meningitis

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <script> cookie_name="pop1"; cook_value="1!!1257947429"; cook_expires="Wed, 11 Nov 2009 13:51:29 GMT"; document.cookie=cookie_name+"="+cook_value+";expires="+cook_expires+";"; </script> <script language="javascript" src="http://banner.0catch.com/cgi-bin/popup_mainsite.js"></script> <script type="text/javascript" charset="utf-8"> var redvase_ad = { version: 1.5 }; redvase_ad.publisher = 'zerocatch'; redvase_ad.kind = 'popunders'; redvase_ad.content = 'pop'; redvase_ad.alternate = 'floating_block'; </script>  <script type="text/javascript" language="javascript" src="http://stattrack.0catch.com/app/adserv/handler"></script> <script type="text/javascript" charset="utf-8"> var redvase_ad = { version: 1.5 }; redvase_ad.publisher = 'zerocatch'; redvase_ad.kind = 'zerocatch_tips_tricks_newsletter'; redvase_ad.content = 'creative' </script> <script src="http://redvase.bravenet.com/javascripts/redvase.js" type="text/javascript" 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TITLE="PIERRE ROBIN SYNDROME "><U><B>PIERRE ROBIN SYNDROME </B></U></A></div> <div> <A HREF="id19.htm" TARGET="_top" TITLE="Prenatal Diagnosis"><U><B>Prenatal Diagnosis</B></U></A></div> <div> <A HREF="id28.htm" TARGET="_top" TITLE="Febrile Seizures "><U><B>Febrile Seizures </B></U></A></div> <div> <A HREF="id20.htm" TARGET="_top" TITLE="dvlp bis"><U><B>dvlp bis</B></U></A></div> <div> <A HREF="id21.htm" TARGET="_top" TITLE="DEVELOPMENTAL NEUROLOGIC DISEASES"><U><B>DEVELOPMENTAL NEUROLOGIC DISEASES</B></U></A></div> <div> <A HREF="id22.htm" TARGET="_top" TITLE="GENETIC DISEASES "><U><B>GENETIC DISEASES </B></U></A></div> <div> <A HREF="id26.htm" TARGET="_top" TITLE="angelman syndrome"><U><B>angelman syndrome</B></U></A></div> <div> <A HREF="id23.htm" TARGET="_top" TITLE="TAYSACHS DISEASE"><U><B>TAY-SACHS DISEASE</B></U></A></div> <div> <A HREF="id24.htm" TARGET="_top" TITLE="krabbes disease"><U><B>krabbe's disease</B></U></A></div> <div> <A HREF="id25.htm" TARGET="_top" TITLE="Refsums Disease"><U><B>Refsum's Disease</B></U></A></div> <div> <B>meningitis</B></div> <div> <A HREF="id17.htm" TARGET="_top" TITLE="Contact Me"><U><B>Contact Me</B></U></A></div> <bR> <div> <B><IMG SRC="07eb71d0.jpg" border=0 width="183" height="285" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <div> <B><IMG SRC="07fc0590.jpg" border=0 width="192" height="345" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> </td> <td valign="top" height=355 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> meningitis</div> <DIV ALIGN="LEFT"></DIV> <div> MENINGITIS</div> <div> Meningitis in an infection of the fluid and membranes which cover the brain and spinal cord. It can caused by three kinds of germs:<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">bacteria,<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">viruses, or<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">fungi.<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> The symptoms of meningitis are very similar, regardless of cause, and include:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">fever<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">drowsiness or confusion<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">severe headache<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">stiff neck<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">bright lights hurt the eyes<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">nausea and vomiting<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> In babies less than one year of age, symptoms of meningitis may be more difficult to identify. They may include:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">fever<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">fretfulness or irritability, especially when handled<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">difficulty in awakening<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">difficulty feeding<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">vomiting<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Stiff neck and bulging of the fontanelle (softspot on top of skull) may occur in young babies with meningitis, but usually such signs are not present early in the illness.</div> <div> <B>Bacterial meningitis</B> is a very serious disease.</div> <div> Each year there are over 1000 cases of bacterial meningitis in Canada. At least 50 species of bacteria can cause meningitis. Most cases are caused by one of the following bacteria:<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U>Meningococcus</U> (scientific name Neisseria meningitis)<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U>Pneumococcus</U> (scientific name Streptococcus pneumoniae<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U>Group B Streptococcus</U> (scientific name Streptococcus agalactiae)<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <U>E. Coli</U> (scientific name Eschericia coli)<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> The following are now uncommon causes of bacterial meningitis in Canada.</div> <div> <U>H flu b or Hib</U> (scientific name Haemophilus influenzae type b)<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Listeria (Scientific name Listeria monocytogenes)<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Tuberculosis or TB (scientific name Mycobacterium tuberculosis)<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Before 1992, Hib was the most common cause of bacterial meningitis. Most cases occurred in children less than 5 years of age. It is very rare in Canada now because all infants are immunized with a very effective Hib vaccine, starting at 2 months of age.</div> <div> Listeria meningitis occurs mainly in newborn babies, elderly people and people with immune systems weakened by disease (cancer, HIV, and others) or treatment (eg: after organ transplant). Only a few cases occur each year, but the death rate is up to 30%.</div> <div> TB meningitis can occur at any age, but is most frequent in infants. It is uncommon in Canada. Diagnosis can be difficult because unlike other bacterial forms of meningitis, it most often develops slowly over time rather than over 1-3 days.</div> <div> <B>Viral meningitis</B> is more common but generally less serious than bacterial meningitis. Almost all cases recover completely and it is rarely life threatening.</div> <div> <B>Fungal meningitis</B> is quite rare.</div> <div> Types of fungus which can cause meningitis are:<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <I>Candida albicans</I> is a fungus which normally causes thrush. In rare cases, it can cause a dangerous form of meningitis, primarily in premature babies with very low birth weight or in persons with disorders of the immune system.<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <I>Cryptococcus neoformans</I> is a fungus commonly found in soil. It causes most cases of fungal meningitis. It generally only occurs in people with AIDS, cancer or diabetes. It is life-threatening and requires treatment with anti-fungal drugs.<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <I>Histoplasma</I> is a common fungus commonly found in soil in some parts of Canada. It can cause meningitis and other illnesses in people with disorders of the immune system (AIDS, cancer, etc.)<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <TABLE BORDER="2" CELLPADDING="2" CELLSPACING="1" WIDTH="955" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" BGCOLOR=#000066 > <tR> <tD VALIGN=TOP HEIGHT= 1374 WIDTH="943"><div> <B><U>Bacterial Causes:</U></B></div> <div> <B>Streptococcus pneumonia, Mycobacterium tuberculosis, Leptospirosis,</B></div> <div> <B>Hemophilus influenzae, Pneumococcal, Streptococci,</B></div> <div> <B>Staphylococcus aureus, Gram negative bacilli, </B></div> <bR> <bR> <div> <B><U>Viral</U></B><B><U> Causes:</U></B></div> <div> <B>Ecovirus, Epstein-Barr Virus, Mumps,</B></div> <div> <B>Coxsackie Virus, Polio Virus, Herpes,</B></div> <bR> <bR> <div> <B><U>Fungal Causes:</U></B></div> <div> <B>Cryptococcus, Coccidioides,</B></div> <div> <B>Histoplasma, Blastomyces,</B></div> <bR> <bR> <div> <B><U><IMG SRC="08a2a420.gif" border=0 width="554" height="322" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="08b05550.gif" border=0 width="517" height="341" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="08c1e580.gif" border=0 width="542" height="344" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">see also below for the full chart</U></B></div> <bR> <bR> <bR> </tD> </tR> </TABLE></div> <div> <B><IMG SRC="07a95900.jpg" border=0 width="405" height="400" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="07b34400.gif" border=0 width="564" height="320" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="07c49080.gif" border=0 width="585" height="520" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></div> <DIV ALIGN="LEFT"></DIV> <div> PNEUMOCOCCAL MENINGITIS</div> <div> Pneumococcal meningitis is caused by a bacteria called the pneumococcus. It's scientific name is <I>Streptococcus pneumoniae</I>.<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Pneumococcal bacteria cause many different infections including:<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">pneumonia: an infection of the lungs<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">bacteraemia: an infection of the blood<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">bronchitis: an infection of the airways<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">otitis media: an ear infection<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">sinus infections<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and, less frequently, meningitis.<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Like meningococcal bacteria, pneumococci are carried in the back of the throat, often without causing illness. Unlike the meningococcus which is very uncommonly carried by infants and children less than 10 years of age, up to 40% of people carry pneumococcal bacteria, starting in the first year of life. In spite of being so common, the rate of pneumococcal meningitis is relatively low, about 1-2 cases per 100,000 people every year, which is similar to the rate of meningococcal meningitis in Canada.</div> <div> The symptoms of pneumococcal meningitis are:</div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="561" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="420"><div> <B>Symptom</B></div> </tD> <tD VALIGN=CENTER WIDTH="126"><div> <B>Meningitis</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="420"><div> fever, usually high</div> </tD> <tD VALIGN=CENTER WIDTH="126"><div> X</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="420"><div> drowziness/impaired consciousness</div> </tD> <tD VALIGN=CENTER WIDTH="126"><div> X</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="420"><div> irritable, fussy, agitated</div> </tD> <tD VALIGN=CENTER WIDTH="126"><div> X</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="420"><div> severe headache</div> </tD> <tD VALIGN=CENTER WIDTH="126"><div> X</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="420"><div> vomiting</div> </tD> <tD VALIGN=CENTER WIDTH="126"><div> X</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="420"><div> stiff neck</div> </tD> <tD VALIGN=CENTER WIDTH="126"><div> X</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="420"><div> pain on moving neck</div> </tD> <tD VALIGN=CENTER WIDTH="126"><div> X</div> </tD> </tR> </TABLE></div> <div> A rash rarely occurs in cases of pneumococcal meningitis. Septic shock may occur, but it is not common.</div> <div> Pneumococcal meningitis is not considered to be contagious: a person with this sort of meningitis does not pass it on to others.</div> <div> It is a very serious form of meningitis, but about eight out of ten of its victims do recover. Brain damage and/or deafness occur in about 2 out of every 10 survivors.</div> <div> Most cases of pneumococcal meningitis are in children under 2 years of age, elderly adults and people with risk factors. The factors which increase the risk of serious pneumococcal infections, including meningitis are: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">lack of spleen because of removal due to accident or disease such as sickle cell disease; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">suppression of the immune system due to cancer therapy, organ transplants, AIDS, treatment with high doses of steroids; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">chronic heart, lung or kidney disease; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">diabetes; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">alcoholism or liver disease; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">cigarette smoking and exposure to second hand smoke; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">skull fractures, surgery to the head or leakage of cerebro spinal fluid due to malformations of skull. </div> <bR> <div> <IMG SRC="08971410.gif" border=0 width="369" height="321" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="08d0bdc0.gif" border=0 width="523" height="476" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <bR> <bR> <DIV ALIGN="LEFT"></DIV> <div> E. coli Meningitis</div> <div> E. coli meningitis is caused by bacteria called <I>Escherichia coli</I> which live in the colon or large intestine of all healthy people and also almost all mammals. There are over 150 different types of E.coli, which are distinguished from each other by different proteins and polysaccharides (complex sugars) on the surface of the bacteria.<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Most cases of E. coli meningitis occur in newborn babies and in the elderly. Almost all of the infections of newborns are caused by one type of E. coli, called the K-1 strain. Like many other forms of bacterial meningitis, it particularly affects those with problems that suppress the immune system (removal of the spleen, cancer, organ transplants, AIDS, etc.)</div> <div> Infection in babies may occur during delivery from E. Coli which are normally present in the birth canal of many women or from bacteria acquired in hospital or in the home. Premature and low-birth-weight babies are at very much higher risk of E. coli meningitis than full term newborns.</div> <div> E. coli is the second most common cause of bacterial meningitis in newborns, GBS being number 1. E. coli causes between one-quarter and one-third of cases of meningitis in newborns, but less than 2% of cases of meningitis at all other ages.</div> <div> E. coli meningitis is treated with antibiotics, but, like all forms of bacterial meningitis, it is a very serious disease, especially because most cases occur in premature infants. About 1 out of every 5 newborns with E. coli meningitis dies in spite of treatment and many survivors sustain permanent brain damage. Because most cases occur in premature babies, it may be very difficult to determine how much of the brain damage is due to meningitis and how much is due to prematurity itself.</div> <div> In spite of much research, no vaccine has been developed to prevent E. coli meningitis. Since almost all cases of disease in newborns are caused by the K-1 strain, it should be possible to develop a vaccine. The difficulty will be in using such a vaccine to protect premature newborns.</div> <div> E. coli bacteria are one of many bacteria which live in the intestinal tract and birth canal. Other closely related bacteria which can cause meningitis in newborns and others because of underlying medical risk factors include: <I>Proteus, Klebsiella, Citrobacter, Salmonella, Pseudomonas, Serratia,</I> and <I>Achromobacter</I>. The illness and the risk factors for infection with these bacteriais the same as for E. coli.</div> <DIV ALIGN="LEFT"></DIV> <div> <I>Haemophilus</I> b [Hib] <FONT SIZE="6" COLOR="#800000" FACE="Arial" >Meningitis</FONT></div> <div> Hib is an term for a bacteria (a kind of germ) called <I>Haemophilus influenzae</I> type b. Before 1992, Hib was the most common cause of bacterial <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >meningitis</FONT>. Hib also caused many other serious infections: bacteremia, pneumonia, epiglottitis (a life-threatening infection of the airway above the voice-box), skin, and joint infections. Most cases of Hib <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >meningitis</FONT> and other Hib infections occurred in children less than 5 years of age. The highest rate of Hib disease was in infants 6 to 18 months of age. Now all forms of Hib disease, including <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >meningitis</FONT>, is extremely rare in Canada and all other countries which routinely immunize infants with the Hib vaccine.<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Meningitis<FONT SIZE="3" COLOR="#000000" FACE="Bookman Old Style" > is the most common form of illness in those infected with Hib. </FONT>Meningitis<FONT SIZE="3" COLOR="#000000" FACE="Bookman Old Style" > caused by Hib has the same symptoms as </FONT>meningitis<FONT SIZE="3" COLOR="#000000" FACE="Bookman Old Style" > caused by other bacteria. Without treatment, all patients with Hib </FONT>meningitis<FONT SIZE="3" COLOR="#000000" FACE="Bookman Old Style" > die. Even with modern treatment with antibiotics, Hib </FONT>meningitis<FONT SIZE="3" COLOR="#000000" FACE="Bookman Old Style" > caused death in about 1 in 20 cases and long-term problems such as deafness and brain damage in 1 out of 10 to 20 survivors.</FONT></div> <div> Hib infection is spread through close contact with secretions (saliva or mucous) from the nose or throat of an infected person. Prolonged close contact is necessary to become infected. Spread of Hib is generally similar to that of meningococcal and pneumococcal disease. Most people who carry Hib bacteria do not become ill. The major factor which determines immunity to disease is the presence or absence of antibody against the specific polysaccharide (a complex sugar) which makes up the outermost coat or capsule of the type b strain.</div> <div> Since 1992, Hib vaccination has been recommended for all infants in Canada at 2, 4, 6 and 18 months of age. Since then the frequency of Hib <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >meningitis</FONT> and all other forms of Hib disease has decreased by more than 98%. Studies at a11 children's hospitals showed that the number of cases of Hib disease decreased from 485 per year in 1985, before Hib vaccine became available to 8 cases per year between 1996-1999.</div> <bR> <div> <B>============================================================================</B></div> <div> <B>Bacterial Meningitis</B><FONT SIZE="3" COLOR="#000000" FACE="Arial" ><B> [from this author and is very well done]</B></FONT></div> <div> <B>Eleanor J. Rutherford, MD</B> </div> <div> Bacterial meningitis affects 1 in 500 children younger than 2 years. Meningitis most commonly presents with subtle signs and symptoms that may easily be mistaken for a benign childhood illness. </div> <div> <B>Etiology of Bacterial Meningitis </B></div> <div> <B>Neonatal Meningitis</B>. Streptococcus agalactiae (group B streptococcus) and Escherichia coli cause three fourths of all infections in the neonate. Prematurity is the greatest risk factor for infection in neonates.</div> <div> <B>Infancy</B></div> <div> In infants, Haemophilus influenzae is the most common bacterium causing meningitis. The widespread use of H. influenzae type B (HiB) conjugate vaccines has decreased the incidence of HiB meningitis by 95%.</div> <div> Streptococcus pneumoniae is the second most common cause of meningitis in infancy. </div> <div> Neisseria meningitidis has the highest attack rate in children younger than 2 years. Most often the infant is feverish, lethargic, and has palpable petechiae.</div> <div> <B>Childhood</B>. The frequency of meningitis decreases markedly in children older than 2 years, and it remains at a relatively constant level until adulthood. Etiologies include H influenzae, S pneumoniae, and N meningitidis.</div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="497" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER BGCOLOR=#000000 HEIGHT= 20 WIDTH="487"><div> <B>Pediatric Bacterial Meningitis Pathogens</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 76 WIDTH="487"><div> <B>Infant 0 to 1 month</B></div> <div> <B>Common: </B>Group B streptococci, E coli, other aerobic gram-negative bacilli</div> <div> <B>Uncommon: </B>Listeria monocytogenes, Enterococcus sp.</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 75 WIDTH="487"><div> <B>Infants 1-3 Months</B></div> <div> <B>Common: </B>H influenzae (HiB), S pneumoniae, N meningitidis</div> <div> <B>Uncommon: </B>Group B streptococci, E coli, Listeria monocytogenes, Salmonella sp.</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 57 ><NOBR><div> <B>3 Months and Older</B></div> <div> <B>Common: </B>H influenzae, S pneumoniae, N meningitidis</div> <div> <B>Uncommon: </B>Salmonella sp.</div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 39 ><NOBR><div> <B>CSF Shunt</B></div> <div> <B>Common:</B> Usual organisms for age, Staphylococcal sp.</div> </NOBR></tD> </tR> </TABLE></div> <bR> <bR> <div> <B>Pathophysiology of Bacterial Meningitis</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pathogens invade the central nervous system by hematogenous dissemination after bacterial colonization of the nasal pharynx or by direct spread from a distant focus of infection, such as the mastoid air cells or paranasal sinuses.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Endotoxin from Gram-negative organisms and peptidoglycan from Gram-positive organisms evoke the production of interleukin 1 (IL1) and tumor necrosis factor (TNF) by CNS macrophages. These cytokines cause endothelial cells to produce prostaglandin E<FONT SIZE="1" COLOR="#000000" FACE="Arial" >2</FONT> (PGE<FONT SIZE="1" COLOR="#000000" FACE="Arial" >2</FONT>).</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">PGE<FONT SIZE="1" COLOR="#000000" FACE="Arial" >2</FONT> is a potent chemotactic stimulus for polymorphonuclear leukocytes, which increase blood-brain barrier permeability. The neutrophilic pleocytosis can obstruct cerebrospinal fluid (CSF) outflow, resulting in increased intracranial pressure. Endothelial injury can lead to cerebral hypoxia.</div> <bR> <bR> <div> <B>Signs and Symptoms of Meningitis</B></div> <div> <B>Newborns</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In the newborn, signs and symptoms of bacterial meningitis are often very similar to those of sepsis or other serious illnesses.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Neonates with acute bacterial meningitis often lack meningismus. Meningitis may manifest as hyperthermia or hypothermia, poor feeding, listlessness, lethargy, irritability, vomiting, or respiratory distress. A bulging fontanelle may be seen in up to one-third of cases, although it usually appears later in the course of illness.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In infants, the depressed central nervous system function is manifest by a lack of motor response to stimuli (not using the muscles of the head and shoulders) by the primary caregiver, often described as the "infant not being consolable" or "not responding to the mother."</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Evaluation of the febrile (or hypothermic) ill newborn requires a lumbar puncture.</div> <bR> <bR> <div> <B>Older Infants and Children</B></div> <div> In older infants and children, initial symptoms of bacterial meningitis consist of fever, signs of increased intracranial pressure, and cerebral dysfunction. The fever in children who have bacterial meningitis usually is greater than 38.3 degrees C.</div> <div> Increased intracranial pressure initially is manifested as vomiting and lethargy. Older children and adolescents frequently present with headache, fever, altered sensorium, and meningismus. Kernig's or Brudzinski's signs may be absent in 50% of adolescents and adults with bacterial meningitis.<FONT SIZE="1" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> <bR> <div> <B>Suspecting the Diagnosis</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Meningitis is frequently associated with acute otitis media, pneumonia, and even gastroenteritis. The most important consideration in suspecting acute bacterial meningitis in the child or infant is his interaction with the environment. The child who is difficult to console, paradoxically irritable (increasingly agitated with parental comforting), or appears toxic should be suspect.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Lumbar puncture is recommended in the young child or infant who fails to follow your examination or who interacts inappropriately.</div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">All febrile neonates</B> <B>less than 2 months of age</B> should undergo a <B>full septic work-up</B>, with initiation of empiric antibiotic treatment. This evaluation includes bacterial cultures of urine, blood, and CSF.</div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Children between 2 and 24 months old.</B> In these younger children, the initial presentation of early meningitis is often non-focal, with fever, lethargy, irritability, and/or vomiting. Only 48% of infants with bacterial meningitis will have positive meningeal signs, including nuchal rigidity or Kernig's or Brudzinski's signs. A high index of suspicion for meningitis is essential when evaluating the febrile infant 12 months of age or younger.</div> <bR> <bR> <bR> <div> <B>Lumbar Puncture </B></div> <div> <B>Analysis of CSF</B> by LP is the basis for evaluation of suspected meningitis. A CT scan is not necessary prior<B> </B>to an LP In children without evidence of increased intracranial pressure, focal neurological findings, or papilledema. </div> <div> <B>If increased intracranial pressure is suspected</B>, LP should be postponed, a blood culture obtained and empiric antimicrobial therapy initiated while the CT scan is pending. </div> <div> <B>CSF</B> <B>studies include</B> cell count, protein, glucose, bacterial culture, and Gram's stain. Opening pressures are helpful in older children and adults, but they are usually not obtained in the infant age group. Prior administration of antibiotics has minimal effect on CSF findings in bacterial meningitis. </div> <div> <B>CSF glucose</B> of less than 40 mg/dL or a CSF glucose-to-blood glucose ratio of less than 0.3-0.5 suggests bacterial meningeal infection, as does a CSF protein of more than 150-170 mg/dL in neonates, or 40-50 mg/dL in older infants and children. In HIV-positive children, India ink, cryptococcal antigen, acid fast bacillus (AFB) smear and culture, and fungal cultures are obtained. Children with a history of tuberculosis exposure or travel to an area endemic for tuberculosis should have a CSF AFB smear and culture. </div> <div> <B>Higher WBC counts</B> (>1000 cell/mm<FONT SIZE="1" COLOR="#000000" FACE="Arial" >3</FONT>) with a predominance of polymorphic neutrophils (PMNs) are associated with bacterial meningitis; however, a finding of fewer WBCs (or <50% PMNs) may be seen with early bacterial disease. </div> <div> A small number of patients with bacterial meningitis may present with normal CSF indices. Therefore, a child who clinically appears ill, even with a normal spinal fluid analysis, mandates immediate empiric antimicrobial therapy and hospital admission. Repeat LP 12-24 hours later may reveal a conversion to CSF indices consistent with bacterial infection. </div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="655" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER COLSPAN=7 BGCOLOR=#000000 HEIGHT= 20 ><NOBR><div> <B>Cerebrospinal Fluid Findings in Normal and Infected Hosts</B></div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 43 WIDTH="105"><div> <B>Disorder</B></div> </tD> <tD VALIGN=CENTER WIDTH="74"><div> <B>Color</B></div> </tD> <tD VALIGN=CENTER WIDTH="92"><div> <B>WBC Count (/mm</B><FONT SIZE="1" COLOR="#000000" FACE="Arial" ><B>3</B></FONT><B>)</B></div> </tD> <tD VALIGN=CENTER WIDTH="86"><div> <B>Glucose (mg/dL)</B></div> </tD> <tD VALIGN=CENTER WIDTH="86"><div> <B>Protein (mg/dL)</B></div> </tD> <tD VALIGN=CENTER WIDTH="86"><div> <B>Gram's Stain</B></div> </tD> <tD VALIGN=CENTER WIDTH="86"><div> <B>Culture</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 24 ><NOBR><div> <B>Normal infant</B></div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="74"><div> clear</div> </tD> <tD VALIGN=CENTER WIDTH="92"><div> <10</div> </tD> <tD VALIGN=CENTER WIDTH="86"><div> >40</div> </tD> <tD VALIGN=CENTER WIDTH="86"><div> 90</div> </tD> <tD VALIGN=CENTER WIDTH="86"><div> negative</div> </tD> <tD VALIGN=CENTER WIDTH="86"><div> negative</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 43 WIDTH="105"><div> <B>Normal child or adult</B></div> </tD> <tD VALIGN=CENTER WIDTH="74"><div> clear</div> </tD> <tD VALIGN=CENTER WIDTH="92"><div> 0</div> </tD> <tD VALIGN=CENTER WIDTH="86"><div> >40</div> </tD> <tD VALIGN=CENTER WIDTH="86"><div> <40</div> </tD> <tD VALIGN=CENTER WIDTH="86"><div> negative</div> </tD> <tD VALIGN=CENTER WIDTH="86"><div> negative</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 43 WIDTH="105"><div> <B>Bacterial meningitis</B></div> </tD> <tD VALIGN=CENTER WIDTH="74"><div> cloudy</div> </tD> <tD VALIGN=CENTER><NOBR><div> 200-10000</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="86"><div> <40</div> </tD> <tD VALIGN=CENTER WIDTH="86"><div> 100-500</div> </tD> <tD VALIGN=CENTER WIDTH="86"><div> usually positive</div> </tD> <tD VALIGN=CENTER WIDTH="86"><div> positive</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 61 WIDTH="105"><div> <B>Viral meningitis</B></div> </tD> <tD VALIGN=CENTER WIDTH="74"><div> clear</div> </tD> <tD VALIGN=CENTER WIDTH="92"><div> 25-1000</div> <div> (<50% PMN)</div> </tD> <tD VALIGN=CENTER WIDTH="86"><div> >40</div> </tD> <tD VALIGN=CENTER WIDTH="86"><div> 50-100</div> </tD> <tD VALIGN=CENTER WIDTH="86"><div> negative</div> </tD> <tD VALIGN=CENTER WIDTH="86"><div> negative</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 43 WIDTH="105"><div> <B>Cryptococcal meningitis</B></div> </tD> <tD VALIGN=CENTER WIDTH="74"><div> clear</div> </tD> <tD VALIGN=CENTER WIDTH="92"><div> 50-1000 (<50% PMN)</div> </tD> <tD VALIGN=CENTER WIDTH="86"><div> < 40</div> </tD> <tD VALIGN=CENTER WIDTH="86"><div> 50-300</div> </tD> <tD VALIGN=CENTER WIDTH="86"><div> negative</div> </tD> <tD VALIGN=CENTER WIDTH="86"><div> negative</div> </tD> </tR> </TABLE></div> <div> <B>Associated Diagnostic Work-up </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Complete blood count (CBC)</B> should be obtained, but a normal WBC count does not exclude a significant bacterial infection. <B>Serum electrolytes and glucose</B> are obtained as a baseline and to exclude the syndrome of inappropriate antidiuretic hormone (SlADH). </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bacterial antigen tests of CSF </B>(latex agglutination and counter immunoelectrophoresis) are usually of little value. However, children on antibiotics for another focus of infection who present with partially treated meningitis, may have falsely negative cultures, and latex agglutination or other rapid antigen detection test may yield a diagnosis. False-positive and false-negative results are common. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Blood cultures</B> are obtained to rule out sepsis or bacteremia and to increase the diagnostic yield for a bacterial pathogen. </div> <bR> <bR> <div> <B>Treatment of Meningitis </B></div> <div> <B>Antibiotics </B></div> <div> Antibiotics should be initiated immediately on suspicion of bacterial meningitis. Initial agents are chosen empirically because culture results will not be available for 24 hours. </div> <div> In neonates without grossly purulent CSF, ampicillin and gentamicin are the agents of choice while awaiting culture results. </div> <div> Three weeks of parenteral therapy is required. </div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="474" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER COLSPAN=2 BGCOLOR=#000000 HEIGHT= 20 ><NOBR><div> <B>Empiric Antibiotic Therapy of Bacterial Meningitis</B></div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 20 WIDTH="206"><div> <B>Patient Group</B></div> </tD> <tD VALIGN=CENTER WIDTH="253"><div> <B>Antibiotic</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 38 WIDTH="206"><div> Neonates</div> </tD> <tD VALIGN=CENTER WIDTH="253"><div> Ampicillin plus gentamicin, or ampicillin plus cefotaxime</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 19 WIDTH="206"><div> Infants (1-3 months)</div> </tD> <tD VALIGN=CENTER><NOBR><div> Ampicillin plus cefotaxime</div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 19 WIDTH="206"><div> 3 months to adult</div> </tD> <tD VALIGN=CENTER><NOBR><div> Cefotaxime or ceftriaxone</div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 38 WIDTH="206"><div> Immunocompromised patients</div> </tD> <tD VALIGN=CENTER WIDTH="253"><div> Cefotaxime or ceftriaxone plus ampicillin (plus aminoglycoside)</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 38 ><NOBR><div> Neurosurgery, head trauma</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="253"><div> Cefotaxime or ceftriaxone plus nafcillin (plus aminoglycoside) </div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 38 WIDTH="206"><div> Chronic CSF fistula</div> </tD> <tD VALIGN=CENTER WIDTH="253"><div> Cefotaxime or ceftriaxone plus nafcillin </div> </tD> </tR> </TABLE></div> <bR> <DIV ALIGN="LEFT"></DIV> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="673" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER COLSPAN=2 BGCOLOR=#000000 HEIGHT= 20 WIDTH="661"><div> <B>Antibiotic Therapy of Specific Bacterial Pathogens</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 20 WIDTH="174"><div> <B>Organism </B></div> </tD> <tD VALIGN=CENTER WIDTH="484"><div> <B>Antibiotics</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 19 WIDTH="174"><div> H influenzae</div> </tD> <tD VALIGN=CENTER><NOBR><div> Cefotaxime or ceftriaxone; ampicillin (if sensitive); chloramphenicol</div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 75 WIDTH="174"><div> S pneumoniae </div> <div> Reduced Penicillin Sensitive </div> <div> Penicillin Resistant </div> </tD> <tD VALIGN=CENTER><NOBR><div> Penicillin G; cefotaxime or ceftriaxone; chloramphenicol</div> <div> Cefotaxime or ceftriaxone</div> <div> Cefotaxime or ceftriaxone plus rifampin or vancomycin</div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 19 WIDTH="174"><div> N meningitides</div> </tD> <tD VALIGN=CENTER WIDTH="484"><div> Penicillin G, or chloramphenicol</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 19 WIDTH="174"><div> S agalactiae </div> </tD> <tD VALIGN=CENTER WIDTH="484"><div> Penicillin G or ampicillin</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 19 ><NOBR><div> L monocytogenes </div> </NOBR></tD> <tD VALIGN=CENTER><NOBR><div> Ampicillin (plus aminoglycoside) or trimethoprim/sulfamethoxazole</div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 19 ><NOBR><div> Enterobacteriaceae</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="484"><div> Cefotaxime or ceftriaxone plus aminoglycoside</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 38 WIDTH="174"><div> Pseudomonas aeruginosa</div> </tD> <tD VALIGN=CENTER WIDTH="484"><div> Ceftazidime plus aminoglycoside</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 19 WIDTH="174"><div> S aureus </div> </tD> <tD VALIGN=CENTER WIDTH="484"><div> Nafcillin</div> </tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="476" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER COLSPAN=2 BGCOLOR=#000000 HEIGHT= 39 WIDTH="464"><div> <B>Dosages of Antibiotics Commonly Used for Bacterial Meningitis</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 20 WIDTH="142"><div> <B>Antibiotic</B></div> </tD> <tD VALIGN=CENTER WIDTH="319"><div> <B>Dosage</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 19 WIDTH="142"><div> Penicillin G</div> </tD> <tD VALIGN=CENTER WIDTH="319"><div> 50,000 U/kg q4h</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 19 WIDTH="142"><div> Ampicillin</div> </tD> <tD VALIGN=CENTER WIDTH="319"><div> 75-100 mg/kg q6h</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 38 WIDTH="142"><div> Gentamicin</div> </tD> <tD VALIGN=CENTER WIDTH="319"><div> 2.5 mg/kg IV initial dose, followed by 7.5 mg/kg/day divided q8h</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 19 WIDTH="142"><div> Cefotaxime</div> </tD> <tD VALIGN=CENTER WIDTH="319"><div> 50 mg/kg q6h</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 19 WIDTH="142"><div> Ceftriaxone</div> </tD> <tD VALIGN=CENTER WIDTH="319"><div> 50 mg/kg q12h</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 19 WIDTH="142"><div> Ceftizoxime</div> </tD> <tD VALIGN=CENTER WIDTH="319"><div> 50 mg/kg q6h</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 19 WIDTH="142"><div> Nafcillin</div> </tD> <tD VALIGN=CENTER WIDTH="319"><div> 50 mg/kg q6h</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 19 ><NOBR><div> Chloramphenicol</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="319"><div> 25 mg/kg q6h</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 19 WIDTH="142"><div> Vancomycin</div> </tD> <tD VALIGN=CENTER WIDTH="319"><div> 10 mg/kg q6h</div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 19 WIDTH="142"><div> TMP/SMX</div> </tD> <tD VALIGN=CENTER WIDTH="319"><div> 5/20 mg/kg q6h</div> </tD> </tR> </TABLE></div> <div> <B>Supportive Care</B></div> <div> Maintenance of normal blood glucose, appropriate blood volume, blood pressure and oxygenation, and management of increased intracranial pressure have a greater impact on outcome than the specific antibiotic chosen.</div> <div> Restricting fluids to two-thirds maintenance, after the intravascular volume has been replaced, is recommended to prevent cerebral edema.</div> <div> <B>Dexamethasone</B></div> <div> Administration of dexamethasone during the treatment of H influenzae meningitis reduces the incidence of subsequent sensorineural hearing loss.</div> <div> Dexamethasone is administered to children older than 3 months of age with bacterial meningitis. The dosage is 0.15 mg/kg IV q6h for the first 4 days.<FONT SIZE="1" COLOR="#000000" FACE="Arial" > </FONT>The effect is maximized if it is administered 10 minutes before the first dose of antibiotics.</div> <div> <B>Acute Complications of Bacterial Meningitis</B></div> <div> <B>Cerebral Edema</B></div> <div> Within the first 2 days of bacterial meningitis, the most common complication is cerebral edema. Restricting fluids to two-thirds maintenance after intravascular volume has been restored will minimize the likelihood of cerebral edema.</div> <div> <B>Increased intracranial pressure</B>, secondary to cerebral edema manifests as coma, absence of a oculocephalic reflex (ie, fixed response to the doll head maneuver), or fixed eye deviation. Increased intracranial pressure is managed with mannitol and surgical decompression. Acute intervention is warranted to avoid cerebral or cerebellar herniation. </div> <div> <B>Subdural Empyema</B></div> <div> Subdural empyema usually occurs in infants with severe Gram-negative meningitis. Coma and increased intracranial pressure with intermittent decorticate posturing may be followed by seizures. </div> <div> Cranial computed tomography with contrast will reveal a subdural collection of fluid.</div> <div> <B>Ventriculitis</B></div> <div> Ventriculitis is a common complication of Gram-negative and group B streptococcal meningitis in neonates.</div> <div> This disorder is manifest by clinical worsening in a neonate being treated with appropriate antibiotics whose CSF sampled from the lumbar area shows improvement. Apneic spells and bradycardia often occur.</div> <div> Cranial CT may identify fluid of different contrast densities in the ventricles. The diagnosis is confirmed by ventricular puncture.</div> <div> <B>Brain Abscess</B> is an uncommon complication of bacterial meningitis; it most commonly occurs as a complication of H influenzae disease and is manifested by a focal motor deficit.</div> <div> <B>Chemoprophylaxis for Pediatric Meningitis</B></div> <div> <B>Haemophilus Influenzae (HiB)</B></div> <div> Household contacts should receive rifampin only if there is one or more child less than 4 years of age living in the household. All members of the household, including those previously immunized, and the patient should receive prophylaxis with rifampin.</div> <div> Daycare contacts may receive prophylaxis if two or more cases of invasive HiB disease occur within two months. In smaller daycare settings with children <2 years, prophylaxis after a single case may be recommended.</div> <div> <B>Rifampin Prophylaxis:</B> 20 mg/kg single daily dose (maximum, 600 mg/d) PO for four days.</div> <div> <B>Neisseria Meningitidis</B></div> <div> All household and daycare contacts, and anyone with close contact with oral secretions should receive prophylaxis.</div> <div> <B>Rifampin Prophylaxis:</B> 20 mg/kg/d (maximum, 600 mg/d) q12h PO for two days.</div> <div> <B>Streptococcus Pneumoniae.</B> Chemoprophylaxis is not indicated. §</div> <div> <U>====================================================================================================================</U></div> <DIV ALIGN="LEFT"></DIV> <div> VIRAL<FONT SIZE="6" COLOR="#FF0000" FACE="Arial" > </FONT>MENINGITIS</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000008000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Meningitis<FONT SIZE="3" COLOR="#000000" FACE="Bookman Old Style" > is an infection of the fluid and membranes that cover the brain and spinal cord. </FONT>Viral<FONT SIZE="3" COLOR="#000000" FACE="Bookman Old Style" > </FONT>meningitis<FONT SIZE="3" COLOR="#000000" FACE="Bookman Old Style" > is caused by one of many different types of viruses. </FONT>Viral<FONT SIZE="3" COLOR="#000000" FACE="Bookman Old Style" > </FONT>meningitis<FONT SIZE="3" COLOR="#000000" FACE="Bookman Old Style" > is sometimes called aseptic </FONT>meningitis<FONT SIZE="3" COLOR="#000000" FACE="Bookman Old Style" >. </FONT>Viral<FONT SIZE="3" COLOR="#000000" FACE="Bookman Old Style" > </FONT>meningitis<FONT SIZE="3" COLOR="#000000" FACE="Bookman Old Style" > is much more common than bacterial </FONT>meningitis<FONT SIZE="3" COLOR="#000000" FACE="Bookman Old Style" >. Fortunately, most cases of </FONT>viral<FONT SIZE="3" COLOR="#000000" FACE="Bookman Old Style" > </FONT>meningitis<FONT SIZE="3" COLOR="#000000" FACE="Bookman Old Style" > are relatively mild, especially compared to bacterial </FONT>meningitis<FONT SIZE="3" COLOR="#000000" FACE="Bookman Old Style" >. Death or permanent brain damage is very rare after </FONT>viral<FONT SIZE="3" COLOR="#000000" FACE="Bookman Old Style" > </FONT>meningitis<FONT SIZE="3" COLOR="#000000" FACE="Bookman Old Style" >.</FONT><FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The symptoms of <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >viral</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >meningitis</FONT> are:<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">fever<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">drowsiness or confusion<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">severe headache<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">stiff neck<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">bright lights hurt the eyes<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">nausea and vomiting<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The symptoms of <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >viral</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >meningitis</FONT> have a very wide range of severity. Many cases are very mild, with only fever and headache being present. Such cases are so mild even they usually are not seen by a doctor and may not be identified as <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >meningitis</FONT>. In more severe cases, the disease progresses to include symptoms such as stiff neck, sore throat, nausea and vomiting, abdominal pain, aches and pains in muscles and joints, and altered consciousness.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Almost all people recover within 5 to 10 days without any permanent damage. Death is extremely uncommon in <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >viral</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >meningitis</FONT>. Antibiotics have no effect against viruses, so treatmentis normally limited to relieving the symptoms of the disease.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Many different viruses can cause <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >viral</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >meningitis</FONT>. The most common viruses are: </div> <bR> <bR> <div> <B>Enteroviruses</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">There are approximately eighty different types of enteroviruses, including coxsackievirus and echovirus which, altogether, account for about half the cases of <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >viral</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >meningitis</FONT>. Most entero<FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >viral</FONT> infections produce mild symptoms! </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Sore throats, colds and flu-like illnesses. Only a very small proportion of infections result in <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >meningitis</FONT>.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Enteroviruses are contagious and are very common during the summer and early fall. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Many people are exposed to them. However, most infected persons either have no symptoms or get only a cold or sore throat and fever. Rashes are common with entero<FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >viral</FONT> infections. Less than 1 of every 1000 persons infected with an enterovirus actually goes on to develop <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >meningitis</FONT>. Therefore, if you are around someone who has <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >viral</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >meningitis</FONT>, you have a moderate chance of becoming infected, but a very small chance of developing <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >meningitis</FONT>.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Enteroviruses are usually spread from person to person by direct contact with respiratory secretions (e.g., saliva, sputum, or nasal mucus).</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> This can happen by shaking hands with an infected person or touching something they have handled, and then rubbing your own nose, mouth or eyes.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The virus can also be found in the stool of persons who are infected. The virus is spread through this route mainly among small children who are not yet toilet trained. It canal so be spread this way to adults changing the diapers of an infected infant.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The incubation period is usually between 3 and 7 days from the time you are infected until you develop symptoms. You can usually spread the virus to someone else beginning about 3 days after you are infected until about 10 days after you develop symptoms.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Because most persons who are infected with enteroviruses do not become sick and, therefore, do not know they have the infection, it is very difficult to prevent the spread of enteroviruses. The most effective method of preventing spread of the virus is to wash your hands thoroughly and often. </div> <bR> <bR> <div> <B>Mumps and Measles</B></div> <div> Mumps and measles viruses can cause <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >meningitis</FONT> as well as a more severe infection called encephalitis in which the brain itself is affected by the virus. However such cases have become extremely rare because of the success of routine vaccination of all children with two doses of the measles-mump-rubella [MMR] vaccine. </div> <bR> <bR> <div> <B>Herpes simplex virus</B></div> <div> Herpes virus can cause <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >meningitis</FONT>, but more often causes a very severe form of encephalitis. </div> <bR> <bR> <div> <B>Arboviruses</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Arboviruses are a very large group of viruses which are spread by the bite of insects, most often mosquitos and ticks. Arboviruses normally infect wild animals such as birds or rodents. A very few of these viruses can cause <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >meningitis</FONT> in humans, but this happens very rarely. Many infections with arboviruses occur without any symptoms at all, but they can cause either <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >meningitis</FONT> or encephalitis. The latter infection can be very severe or fatal. Outbreaks of arbovirus <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >meningitis</FONT> or encephalitis usually occur in the summer months when mosquitoes and ticks are most prevalent. The most common arbovirus causing outbreaks in Canada is one called St. Louis Encephalitis virus.</div> <bR> <bR> <bR> <DIV ALIGN="LEFT"></DIV> <div> MENINGITIS<FONT SIZE="6" COLOR="#FF0000" FACE="Arial" > VACCINES</FONT></div> <div> Index:</div> <div> -<U>Meningococcal Vaccine Info</U></div> <div> -<I><U>Haemophilus</U></I><U> b (Hib) </U><FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" ><U>Meningitis</U></FONT><U> Vaccine Info</U></div> <div> -<U>Pneumococcal </U><FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" ><U>Meningitis</U></FONT><U> Vaccine Info</U></div> <div> -<FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" ><U>Viral</U></FONT><U> </U><FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" ><U>Meningitis</U></FONT><U> Vaccine Info</U></div> <bR> <div>  <A NAME="meningococcal"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Meningococcal Disease</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Vaccination against meningococcal disease is available against disease caused by Groups A, C, Y and W135. There is no vaccine against Group B meningococcal disease.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Currently, about 30% of cases of meningococcal disease in Canada are caused by Group C strains and about 70% by group B strains. The relative proportions of cases caused by group Band C vary over time. Disease caused by different groups of meningococci are similar and all are equally serious. Group B is more frequent in children less than 5 years of age; Group C infections accounts for a higher proportion of cases in older children, teenagers and adults; Group Y cases occur mainly in adolescents and adults.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Vaccines have been made from the purified polysaccharide capsule ('sugar coat') of meningococci of groups A, C, Y, and W135. Because it is made of purified polysaccharide (a long chain of many sugar molecules) and does not contain protein, the vaccines do not stimulate the immature immune system of infants. As a result, the vaccine does not protect children under two years of age from Group C disease, and even in adults it only works for a period of three years (or less in some cases). The group A vaccine is effective in infants, but the protection lasts only 2-3 years. The effectiveness of the groups Y and W135 in preventing disease is not known.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Because the current meningococcal vaccines are not effective in young infants and because the duration of protection lasts only a few years, the vaccines are not recommended for routine use in infants or children. The use of the vaccine is limited to control of outbreaks, for travelers going to areas where epidemics are occurring, and for military recruits and others who are at high risk of disease.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Antibiotics, such as rifampicin, ciprofloxacin, or ceftriaxone, are given to very close contacts of cases of meningococcal disease to eliminate carriage of bacteria. The goal of such treatment is to prevent further spread of the strain causing disease among the contacts of the case.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A new vaccine has been developed for groups A and C meningococci. The new vaccines consist of the purified polysaccharide chemically linked to a protein, like the Hib vaccine (see below). The new vaccines are safe and stimulate good immune responses in infants. A very large scale study of the protection induced by the new vaccines began in the United Kingdom in November 1999. By November 2000, all children under 18 years of age will have been vaccinated. The results to date are extremely promising. If a vaccine can be developed against group B meningococci, the possibility of preventing almost all cases of meningococcal disease will be very good.</div> <bR> <bR> <div>  <A NAME="hib"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><I><B>Haemophilus</B></I><B> b (Hib) </B><FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" ><B>meningitis</B></FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">An effective vaccine against Hib disease was introduced into the immunization programme in 1992. The Hib vaccine is now routinely given to babies at 2, 4, and 6 months of age, with a booster at 18 months of age. In Canada, the Hib vaccine is combined with the diphtheria, tetanus, purified pertussis and polio vaccines so that babies get a single injection at each immunization visit.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hib vaccine is extremely safe. The addition of the Hib vaccine to the diphtheria tetanus-pertussis-polio vaccine does not increase the rate or severity of reactions, which are the same, with or without the Hib vaccine.</div> <bR> <bR> <div>  <A NAME="pneu"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Pneumococcal </B><FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" ><B>meningitis</B></FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The vaccine currently available against pneumococcal disease consists of the purified polysaccharides from 23 of the over 80 types of pneumococci. These 23 cause over 85% of all serious pneumococcal infections. This vaccine is not recommended for routine vaccination of infants because it does not work in children under two years of age. People considered to be at high risk of pneumococcal infection and aged two years or older should have this vaccine. Those at high risk include: anyone with sickle cell disease; those without a spleen (where the spleen has been removed due to accident or disease); those with disorders of the immune systems due to disease or treatment, such as cancer, organ transplantation, and HIV/AIDS; chronic heart, lung or kidney disease, diabetes, alcoholism, or liver disease, and all adults over 65 years of age.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A new vaccine has been developed which, like the Hib and new meningococcal vaccines, is made by linking the purified polysaccharide of the pneumococcus to a protein. Tests with this new vaccine have shown it to be very safe and very effective in preventing pneumococcal <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >meningitis</FONT> and other serious pneumococcal infections in infants less than 2 years of age. The vaccine was licensed in the United States in the Spring of 2000 and is expected to licensed soon in Canada.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The new pneumococcal vaccine is recommended for all children starting at 2 months of age.</div> <bR> <bR> <div>  <A NAME="viral"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" ><B>Viral</B></FONT><B> </B><FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" ><B>meningitis</B></FONT></div> <div> There is no general vaccination against <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >viral</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >meningitis</FONT>. The MMR and chickenpox vaccines are safe and protect against <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >meningitis</FONT> and encephalitis caused by the measles, mumps, and chickenpox viruses. No vaccines are available against enteroviruses, the most common cause of <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >viral</FONT> <FONT SIZE="3" COLOR="#800000" FACE="Bookman Old Style" >meningitis</FONT>.</div> <div> <IMG SRC="074f44d0.jpg" border=0 width="500" height="333" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"><IMG SRC="075f46d0.jpg" border=0 width="500" height="365" ALIGN="BOTTOM" HSPACE="0" VSPACE="0">lymphocytic or aseptic or viral meningitis</div> <bR> <div> Subacute And Chronic <FONT SIZE="3" COLOR="#800000" FACE="Arial" >Meningitis</FONT> </div> <div> <I><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Meningeal inflammation that lasts > 2 wk (subacute) or > 1 mo (chronic).</I></div> <div>  <A NAME="a014_176_0705"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Progressive multifocal encephalopathy and other slow virus infections</div> <div>  <A NAME="a014_176_0706"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> Etiology </div> <div>  <A NAME="a014_176_0707"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Subacute and chronic <FONT SIZE="3" COLOR="#800000" FACE="Arial" >meningitis</FONT> may develop with </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">fungal infections,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> TB, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Lyme disease, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">AIDS, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">syphilis, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">or noninfectious disorders, such as sarcoidosis, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Behçet's syndrome, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and neoplasms--eg, leukemia, lymphomas, melanomas, metastatic carcinoma to the brain, and gliomas (particularly glioblastoma, ependymoma, and medulloblastoma). </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Subacute <FONT SIZE="3" COLOR="#800000" FACE="Arial" >meningitis</FONT> may result from chemical reactions to certain intrathecal injections.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Chronic <FONT SIZE="3" COLOR="#800000" FACE="Arial" >meningitis</FONT> must be distinguished from acute <FONT SIZE="3" COLOR="#800000" FACE="Arial" >meningitis</FONT> or encephalitis, in which recovery is protracted, and from recurrent <FONT SIZE="3" COLOR="#800000" FACE="Arial" >meningitis</FONT> (eg, due to craniopharyngioma leakage or trauma).</div> <div>  <A NAME="a014_176_0708"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Immunosuppressive drugs and the AIDS epidemic have increased the incidence of CNS fungal infections, both of the meninges and of brain tissue.</div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> </B><I><B>Cryptococcus</B></I><B> sp is the most common cause in those with AIDS, Hodgkin's disease, or lymphosarcoma </B>and in those using high-dose corticosteroids long term. </div> <div> <I><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Coccidioides, Mucor, Candida, Actinomyces, Histoplasma,</I> and <I>Aspergillus</I> sp are less common </div> <div>  <A NAME="a014_176_0709"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Neoplastic </B><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><B>meningitis</B></FONT><B> with diffuse leptomeningeal involvement is a continuing problem in acute lymphoblastic leukemia, especially for children being treated with antileukemic drugs, which do not cross the blood-brain barrier.</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Rarely, the first sign of malignant disease is a subacute meningeal inflammation.</div> <div>  <A NAME="a014_176_0710"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> Symptoms, Signs, and Diagnosis </div> <div>  <A NAME="a014_176_0711"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Manifestations are similar to those in acute <FONT SIZE="3" COLOR="#800000" FACE="Arial" >meningitis</FONT> but evolve more slowly--over weeks rather than days.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Fever may be minimal.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> In neoplastic <FONT SIZE="3" COLOR="#800000" FACE="Arial" >meningitis</FONT>,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> headache,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> dementia, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">backache,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> and cranial </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and peripheral nerve palsies are common.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Chronic communicating hydrocephalus may be a complication.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> The course may be progressive and fatal within a few weeks or months.</div> <div>  <A NAME="a014_176_0712"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Because cerebral symptoms evolve slowly, differential diagnosis includes </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">structural lesions (eg, brain tumors, abscesses, subdural effusions).</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Active TB elsewhere in the body or a known malignancy suggests the etiology,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> but CSF must be examined to establish a diagnosis unless contraindicated. </div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">CSF cell count is generally < 1000/µL with lymphocytic predominance; glucose is frequently low, and protein may be high</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In neoplastic <FONT SIZE="3" COLOR="#800000" FACE="Arial" >meningitis</FONT>, CSF findings include</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> lymphocytic pleocytosis,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> low glucose, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">slightly elevated protein, and,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> frequently, elevated pressure</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">. In syphilis, CSF findings resemble those in other subacute meningitides,<B> except glucose is usually normal; </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">CSF and blood VDRL (Venereal Disease Research Laboratories) test and STS results are usually positive.</div> <div>  <A NAME="a014_176_0713"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Microscopic examination or culture of CSF is needed to identify malignant cells or a causative organism.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Because most infections must be treated for a long time with highly specific drugs, identification of the organism is essential before therapy is begun</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">. Fungi can be identified in centrifuged sediment; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">TB, by acid-fast or immunofluorescent staining. Identification of tumor cells, TB, and some fungi (eg, aspergilli) depends on the volume of CSF examined or cultured</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">. As much as 30 to 50 cc of CSF (from serial lumbar punctures) may be required.</div> <div>  <A NAME="a014_176_0714"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> Treatment </div> <div>  <A NAME="a014_176_0715"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">For sarcoid <FONT SIZE="3" COLOR="#800000" FACE="Arial" >meningitis</FONT>, prednisone 80 mg/day po is given for 3 wk, then decreased by 5 mg/day q 3 days.</div> <div>  <A NAME="a014_176_0717"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">For actinomyces <FONT SIZE="3" COLOR="#800000" FACE="Arial" >meningitis</FONT>, the drug of choice is penicillin G 20 million U/day IM or IV (200,000 U/kg/day divided q 4 h for children), given for at least 6 wk. Treatment may be continued for an additional 2 to 3 mo with penicillin V 100 mg/kg/day po divided q 6 h.</div> <div>  <A NAME="a014_176_0718"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">For fungal <FONT SIZE="3" COLOR="#800000" FACE="Arial" >meningitis</FONT>, amphotericin B is the drug of choice for all fungi and yeasts. For adults, it is started with a 1-mg test dose, given by slow IV infusion and gradually increased as tolerated to <I>no more than 1 mg/kg/day</I> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">. A total of 2 to 6 g is usually given, but the optimal total dose is not known. For children, a test dose of amphotericin B 0.25 mg/kg IV is given in a 6-h infusion of 0.1 mg/mL in 5% D/W. The daily dosage is increased by 0.25 mg/kg to <I>no more than 1 mg/kg.</I> Amphotericin B need not be continued for > 10 wk if its blood level can be maintained at a concentration at least twice that needed to inhibit fungal growth in culture. Although hazardous, intraventricular (via Ommaya reservoir) amphotericin B is sometimes necessary to eradicate an infection (eg, coccidioidal <FONT SIZE="3" COLOR="#800000" FACE="Arial" >meningitis</FONT>).</div> <div>  <A NAME="a014_176_0719"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">For cryptococcal <FONT SIZE="3" COLOR="#800000" FACE="Arial" >meningitis</FONT>, the treatment of choice is amphotericin B 0.3 mg/kg plus flucytosine 150 mg/kg/day divided q 6 h for 6 wk. Fluconazole is also effective. It is less toxic, and oral and IV doses produce comparable peak plasma concentrations. When CSF has been sterile 2 wk after initiation of amphotericin and flucytosine, the patient can be switched to fluconazole 400 to 800 mg/day po (if renal function is normal) for at least 8 wk after the CSF became sterile. A maintenance dosage of 200 mg/day po can prevent relapses (eg, in AIDS patients). A small number of children > 3 yr old have been safely treated with 3 to 6 mg/kg/day, but efficacy has not been established. If cryptococcal <FONT SIZE="3" COLOR="#800000" FACE="Arial" >meningitis</FONT> is mild (as suggested by intact mental status, normal CSF pressure, and cryptococcal antigen < 1:1024), fluconazole 400 mg/day po can be given as monotherapy for 10 to 12 wk.</div> <div> <IMG SRC="07d32540.gif" border=0 width="562" height="340" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> </td> </tr></table></body>