Presentation On Acute Bacterial Meningitis

CASE PRESENTATION
BY DR. TUSHAR BADWAIK

DNB 1ST YEAR IN DEPARTMENT OF PAEDIATRICS
GOVT. MEDICAL COLLEGE, JAGDALPUR
Vidhan Rao shadame, a 5 year old male child presented with sudden onset of altered
sensorium for 1-2 days .
There was preceding history of fever for 2 days before child got admitted to the CHC
Bhopalpattanam on 23/2/2024 for presenting complaint of fever.
PRESENTING COMPLAINTS:
• Fever for 8 days
• Decreased appetite , weakness for 8 days
• Weakness in b/l lower limbs since 3 days
• Abnormal body movement since 1 day

HISTORY OF PRESENT ILLNESS:
As narrated by child’s father and uncle , the child was apparently alright and playing well with his
peers until evening of 21/2/2024 from when child suddenly started having acute onset of fever which was
remittent in nature, followed by loss of appetite and anorexia from the evening of same day of onset fever.
Child was neither taken to any hospital, nor given any medication for fever for initial 2 days. On
23/2/2024 child then taken to the CHC, Bhopalpattanam with presenting complaint of fever with anorexia
and weakness. Sensorium of child was intact on admission in CHC, Bhopalpattanam. Child kept admitted in
CHC for 3 days and after progressive nature of disease with failure to regression of fever child got reffered to
DH, Bijapur on 26/2/2024 in the morning. In DH, Bijapur child was treated with inj. Ceftriaxone , inj.
Amikacin and inj. Paracetamol.
On 27/2/2024 At DH, Bijapur child had 3-4 episodes of generalized tonic-clonic convulsions with each
episode was lasted for 20-30 seconds followed by intact level of consciousness in child after each episode of
convulsion. On 28/2/2024 child then got refered to govt. medical college , jagdalpur for further management
of convulsions.
At paediatrics department of govt. medical college, jagdalpur child received in dull state with sudden onset
of altered sensorium.
No history of cough, cold, sore throat, diarrhea, vomiting, loss of consciousness, facial trauma has been
given by parents.
PAST MEDICAL HISTORY:
• No significant past medical history present
• No history of convulsion disorder and febrile seizures in past
• No history of primary TB and contact with TB positive patient has been given by parents
• Child is not a known case of asthma
PERINATAL AND POSTNATAL HISTORY:

• Child was born with institutional normal vaginal delivery in local PHC
• Immediate cry after birth was present with initiation of breast feeding within 1 hour
• No history of immunization has been given by parents
FAMILY HISTORY:
• No any genetic disorder and convulsion disorder in maternal and paternal side
• Child has one elder sister (8 year old) and one younger sister (3 months old) and elder sister has no h/0
any convulsion disorder
• Both other siblings are healthy till date
EXAMINATION ON ADMISSION:
General condition: dull and confused
BP: 90/50 mmhg
PR: 101 bpm
Spo2: 98% on room air
Temp: 101 degree ferenhit
Systemin examinations-
1. CNS : Conscious
GCS score- E4 V4 M6 (14/15)
POWER in upper limb- 2 score ( active movements with gravity eliminated)

in lower limbs- 1 score ( flicker or trace of contractions)
PUPILS- b/L pupils are mid dilated and slightly reactive to light
PLANTER – B/L dorsiflexion of big toe with fanning of rest 4 toes
DEEP TENDON REFLEXES: knee jerk reflex – grade 0 ( areflexia)

biceps jerk reflex- grade 2 ( normal)
triceps jerk reflex- could not be elicited
Cranial nerve examination:
oculomotor nerve examination – anisocoria absent
ptosis absent
extraocular muscle movement intact in all gaze
abducens nerve examination - lateral rectus muscle contraction present
trochlear nerve examination – superior oblique muscle contraction present
facial nerve examination - facial symmetry present
NUCHAL RIGIDITY – present
KERNIG SIGN- positive
BRUDZINSKI SIGN – positive
PHOTOPHOBIA- absent
TACHE CEREBRALE- absent
MAC EWAN SIGN -Present

2. CVS:
s1 s2 present
No murmurs present on auscultation
3. R/S :
AEEBS
B/L clear chest fields
4. P/A:
soft , non-distended
bowel sound present
no organ appreciable on palpation
5. OCULAR EXAMINATION: Setting-sun sign absent
ANTHROPOMETRY:
Weight- 11 kg (expected weight -18.4kg)

height- 111 cm
Head circumference -49 cm
Arm span – 107 cm
INVESTIGATIONS :
1. CBC-
WBC- 17.7*10^9/L (RANGE 5.5-15.5)
NEU%- 87.0% (UPPER LIMIT IS 47%)
LYM%- 10.4% (UPPER LIMIT IS 46 %)
HBG- 9.5gm/dl (RANGE 11.1-14.7 gm/dl)
PLT- 277*10^9/L ( RANGE 217-533)
2. KFT-
SR. UREA- 20 mg/dl
sr. creatinine- 0.6 mg/dl
3. SR. ELECROLYTE-
SODIUM- 124 meq/l
POTTASIUM- 4.0 meq/l
4. JEV test- negative
5. CSF CULTURE- Has not been done ,as early empirically initiation of antibiotics therapy renders CSF sterile.
It is a gold standered diagnostic modality .
6. FUNDUS EXAMINATION: No evidence of papilledema in both eyes
7. NCCT Scan of brain- Has been done to evaluate for evidence of increased ICP, as LP in the setting of elevated ICP
could cause brain herniation
In NCCT brain, we look for brain abscess, subdural affusion or
empyema, ventriculitis and hydrocephalus.
SUMMARY OF MY CASE
It is an acute suspected bacterial meningitis with unknown pathological agent as

CSF culture, PCR has not been done and which is static in nature .
POSSIBLE RISK FACTORS FOR CAUSING MENINGITIS IN THIS CASE:
• Lack of pre-existing immunity to specific pathogens and serotype ,as child has no history of
immunization against streptococcus pneumoniae and Haemophilus influenzae type b.
DIFFERENTIAL DIAGNOSIS WHICH CAN BE MADE ON BASIS OF CSF CULTURE
AND PCR report IN THIS CASE:
1. Partially treated bacterial meningitis, as child was already treated empirically with antibiotics in previous health
care centers.
2. Viral meningitis or meningoencephalitis , In which HSV encephalitis is suggested by focal seizures or by focal
findings on CT scan . Other viruses can be detected by PCR of CSF.
3. Tuberculous meningitis , where lymphocytes predominate through most of the course and Acid-fast organisms
seen on CSF culture
4. Fungal meningitis , in which PMNs predominate in early course and budding yeast may be seen on CSF culture
5. Subdural empyema , in which PMNs predominate and no organism on smear or culture of CSF unless meningitis
also present
6. SIADH
TREATMENT THAT HAS BEEN GIVEN IN THIS CASE:
1. In previous health center (DH, Bijapur) child was empirically treated with Inj. CEFTRIAXONE (a 3 rd generation
cephalosporin with the dose of 50mg/kg/dose every 12 hourly and Inj. AMIKACIN with the dose of 15 mg/kg/day and
inj. PARACETAMOL for 3 days .
2. At Govt. medical college, jagdalpur, we are treating child with Inj. Cftriaxone (50mg/kg /dose every 12 hourly), Inj.
Amikacin (15mg/kg/day 24 hourly), Inj. Vancomycin (15 mg/kg/dose every 8 hourly), Inj. Paracetamol , Inj. Phenytoin
for seizures management. Inj. Dexamethasone 3mg 24 hourly
The recommended treatment duration for uncomplicated s. pneumoniae meningitis is 10-14 days with a 3 rd
generation cephalosporin or intravenous penicillin (300000-400000 units/kg/day divided every 4-6 hrs or
VANCOMYCIN if the isolate is resistant to penicillin and cephalosporins
For N. Meningitidis meningitis, the recommended treatment duration is 5-7 days with iv. Penicillin
Uncomplicated H. influenzae type b meningitis should be treated for 7-10 days with Ampicillinfor beta- lactamase
negative strains or 3rd generation cephalosporin for beta lactamase positive lactamase isolates.
Intravenous Dexamethasone 0.15 mg/kg/dose given every 6 hours for 2 days . Corticosteroids appear to have
maximum benefit if given 1-2 hours before antibiotics are initiated .
THANK YOU

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CASE PRESENTATION

BY DR. TUSHAR BADWAIK

• Decreased appetite , weakness for 8 days

• Weakness in b/l lower limbs since 3 days

• Abnormal body movement since 1 day

PERINATAL AND POSTNATAL HISTORY:

POWER in upper limb- 2 score ( active movements with gravity eliminated)

PLANTER – B/L dorsiflexion of big toe with fanning of rest 4 toes

DEEP TENDON REFLEXES: knee jerk reflex – grade 0 ( areflexia)

NUCHAL RIGIDITY – present

KERNIG SIGN- positive

BRUDZINSKI SIGN – positive

TACHE CEREBRALE- absent

MAC EWAN SIGN -Present

Weight- 11 kg (expected weight -18.4kg)

4. JEV test- negative

6. FUNDUS EXAMINATION: No evidence of papilledema in both eyes

It is an acute suspected bacterial meningitis with unknown pathological agent as

POSSIBLE RISK FACTORS FOR CAUSING MENINGITIS IN THIS CASE:

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