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Meningitis in Children

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Overview

Meningitis is the inflammation of the meninges and bacterial meningitis is the inflammation of the meninges due to bacteria. 

Meningococcal meningitis is the inflammation of the meninges due to Neisseria meningitidis (the meningococcus) and meningococcal septicaemia refers to sepsis caused by Neisseria meningitidis.

All cases of suspected meningitis are bacterial until proven otherwise.

Bacterial meningitis most commonly affects children <2 years old due to their immune systems being immature. 

Causes

Bacterial causes

  • Neonates (<3 months):
  • Infants (3 months – 6 years):
    • Neisseria meningitidis
    • Streptococcus pneumoniae
    • Haemophilus influenzae
  • >6 years:
    • Neisseria meningitidis
    • Streptococcus pneumoniae

Risk Factors

  • Young age – meningitis and meningococcal disease are highest in children <2 years
  • Prematurity
  • Low birth weight

Presentation

Some children and young people may present with mostly non-specific signs and symptoms which may make it difficult to differentiate meningitis from other infections. If specific signs and symptoms are present, the patient is more likely to have bacterial meningitis or meningococcal septicaemia.

  • Non-specific features include:
  • Specific features include:
    • Non-blanching rash
      • May be more difficult to see in darker skin tones, check the palms, soles, and conjunctivae
    • Neck stiffness
    • Photophobia
    • Bulging fontanelle (if <2 years old)
    • Kernig’s sign
    • Brudzinski’s sign
    • Back rigidity
    • Features of shock:
      • Capillary refill time >2 seconds
      • Tachycardia and/or hypotension
      • Shortness of breath, breathing difficulty
      • Unusual skin colour
      • Leg pain
      • Cold hands and feet
      • Toxic/moribund state
      • Altered mental state, decreased conscious level, or unconsciousness
      • Poor urine output
    • Features of raised intracranial pressure:
      • Focal neurological deficits
      • Paresis
      • Seizures

Investigations

Referral in primary care

  • Immediate IM benzylpenicillin then emergency transfer to hospital via 999
    • Do not delay admission to hospital if antibiotics are not available immediately
    • Withhold IM benzylpenicillin if allergic

In secondary care

Escalate early and consult a senior paediatrician immediately if bacterial meningitis is suspected.

  • Blood cultures:
    • Ideally before giving antibiotics but do not delay treatment
  • Lumbar puncture (LP):
    • Ideally before antibiotics if the child is clinically stable but do not delay treatment and do not perform if contraindicated (see below)
    • Details on interpreting LP results can be found here.
  • Full blood count (FBC):
    • May show leukocytosis or neutropenia/thrombocytopenia if severe
  • C-reactive protein (CRP):
    • Non-specific marker of inflammation, may be elevated
  • Coagulation screen:
  • Blood glucose:
  • Blood gases:
    • May show features associated with septic shock including metabolic acidosis and raised lactate
  • Whole-blood polymerase chain reaction (PCR) for N. meningitidis:
    • May identify the presence of N. meningitidis
  • Urea and electrolytes (U&Es):
  • Liver function tests (LFTs):
    • May be deranged
  • Head CT:
    • To screen for alternate pathology if features of raised intracranial pressure are present (e.g. fluctuating consciousness or focal neurological deficits)

Lumbar puncture contraindications

Contraindications to a lumbar puncture (LP) include:

  • Features of meningococcal septicaemia:
    • Shock
    • Extensive or spreading purpura
  • Features of elevated intracranial pressure:
    • Focal neurological signs
    • Papilloedema
    • Unequal, dilated, or poorly responsive pupils 
    • Fluctuating/reduced consciousness (Glasgow coma score <9 or a drop of 3 or more)
    • Relative bradycardia and hypertension (Cushing’s reflex)
    • Abnormal posture or posturing
    • Abnormal dolls’ eye movements
    • Seizures until stabilised
  • Features of coagulopathy:
  • Local infection at the LP site
  • Respiratory insufficiency

A delayed LP may be performed once these contraindications are no longer present.

Lumbar Puncture Findings

Bacterial meningitis

  • CSF findings:
    • Colour: cloudy/turbid
    • Protein: elevated, >1.5g/L
    • Glucose: <50% of plasma glucose
    • White cell count: raised, mostly neutrophils
    • Opening pressure, usually raised

Viral meningitis

  • Clinical features may be identical
  • CSF findings:
    • Colour: clear
    • Protein: raised/upper limit of normal
    • Glucose: normal
    • White cell count: raised, mostly lymphocytes
    • Opening pressure: may be normal/raised

Encephalitis

  • Fever and altered behaviour, speech, or motor function suggest encephalitis
  • CSF findings may be the same as viral meningitis

Tuberculous meningitis

  • Pulmonary features of tuberculosis may be present e.g. cough/haemoptysis/weight loss 
  • CSF findings:
    • Colour: slightly cloudy, may have a fibrin web
    • Protein: elevated, usually much more than bacterial meningitis
    • Glucose: <50% of plasma glucose
    • White cell count: raised, mostly lymphocytes

Fungal meningitis

  • Patients may have HIV/other causes of immunodeficiency
  • CSF findings:
    • Colour: cloudy
    • Protein: protein
    • Glucose: <50%
    • White cell count: raised, mainly lymphocytes
    • Opening pressure: elevated
    • Other: India ink staining may be positive

Management

In the community

  • Immediate IM benzylpenicillin then emergency transfer to hospital via 999
    • Do not delay admission to hospital if antibiotics are not available immediately
    • Withhold IM benzylpenicillin if allergic

In hospital

  • 1st-line: initial empirical IV antibiotics while awaiting test results
    • <3 months: IV cefotaxime + IV amoxicillin/ampicillin
    • >3 months: IV cefotaxime/ceftriaxone
  • Corticosteroids not given in children <3 months but can be considered if an LP reveals:
    • Cerebrospinal fluid white cell count >1000/microlitre
    • Raised cerebrospinal fluid white blood cell count and protein concentration >1g/L
    • Frankly purulent cerebrospinal fluid
    • Bacteria present on Gram stain of cerebrospinal fluid

Confirmed viral meningitis

  • 1st-line: supportive care, some specialists may start aciclovir

All patients

  • Notify public health England – meningitis is a notifiable disease
  • Give prophylaxis to people who have had close contact within the last 7 days:
    • Options are oral ciprofloxacin or rifampicin

Monitoring

  • All children should be reviewed by a paediatrician 4-6 weeks after discharge
  • Give prophylaxis to people who have had close contact within the last 7 days:
    • Options are oral ciprofloxacin or rifampicin

Complications

  • Neurological complications:
    • Sensorineural hearing loss – most common
    • Seizures
    • Cognitive impairment
    • Motor deficits
    • Visual impairments
    • Focal neurological deficits
  • Septic shock
  • Intracerebral abscess
  • Increased intracranial pressure
  • Hydrocephalus
  • Brain abscess

Prognosis

  • Bacterial meningitis is one of the leading causes of infection-related death globally and in the UK
  • Viral meningitis has a better prognosis and usually completely resolves within 10 days
  • Up to 30% of children may develop complications 

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