (<2 yrs)0.5 ml is given IM (<2 yrs)

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PreventionPrevention

High-risk children should also be immunized routinely.High-risk children should also be immunized routinely.

Vaccination before travelling to an endemic areaVaccination before travelling to an endemic area

Chemoprophylaxis for susceptible individuals or close Chemoprophylaxis for susceptible individuals or close contacts:contacts:

H influenzaeH influenzae type b : Rifampin(20 mg/kg/d) for 4 days type b : Rifampin(20 mg/kg/d) for 4 days N meningitidis: Rifampin (600 mg PO q12h) for 2 days upto N meningitidis: Rifampin (600 mg PO q12h) for 2 days upto

10weeks10weeks Ceftriaxone (250 mg IM) single dose or Ceftriaxone (250 mg IM) single dose or

Ciprofloxacin(500-750 mg) single dose. Ciprofloxacin(500-750 mg) single dose.

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ComplicationsComplications

Bacterial meningitis may result inBacterial meningitis may result in Cranial nerve palsies Cranial nerve palsies Subdural empyema Subdural empyema Brain abscess Brain abscess Hearing loss Hearing loss Obstructive hydrocephalus Obstructive hydrocephalus Brain parenchymal damage: Learning disability, CP, Brain parenchymal damage: Learning disability, CP,

seizures, Mental retardation.seizures, Mental retardation. Septic shock/ DIC Septic shock/ DIC AtaxiaAtaxia StrokeStroke SIADH (Na+ <130 mE/l), puffiness of face, dec UO.SIADH (Na+ <130 mE/l), puffiness of face, dec UO.

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Treatment of Complications:Treatment of Complications:Convulsions:Convulsions: Diazepam I.V, Can be Diazepam I.V, Can be

repeated q4 hours as required.repeated q4 hours as required.

Cerebral edema:Cerebral edema: *I.V Mannitol 1g/kg in *I.V Mannitol 1g/kg in 20-30 mins 6-8 hourly given for first few 20-30 mins 6-8 hourly given for first few days.days.

IV Dexamethasone can then be used 6 IV Dexamethasone can then be used 6

hourlyhourly. .

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Subdural effusion:Subdural effusion:

Aspirate subdural effusion if large.Aspirate subdural effusion if large.

Shock:Shock: Treat with IV Fluids, maintanence of BP. Treat with IV Fluids, maintanence of BP.

SIADH:SIADH: Increase body weight, decreased serum Increase body weight, decreased serum osmolality, hyponatremia.osmolality, hyponatremia.

Prevented by fluid restriction to 800-1000ml/m2/24 Prevented by fluid restriction to 800-1000ml/m2/24 hours.hours.

Hyperpyrexia:Hyperpyrexia: Tepid sponging, correction of Tepid sponging, correction of dehydration.dehydration.

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PrognosisPrognosis It depends on the age of the patient, the duration of the It depends on the age of the patient, the duration of the

illness, complications, micro-organism & immune status. illness, complications, micro-organism & immune status.

Patients with viral meningitis usually have a good Patients with viral meningitis usually have a good prognosis for recovery.prognosis for recovery.

The prognosis is worse for patients at the extremes of The prognosis is worse for patients at the extremes of age (ie, <2 y, >60 y) and those with significant age (ie, <2 y, >60 y) and those with significant comorbidities and underlying immunodeficiency.comorbidities and underlying immunodeficiency.

Patients presenting with an impaired level of Patients presenting with an impaired level of consciousness are at increased risk for developing consciousness are at increased risk for developing neurologic sequelae or dying.neurologic sequelae or dying.

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PrognosisPrognosis A seizure during an episode of meningitis also is A seizure during an episode of meningitis also is

a risk factor for mortality or neurologic sequelae.a risk factor for mortality or neurologic sequelae.

Acute bacterial meningitis is a medical Acute bacterial meningitis is a medical emergency and delays in instituting effective emergency and delays in instituting effective antimicrobial therapy result in increased morbidity antimicrobial therapy result in increased morbidity and mortality. and mortality.

The prognosis of meningitis caused by The prognosis of meningitis caused by opportunistic pathogens depends on the opportunistic pathogens depends on the underlying immune function of the host as may underlying immune function of the host as may require lifelong suppressive therapy. require lifelong suppressive therapy.

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ReferencesReferences

Nelson textbookNelson textbook Basis of pediatricsBasis of pediatrics WHO recommendationsWHO recommendations E-medicine E-medicine