Welcome Applicants!

Friday, January 16, 2015

Prep QuestionA 5-year-old boy is brought to the office 4 hours after falling off his bicycle. His mother reports that he was not wearing a helmet, and bystanders said that he did not lose consciousness. When his friends brought him home, he was tearful and sleepy but was answering questions appropriately. His mother noted an abrasion on the left side of his head and applied ice to a small area of swelling on the left temple. Over the last several hours, however, he has become increasingly confused and has had multiple episodes of vomiting. On physical examination, he is difficult to arouse, and his right pupil is larger than his left.

Of the following, a TRUE statement regarding the patient’s likely diagnosis is that

A. Improved survival is associated with prompt neurosurgical intervention in symptomatic patients

B. Intracranial injury is unlikely because there was no loss of consciousness

C. Mannitol is the initial treatment of choice

D. The gradual onset of symptoms is most consistent with a concussion

E. The injury is caused by laceration of the veins that bridge the dural sinuses and the brain

What are your first thoughts** in terms

of treatment/stabilization

Let’s meet our patient….

Qualifying our patient’s level of

consciousness

Level of Consciousness Description

Normal Awake, easy to arouse and

maintain alertness

Lethargic Difficult to maintain

alertness

Obtunded Decreased alertness,

responsive to pain, other

stimuli

Stuporous Decreased alertness,

responsive only to pain

Comatose Unresponsive, even to pain

Let’s go to the thinking chair….

Why is our patient stuporous?**

• Metabolic derangement

• Toxin or overdose

• Seizure

• Increased ICP

• Vascular

• Trauma

Let’s talk with mom

Finishing the exam….

Meningitis

Epidemiology & Pathophysiology

• Bacteria/viruses gain entry into bloodstream through

mucosal surfaces, invade the meninges and

replicate, which induces an inflammatory response

• Bacterial vs Aseptic*

– 1 in 4 aseptic cases will have definitive cause found

• Who gets what bug?

– Well it depends

Etiology

Viruses

Fungi

Bacteria

What are the 3 most common

causes of bacterial meningitis

in neonates?**

GBS, E coli, Listeria

What are the two most common

bacterial pathogens that cause

meningitis in children >1

month?**

Strep pneumoniae

Neisseria meningitidis

You are taking care of a very ill-appearing

baby who you suspect is septic. An LP is

suspicious for meningitis. Mom reports

AGE sxs prior to delivery and also received

imported cheese from France as a gift.

What organism are you worried about?

Listeria

Which bacteria should you also consider in

a patient adopted from a foreign country or

a patient whose mom has withheld

vaccinations due to fears of

complications?

Hib

Predisposing problems….

1) Your patient has a history of multiple infections and

now has Neisseria meningitis. What disorder

should you test this patient for?

• Terminal complement deficiency (C5-9)

2) You are taking care of a HgbSS patient with

suspected bacterial meningitis based on CSF

studies. What 3 organisms are you worried about?

• Neisseria, Strep pneumo, Hib

3) Other:

• Neurosurgery or head trauma within past month, CSF

leak, presence of neurosurgical devices, cochlear

implants, recent illness

It’s in the history**

Infants

• Fever

• Lethargy

• Irritability

• Especially with exam

• Prefer to be motionless

• AMS

• Vomiting

• Seizures

Older Children

• Malaise

• Myalgia

• HA

• Photophobia

• Neck stiffness

• Anorexia

• Nausea

Kernig sign- thigh is bent at the hip and knee

at 90 degree angles, and subsequent

extension in the knee is painful

Brudzinski sign- involuntary lifting of the legs

when lifting a patient’s head

Absence DOES NOT exclude meningitis!!

Clinical Manifestations**• What is this physical exam finding?

• What organism do you suspect?

• Other than an LP, what diagnostic test can you do in an unstable patient to detect the organism?– Purpura fulminans

– N. meningitidis**

– Skin biopsy

• Remember the fontanelle

• Neurologic findings– AMS

– Papilledema

– Cranial nerve palsies (Lyme disease)**

– Focal deficits

Diagnostically speaking

• Labs: BCx, CBC/diff, chemistry panel, LFTs

(especially if suspecting HSV)

• CSF Studies

• Radiology

What kind of imaging?**

A CT of the head is necessary before LP in patients with signs or

symptoms of increased ICP and should be considered for…

– Altered mental status (GCS <12 or drop in GCS of ≥2)

– Immune deficiency

– Papilledema

– Focal neurologic deficit [excluding isolated CN VI or VII palsy]

– CSF shunt

– Hydrocephalus

– CNS trauma

– History of neurosurgery or a space-occupying lesions

– Signs or symptoms of parameningeal infection or tumor

Order of tubes

1. Gram stain, culture,

sensitivity

2. Glucose, protein

3. Cell count and differential

4. Miscellaneous studies

(fungal/viral/chemistry)

CSF analysis**

Glucose

(mg/dL)

Protein

(mg/dL)

WBC

(cells/µL)

Diff Gram stain

Healthy newborn 30-120 30-150 < 30 No PMNs Negative

Healthy child 40-80 20-40 < 10 No PMNs Negative

Bacterial

meningitis

< 1/2

serum,

often < 10

> 100 > 1000 >50% PMNs,

often >90%

Positive in

60-80%

Enteroviral

meningitis

Normal 40-60 50-500,

often < 100

>50%PMNs

early

<50%PMNs

late

Negative

Fungal

Meningitis

< 1/2

serum

> 100 50-500 Lymphocyte

predominant

+/-hyphae

TB meningitis < 1/2

serum,

often < 10

>100 50-500 Lymphocyte

predominant

Negative

Management

• Bacterial meningitis**

– Neonate: Ampicillin, Gentamicin/Claforen, consider

Acyclovir!!Supportive Care!!

– > 2 months: Vancomycin and Ceftriaxone/Claforen

– *Tailor antibiotic therapy once culture results obtained!

• Aseptic meningitis

– Supportive care

– Acyclovir for HSV meningitis

– Empiric therapy if suspect/cannot rule out bacterial

meningitis until cultures are negative

Complications**

• Shock

• Seizures

• Increased ICP

• Subdural effusions**

• Focal neurologic deficits

• Cerebral edema

• SIADH**…close monitoring of I/Os and electrolytes

is very important, especially for bacterial meningitis

cases!

In the long run…**

– Mortality - 5-10% for bacterial meningitis

– Intellectual deficits**

– Hydrocephalus

– Spasticity

– Blindness

– Hearing loss**

• Caused by infection +/- antibiotics

Have a great day!

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Our patient’s course…