Meningitis in Children - I.V. Bohadelnikov 2005

Secondary purulent meningitis in children. General data
Features of purulent meningitis in newborns and infants

Diagnosing Purulent meningitis in newborns and infants under one year of age is often challenging due to the atypical Clinical presentation of the disease in this age group. The Main Features of purulent meningitis in infants include:

1. The clinical picture is invariably dominated by manifestations of infectious-toxic syndrome, while other syndromes may be absent, appear later, or be poorly expressed.

2. In some infants, the disease has an acute onset—often presenting as a fulminant form—runs a severe course, and immediately manifests as meningoencephalitis: with seizures, impaired consciousness, tremor of the limbs and chin, focal symptoms (strabismus, facial Muscle paresis, constricted pupils), and somnolence progressing to stupor.

3. Meningitis does not always have an acute onset. Often, the onset is not sudden but gradual, accompanied by normal or subfebrile body Temperature, which, however, does not rule out a purulent process in the CNS.

4. The disease frequently begins with tonic-clonic seizures, followed by other symptoms. Notably, the younger the child, the more frequent the seizures. A sharp fluctuation between somnolence and agitation is characteristic. The infant startles during Sleep and often cries out. Headache may manifest as frowning, or rubbing the HEAD against the pillow. Frequently, despite their severe condition, infants can actively suckle at the breast, and anorexia is almost entirely absent.

5. Distinctive Clinical Features of purulent meningitis in this age group include The high frequency of infectious-toxic Shock, Waterhouse-Friderichsen syndrome, acute cerebral edema and Swelling, meningoencephalitis, and ependymitis.

6. Meningeal syndrome is usually incomplete and mild due to the underdevelopment of the Pyramidal Tracts. Nuchal rigidity is the most consistent symptom, though it is frequently absent as well. Kernig's sign is inconsistent and represents a physiological finding in infants under three months of age. Brudzinski's sign is observed relatively rarely. Flatau's sign (pupillary dilation upon rapid forward flexion of the head) and Leschchyshyn's (or Lessage) suspension sign are of great diagnostic significance: when an infant held suspended under the axillae flexes their legs at the knee and hip joints and maintains this flexion for a prolonged period. By contrast, a healthy infant freely flexes and extends their legs.

7. A constant sign in infants during their first year of life is marked hyperesthesia (tactile, visual, and auditory). This becomes evident when picking the child up, breastfeeding, placing them on a potty, or changing their clothes (the "mother's hands" and "potty" signs, among others).

8. Intracranial Hypertension in infants is less pronounced compared to older children. Furthermore, the instability and lability of Water-electrolyte METABOLISM in this specific age group account for the frequent occurrence of hypotensive forms of meningitis. Frequently, the only sign of hypertension is the condition of the fontanelle, which is best assessed during sleep: bulging, tension of the large fontanelle, and the absence of pulsation. However, this is not a 100% reliable sign, as it may be absent in malnutrition (hypotrophy), dehydration associated with frequent and profuse vomiting, and—crucially—failure to restore fluid losses or the irrational use of Diuretics. Headache manifests as sudden, seemingly causeless crying spells, most often at night ("hydrocephalic cry"), and restlessness.

9. Tendon Reflexes are usually brisk, but may also be depressed. The disappearance of abdominal and cremasteric reflexes, along with the presence of red dermographism, is frequently observed.

Expansion of reflexogenic zones is possible, where eliciting a reflex on one side provokes a response on the contralateral side. Occasionally, pyramidal signs appear in the form of hyperreflexia, Babinski's sign, Oppenheim's sign, Gordon's sign, or ankle clonus.

10. One of the Specific features of meningitis in infants is the clinical form characterized by CSF hypotension syndrome. It develops when an infant experiences incessant vomiting, frequent watery diarrhea, and—most importantly—inadequate replenishment of these losses through oral rehydration and intravenous fluid administration. In such cases, profound dehydration is observed, accompanied by sharpened facial features, dry mucous membranes, sinking of the large fontanelle, and decreased tissue turgor; stupor develops, and tonic-clonic seizures may occur. Meningeal signs fade. Lumbar puncture reveals turbid CSF that emerges in slow drops under zero pressure, sometimes requiring aspiration. Frequently, following rehydration measures, alongside the disappearance of exicosis symptoms, typical signs of meningitis appear (nuchal rigidity, bulging of the large fontanelle, etc.). The course of hypotensive meningitis is malignant, with a lethality rate reaching 50%. However, this is driven not by any intrinsic fatality of the hypotensive form, but typically by delayed Diagnosis (later than the 5th day of illness) and inadequate Treatment (unsuccessful lumbar puncture, misinterpretation of CSF findings, overly cautious intensive therapy, failure to use endolumbral antibiotic administration, and incorrect antibiotic Selection).

11. Recovery in infants is slower; improvement in general condition and CSF sanitation occur later than in older children, and residual effects such as paresis, paralysis, and Inner ear damage are more common. Secondary bacterial flora frequently supervenes, leading to The Development of otitis media or Pneumonia.

12. Late diagnosis—and consequently, delayed initiation of treatment—is another characteristic feature of meningitis in infants. This occurs because the primary focus of parents and physicians is usually drawn not to neurological disorders, but to upper respiratory catarrhal symptoms, Skin changes (rashes), and gastrointestinal dysfunction (poor appetite, vomiting, frequent loose stools), which frequently accompany meningitis. These symptoms typically misdirect the clinician, so that suspicion of meningitis usually arises only on the 3rd or 4th day of illness, or even later, which is completely unacceptable for this condition. Under these circumstances, lumbar puncture acquires exceptional diagnostic value. The guiding principle must be: "The younger the child, the broader the indications for lumbar puncture." In clinical practice, it is appropriate to be guided by symptoms that mandate a lumbar puncture: the presence of even mildly expressed meningeal signs; the development of focal CNS symptoms (cranial nerve palsies, paresis, a "blank" stare, strabismus, constricted pupils, anisocoria); persistent bulging or tension of the large fontanelle; unexplained, newly onset seizures; loss of consciousness against the Background of infectious-toxic syndrome; hyperthermia and toxemia lasting for 3 days with an unestablished Etiology; persistent, recurrent projectile vomiting accompanied by high fever in the absence of diarrheal syndrome; muscular hypertonia, startling, and tremor of the limbs or chin in the presence of fever; hyperthermia combined with restlessness, crying, or lethargy, somnolence, and hyperesthesia; purulent otitis media with prolonged fever unresponsive to therapy; and severe toxemia without a clearly defined local focus, showing no response to ongoing treatment.

A lumbar puncture in children must be preceded by a thorough clinical examination, consultations with an ENT specialist, neurologist, ophthalmologist, and—if necessary—a neurosurgeon and hematologist, as well as minimal Laboratory tests: a complete Blood count and urinalysis. However, the unavailability of consultants is never a justification for postponing a lumbar puncture. If meningitis is suspected, lumbar puncture under no circumstances can be postponed "until tomorrow" or "until morning."