Case Report Serous Meningitis

Department of PediatricsH. Adam Malik General Hospital

Faculty of Medicine North Sumatera UniversityMedan 2012

Serous meningitis

case report

by :Ira Mendrofa 080100005Astinal Eka sari 080100009

Supervisor :

dr. H. Hakimi, Sp.A(K)

INTRODUCTION

2

Incidence of bacterial meningitis infection in Indonesia is not known with certainty. In the U.S. in 1994, found as many as 8.7 cases per 100,000 pediatric patients under 5 years old, and 2.2 cases per 100,000 patients over the age of 5 years. According to data from the Hospital Surabaya Dr.Soetomo year 1986-1992 is estimated incidence of infection of 60-80 cases per year. In Jakarta in 1980, found meningitis infection in 1.9% of inpatients

DEFINITION

EtiologyNew born • Group B streptococci

• Escherichia coli K1 and other gram negative enteric bacilli.

• Listeria monocytogenes• Enterococci

Infants and children • S. pneumonie• Neisseria meningitis • H. Influenza type b

Children older than 5 years • S. pneumonie• N. meningitis

Pathogenesis

causative agent

The invasion of the CNS through the bloodstream

Migrate to the subarachnoid layer

Inflammatory response in piamater, arachnoid, cerebrospinal fluid, and

ventricular

Cont....

Exudate spreads across the cranial nerves and spinal

nerves

neurological damage

Risk FactorsMale gender.Premature babies and low birth weight (LBW)Processes that allow the infection during pregnancy and birth, for example

premature rupture of membranes (PROM), parturition length, and infections in the last trimester of pregnancy.

Low leukocyte bactericidal activity, serum complement deficiency, lowproperdin serum, low concentrations of IgM and IgA in the infant's body.

IGA congenital deficiency, IgG, and IgM in infants.Malignancy in the RES system, leukemia, multiple myeloma, lymphoma,

which led to decrease in immunoglobulin production, making it easier to infection.

Antibiotics, radiation, and immunosuppressants.The state of malnutrition Environmental factors that influence the risk of

meningitis infections are: Densely populated environment Lack of cleanliness of the environmen Low education and low socioeconomic status Transmission at daycare.

Clinical Symptom

Clinical Symptom

Diagnosis

Anamnesis : prodromal symptoms of headache, anorexia, nausea / vomiting, fever subfebris, accompanied by behavioral changes and impairment of consciousness, sub-acute onset, a history of TB or a focus of infection is very supportive

Physical examination : Examination of meningeal stimulation with a stiff neck examination. In patients with meningitis usually have a stiff neck in a positive

Differential Diagnosis

Aseptic meningitisTuberculous meningitisBrain abscessBrain tumorMeningismusLead encephalatomy

Treatment

Age <1 month of : Ampicillin (50-100 mg / kg every 6 hours) + gentamicin (2-5 mg / kg every 8 hours), or cefotaxime (50 mg / kg every 6-8 hours) can be used in patients with suspected gram-negative bacilli.

Age 1-3 months : Ampicillin (50-100 mg / kg every 6 hours + cefotaxim (75 mg / kg every 6-8 hours) or ceftriaxone (50 mg / kg every 12 hours) or vancomycin (15 mg / kg every 6 hours) can be added in patients with suspected meningitis pneumococus (eg gram staining).

Ages 3 months-21 years : cefotaxime (75 mg / kg every 6-8 hours, maximum 2 g per day) or ceftriaxone (50 mg / kg every 12 hours, maximum of 4 g per day) + vancomycin (15 mg / kg every 6 hours, maximum 1 g per day), or rifampicin (10 mg / kg every 12 hours, maximum 600 mg per day) may consider granting dexametason.

Prognosis

Meningitis patients with decreased consciousness and seizures have an increased risk of neurological impairment or death

Poor prognosis occurs in patients with cerebral infarction, cerebral edema, Dissemenated intravascular coagulation, and endotoxic shock

OBJECTIVE

To report a case of Serous Meningitis in a

2 years 11 month old boy

experienced since 1 day before admitted

AnamnesisFever has been found since 2 days agoIs a high fever, fever up and down and

recovered with a febrifugeHeadaches since 2 weeks agoVomiting since 2 weeks ago, with a frequency

of 1-2 times / dayCough with phlegm since 2 weeks ago, a

history of contact with an infected person coughs old grandmother

Rigid body experienced by patients from 1 day ago

Physical Examination

Physical Examination

DiagnosisWorking Diagnosis:

Encephalitis

Differential Diagnosis: Encephalitis Meningitis Meningoencephalitis

ManagementO2 1/2-1 L/iIVFD D5% NaCl 0,9% 32 gtt/i microInj. Cefotaxime 500 mg/12 hour IVInj. Ampicillin 600 mg/6 hour IVParacetamol 3x150 mg Diazepam 5,5 mg if neededDiet SV 1260 kcal with 30 gram protein

•Appear hypodense lesion in the right posterior horn of the lateral periventrikel / lobe occipitalis.•Visible dilatation of the lateral ventricles, third ventricle, IV ventricle.•Sulci, gyri and fissures good Sylvii•Falx middle cerebral•Differentiation of both gray and white Satter•Sisterna magna prominent•Both intact ocular bulbus.•Both ethmoid sinuses. Other paranasalis sinus has not been established

CT-SCAN

Follow Up March 2nd 2012Subjective Objective Assessmen

tPlanning/Treatment

Loss consiusness (+)

Sens: sopocoma (GCS5 – E1V1M5), Temp: 36oCBody weight: 11 kg, Body length: 95 cm, BW/BL: 78,5%Head : Eye : Light reflexes (+↓/+↓), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear and Mouth: within normal limit; Nose: nasal flare (+)Neck : Lymph node enlargement (+) o/t regio colli the left and right, mobile, no tendernessThorax : Symmetrical fusiform , retraction (-), HR: 150 bpm, regular, murmur (-)RR : 30 bpm, regular, ronchi (-/-)Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargementExtremities : Pols : 150 bpm, regular, adequate pressure/volume, CFT<3”, warmGenital : Male, within normal limit

DD :- Encephalitis - Meningitis-Meningoencephalitis

•O2 1/2-1 L/i•IVFD D5% NaCl 0,9% 32 gtt/i micro•Inj. Cefotaxime 500 mg/12 hour IV•Inj. Ampicillin 600 mg/6 hour IV•Paracetamol 3x150 mg •Diazepam 5,5 mg if needed•Diet SV 1260 kcal with 30 gram protein

Follow Up March 3rd 2012Subjective Objective Assessmen

tPlanning/Treatment

Loss consiusness (+)Fever (+)

Sens: sopocoma (GCS5 – E1V1M5), Temp: 38oCBody weight: 11 kg, Body length: 95 cm, Head : Eye : Light reflexes (+↓/+↓), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear: cerumen prop; Mouth: within normal limit; Nose: nasal flareNeck : Lymph node enlargement (+) o/t regio colli the left and right, mobile, no tendernessThorax : Symmetrical fusiform , retraction (-), HR: 120 bpm, regular, murmur (-)RR : 28 bpm, regular, ronchi (-/-)Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargementExtremities : Pols : 120 bpm, regular, adequate pressure/volume, CFT<3”, warmGenital : Male, within normal limit

DD :- Encephalitis - Meningitis-Meningoencephalitis-OMSK Dextra

•O2 1/2-1 L/i•IVFD D5% NaCl 0,9% 32 gtt/i micro•Inj. Cefotaxime 500 mg/12 hour IV•Inj. Ampicillin 600 mg/6 hour IV•Paracetamol 3x150 mg •Diet SV 1260 kcal with 30 gram protein•Diazepam 5,5 mg if needed•Inj. Phenitoin MD 30mg/12 hour IV (in 20 cc NaCl 0,9%, out in 20 minutes)•Suction Reguler

Follow Up March 4th - 5th 2012Subjective Objective Assessmen

tPlanning/Treatment



Laboratory Finding :Gastric fluid : Enterobacter aerogenes

DD :- Encephalitis - Meningitis-Meningoencephalitis-OMSK Dextra


Follow Up March 6th - 7th 2012Subjective Objective Assessmen

tPlanning/Treatment


Sens: sopocoma (GCS9 – E4V2M3), Temp: 37,7oCBody weight: 11 kg, Body length: 95 cm, Head : Eye : Light reflexes (+↓/+↓), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear: cerumen prop; Mouth: within normal limit; Nose: nasal flareNeck : Lymph node enlargement (+) o/t regio colli the left and right, mobile, no tendernessThorax : Symmetrical fusiform , retraction (-), HR: 100 bpm, regular, murmur (-)RR : 32 bpm, regular, ronchi (-/-)Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargementExtremities : Pols : 100 bpm, regular, adequate pressure/volume, CFT<3”, warmGenital : Male, within normal limit

Laboratory Finding :Gastric fluid : Enterobacter aerogenes

DD :- Encephalitis - Meningitis-Meningoencephalitis-OMSK Dextra-Susp. TB paru


Follow Up March 8th 2012Subjective Objective Assessment Planning/Treatment



Laboratory Finding :Hb/Ht/WBC/PLT9.40% / 28.50% / 12.75 103/mm3 / 536 103/mm3

EletrolitCa/Na/K/Cl/Mg7.8/121/4.1/94/2.10

Serous meningitis + Susp. TB paru

•O2 1/2-1 L/i•IVFD D5% NaCl 0,9% 32 gtt/i micro•Inj. Cefotaxime 500 mg/12 hour IV•Inj. Ampicillin 600 mg/6 hour IV•Paracetamol 3x150 mg •Diet SV 1260 kcal with 30 gram protein•Diazepam 5,5 mg if needed•Inj. Phenitoin MD 30mg/12 hour IV (in 20 cc NaCl 0,9%, out in 20 minutes)•INH 1x500mg (H1)•Rifampicin 1x150mg (H1)•Pyrazinamid 1x300mg (H1)•Etambutol 1x250mg (H1)

Follow Up March 9th - 13th 2012Subjective Objective Assessment Planning/Treatment

convulsions (-), fever (+), spastic (+)


Laboratory Finding :pH/pCO2/pO2/HCO2/O2

7,372/46,7mmHg/78,4mmHg/26.5mmol/L / 93.6%


•O2 1/2-1 L/i•IVFD D5% NaCl 0,9% 30 gtt/i micro•Inj. Cefotaxime 500 mg/12 hour IV•Inj. Ampicillin 600 mg/6 hour IV•Paracetamol 3x150 mg •Diet SV 1260 kcal with 30 gram protein•Diazepam 5,5 mg if needed•Inj. Phenitoin MD 30mg/12 hour IV (in 20 cc NaCl 0,9%, out in 20 minutes)•INH 1x500mg (H2-5)•Rifampicin 1x150mg (H2-5)•Pyrazinamid 1x300mg (H2-5)•Etambutol 1x250mg (H2-5)


Lose consiusness (+), fever (+), spastic (+)

Sens: sopocoma (GCS9 – E4V2M3), Temp: 38,3oCBody weight: 11 kg, Body length: 95 cm, Head : Eye : Light reflexes (+↓/+↓), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear/Mouth: within normal limit; Mouth: within normal limit; Nose: nasal flareNeck : Lymph node enlargement (+) o/t regio colli the left and right, mobile, no tendernessThorax : Symmetrical fusiform , retraction (-), HR: 145 bpm, regular, murmur (-)RR : 35 bpm, regular, ronchi (-/-)Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargementExtremities : Pols : 145 bpm, regular, adequate pressure/volume, CFT<3”, warmGenital : Male, within normal limit



•O2 1/2-1 L/i•IVFD D5% NaCl 0,9% 30 gtt/i micro•Inj. Cefotaxime 500 mg/12 hour IV•Inj. Ampicillin 600 mg/6 hour IV•Paracetamol 3x150 mg •Diet SV 1260 kcal with 30 gram protein•Diazepam 5,5 mg if needed•Inj. Phenitoin MD 30mg/12 hour IV (in 20 cc NaCl 0,9%, out in 20 minutes)•INH 1x500mg (H6-9)•Rifampicin 1x150mg (H6-9)•Pyrazinamid 1x300mg (H6-9)•Etambutol 1x250mg (H6-9)•Blood Transfusion


Lose consiusness (+), fever (+),

Sens: sopocoma (GCS9 – E4V2M3), Temp: 38,2oCBody weight: 11 kg, Body length: 95 cm, Head : Eye : Light reflexes (+↓/+↓), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear/Mouth: within normal limit; Mouth: within normal limit; Nose: nasal flareNeck : Lymph node enlargement (+) o/t regio colli the left and right, mobile, no tendernessThorax : Symmetrical fusiform , retraction (-), HR: 126 bpm, regular, murmur (-)RR : 30 bpm, regular, ronchi (-/-)Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargementExtremities : Pols : 126 bpm, regular, adequate pressure/volume, CFT<3”, warmGenital : Male, within normal limit


EletrolitCa/Na/K/Cl/Mg6.9/118/3.8/86

Serous meningitis + OMSK Dextra

•IVFD D5% NaCl 0,9% 30 gtt/i micro•Inj. Meropenem 200 mg/8 hour IV•Inj. Phenitoin MD 30mg/12 hour IV (in 20 cc NaCl 0,9%, out in 20 minutes)•Prednison 3x4 mg•Aspilet 1x80 mg•INH 1x500mg (H10-13)•Rifampicin 1x150mg (H10-13)•Pyrazinamid 1x300mg (H10-13)•Etambutol 1x250mg (H10-13)•Diet SV 1260 kcal with 30 gram protein


Lose consiusness (+), fever (+),

Sens: sopocoma (GCS9 – E4V2M3), Temp: 37,7oCBody weight: 11 kg, Body length: 95 cm, Head : Eye : Light reflexes (+↓/+↓), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear/Mouth: within normal limit; Mouth: within normal limit; Nose: nasal flareNeck : Lymph node enlargement (+) o/t regio colli the left and right, mobile, no tendernessThorax : Symmetrical fusiform , retraction (-), HR: 108 bpm, regular, murmur (-)RR : 34 bpm, regular, ronchi (-/-)Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargementExtremities : Pols : 108 bpm, regular, adequate pressure/volume, CFT<3”, warmPhysiological reflex : APR/KPR : +↑/+↑Pathological reflex : Babinsky (+/+), Oppenheim (+/+), Chaddock (+/+), Gordon (+/+)Meningeal Refleks : +Laboratory Finding :Hb/Ht/WBC/PLT10.9% / 33.20% / 11.62 103/mm3 / 91 103/mm3


•O2 1/2-1 L/i•IVFD D5% NaCl 0,9% 30 gtt/i micro•Inj. Meropenem 200 mg/8 hour IV•Phenytoin 2x30 mg•Prednison 3x4 mg •Aspilet 1x80 mg•INH 1x500mg (H14-17)•Rifampicin 1x150mg (H14-17)•Pyrazinamid 1x300mg (H14-17)•Etambutol 1x200mg (H14-17)•Diet SV 1450 kcal with 20 gram protein → 225cc/6hour/NGT


Lose consiusness (+), fever (-),

Sens: sopocoma (GCS10 – E4V2M4), Temp: 36,8oCBody weight: 11 kg, Body length: 95 cm, Head : Eye : Light reflexes (+↓/+↓), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear/Mouth: within normal limit; Mouth: within normal limit; Nose: nasal flareNeck : Lymph node enlargement (+) o/t regio colli the left and right, mobile, no tendernessThorax : Symmetrical fusiform , retraction (-), HR: 108 bpm, regular, murmur (-)RR : 34 bpm, regular, ronchi (-/-)Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargementExtremities : Pols : 108 bpm, regular, adequate pressure/volume, CFT<3”, warm


•O2 1/2-1 L/i•IVFD D5% NaCl 0,9% 30 gtt/i micro•Inj. Meropenem 200 mg/8 hour IV•Phenytoin 2x30 mg•Prednison 3x4 mg •Aspilet 1x80 mg•INH 1x500mg (H18-21)•Rifampicin 1x150mg (H18-21)•Pyrazinamid 1x300mg (H18-21)•Etambutol 1x200mg (H18-21)•Diet SV 1450 kcal with 20 gram protein → 225cc/6hour/NGT

Follow Up March 30th - April 3rd

2012Subjective Objective Assessment Planning/Treatment

Fever(+), Spastic (+),

Sens: sopocoma (GCS10 – E4V2M4), Temp: 37,8oCBody weight: 11 kg, Body length: 95 cm, Head : Eye : Light reflexes (+↓/+↓), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear/Mouth: within normal limit; Mouth: within normal limit; Nose: nasal flareNeck : Lymph node enlargement (-), stiff neck (+)Thorax : Symmetrical fusiform , retraction (-), HR: 100 bpm, regular, murmur (-)RR : 29 bpm, regular, ronchi (-/-)Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargementExtremities : Pols : 100 bpm, regular, adequate pressure/volume, CFT<3”, warm



•O2 1/2-1 L/i•IVFD D5% NaCl 0,9% 30 gtt/i micro•Inj. Meropenem 200 mg/8 hour IV•Phenytoin 2x30 mg•Prednison 3x4 mg •Aspilet 1x80 mg•Asetazolamid 1x65 mg•Lasix 1x15 mg•INH 1x500mg (H22-26)•Rifampicin 1x150mg (H22-26)•Pyrazinamid 1x300mg (H22-26)•Etambutol 1x200mg (H22-26)•Oralit 160cc/time diarrhea•Diet SV 1450 kcal with 26 gram protein •Chest physiotherapy 3x/week

DiscussionTheory Case

Meningitis is characterized by fever, lose consciousness, convulsions, anorexia, myalgia, arthralgia, tachycardia.

This patient was lose consciousness from 1 day before in the hospital, having history fever, fever decreased with fever medicines, headache is felt 2 weeks before in the hospital

Physical examination : Examination of meningeal stimulation with a stiff neck examination. In patients with meningitis usually have a stiff neck in a positive

Physiological reflex : APR/KPR : +↑/+↑; Pathological reflex :Babinsky (+/+), Oppenheim (+/+), Chaddock (+/+), Gordon (+/+); Meningeal Refleks : +

Analysis of cerebrospinal fluid :Color : LiquidProtein : slightly higherGlucose : N/↓

Analysis of cerebrospinal fluid :Color : LiquidProtein : 84 mg/dLGlucose : 20 mg/dL

Treatment : appropriate antibiotic treatment (Ampicillin + cefotaxime) + a combination of anti-tuberculosis

The pateint was given all recommended therapies

Documents

Case Report Serous Meningitis