Meningitis in Children - I.V. Bohadelnikov 2005

Secondary purulent meningitis in children. General data
Purulent meningitis in ENT diseases

Secondary Purulent meningitis may develop in the course of acute or exacerbated chronic ENT conditions, such as otitis media and sinusitis, and can also be associated with other intracranial complications of otogenic origin. The causative agents of otogenic or sinusogenic purulent meningitis include streptococci, pneumococci, staphylococci, Escherichia coli, and others. The infection invades the Meninges either by direct contact or via the segmental vascular route. Labyrinthogenic and tympanogenic meningitis are distinguished. In the former case, the inflammatory process spreads from the Middle ear to the Inner ear, and subsequently reaches the subarachnoid space through the internal acoustic meatus. The tympanogenic pathway of infection spread runs through gaps in the tegmen tympani that serve for the passage of Blood Vessels. Newly formed connections between the middle ear cavity, Paranasal Sinuses, and the meninges resulting from purulent bone resorption also play a significant role in the onset of meningitis.

The Clinical presentation of purulent meningitis secondary to acute purulent otitis media develops rapidly: severe headache appears suddenly, body Temperature rises to 39°–40 °C, accompanied by persistent vomiting and loss of consciousness. At the same time, pronounced meningeal syndrome becomes evident. Occasionally, papilledema can be detected as early as the first hours of meningitis development. CEREBROSPINAL FLUID (CSF) analysis reveals pleocytosis (2–7 thousand per 1 µl or more) due to neutrophils, an elevated protein content of up to 5 g/l, and a decreased glucose level.

Without timely and adequate Treatment, a fatal outcome may occur within 24–48 hours.

Meningitis resulting from the Exacerbation of chronic otitis or sinusitis has a more gradual onset. Headaches appear long before the inflammation of the Brain membranes. Body temperature is more often low-grade (subfebrile), and vomiting is infrequent. Among the meningeal signs, nuchal rigidity appears earlier and is more pronounced, while Kernig's and Brudzinski's signs emerge later. Focal neurological signs are sometimes observed.

Key diagnostic criteria for purulent meningitis in ENT diseases:

1. Epidemilogical history: presence of acute otitis/sinusitis or an exacerbation of chronic otitis/sinusitis; older children are more frequently affected.

2. The acuteness of meningitis onset directly depends on the severity of the ENT pathology: a fulminant onset in acute purulent otitis or sinusitis, and a more gradual course during the exacerbation of a chronic condition.

3. The severity of the meningeal syndrome also depends on the acuteness of the otogenic or sinusogenic disease.

4. The outcome of meningitis is directly related to the promptness of therapeutic and surgical intervention.

5. CSF examination and bacteriological Isolation of the pathogen are of decisive diagnostic importance, as they confirm the Etiology of the disease.

Concluding the Analysis of the clinical manifestations of the most common secondary purulent meningitides, several characteristic features common to them regardless of etiology should be noted:

- they occur in Sepsis of any etiology on the 5th–10th day of the illness;

- they proceed with a pronounced general Intoxication syndrome: high body temperature, lethargy, adynamia alternating with periodic agitation, pallor of the Skin, hepatosplenomegaly, and a hemorrhagic rash;

- there is always a clear, consistent development of meningeal and hypertensive syndromes;

- frequent involvement of the brain parenchyma in the pathological process, leading to meningoencephalitis with pronounced focal signs;

- cranial nerve palsies are not uncommon, most frequently affecting the oculomotor nerves;

- a high mortality rate (20–40% or more) and persistent residual neurological complications in surviving children.

A high index of suspicion on the part of the physician, timely lumbar puncture, and cytological, biochemical, and bacteriological analysis of the CSF are of critical importance for the Diagnosis of Secondary purulent meningitis.