Shake…Shake….

Shake

Neurology Module
PEDIATRICS II
Salient Points:
ES, 16 months old, admitted
because of convulsions
Five days PTA  cough and fever
Two days later  grand mal
seizures for 10 minutes
Birth, neonatal, developmental
history unremarkable
First attack of febrile seizures at 6
months of age
Father and cousins with febrile
seizures
Salient Points:

Pertinent Physical
Examination Findings:
Febrile, awake, with mild dehydration
Congested pharyngeal wall, no
exudates, (+) crackles on both lungs
Neurological Examination
Findings:
Essentially normal
No meningeal signs
Is there a neurologic
disease?
The description of event
appears to be a seizure.
Seizures refer to excessive
neuronal
discharge with change in
motor activity or behavior.
Is there a neurologic
disease?
Causes of
seizure:
Non-neurologic Neurologic
Metabolic Tumors
disorders CNS malformation
Electrolyte Vascular disorders
imbalance Idiopathic epilepsy
Hypoglycemia
Hypoxia
Fever
Systemic infections
Toxins
Drug-related
What is the neurologic
disease?
In this patient, the seizures are ushered in
by fever
and respiratory infection.

Benign Febrile Seizures should be

ruled out.
The typical benign FS is characterized
by:
1. Grand mal lasting for <15 min
2. Occurring once in the same illness
3. Age incidence: 3 months to 5 years
4. Occurs at temperature 380 C and
Complex Febrile
Seizure
Atypical - May occur more than
once in an illness, focal
seizure, more than15
minutes
May need investigation to rule
out
epilepsy
With focal manifestations
Diagnostic
possibilities:
Benign febrile seizures
In the presence of fever,
pneumonia and seizure, a CNS
infection should be
considered.
An infant may not show any
meningeal signs even in the
presence of meningitis.
Management of BFC:

Search for cause of fever

No anticonvulsants needed
Antipyretics
Education of parents
Oral diazepam at onset of
febrile episode (1 mg/kg/24
hrs) for 2-3
days
Laboratory Tests:
Not necessary if clear-cut BFC
Tests mainly to determine
cause of fever and rule out
meningitis
If done, CSF examination is
normal
EEG - Normal and not useful in
BFC
Neuroimaging - No role
Blood tests / chest X-ray, etc
Diagnosis:

Tests are usually directed

towards ruling out meningitis
especially in infants where
meningeal signs are often
lacking.
Do lumbar puncture and CSF
examination
Patient E.S.

While in the hospital, he

developed another seizure.
Fever persisted. On
examination, he was ill-
looking, irritable, with some
resistance on neck flexion.
Differential Diagnosis:
Fever with Seizures

CNS Infections
CNS Infections

Etiology
Forms: Viral
Meningitis Bacterial (Acute
Suppurative)
Encephalitis
Tuberculous
Brain Abscess Fungal
Acute Meningitis-
Causes:
Bacterial
0 - 2 months: Grp B and D strep
gram-negative enteric
bacilli
Listeria
2 mo – 2 yrs: S. pneumoniae
N. meningitis
H. influenza B
Older children: S. pneumoniae
N. meningitides
Bacterial Meningitis

Acute
Route of Infection
Hematogenous
Contiguous focus of infection
CSF leak (trauma, congenital
defect)
Neurosurgical procedure
Clinical Features:
Signs and Neonates Older infants and children
symptoms
Nonspecific Fever or hypothermia, Fever, anorexia, confusion,
abnormally sleepy or irritability, photophobia,
lethargic, disinterest in nausea, vomiting,
feeding, poor feeding, headache, seizure
cyanosis, grunting, apneic
episodes, vomiting
Meningeal +/- Neck rigidity Neck rigidity, Kernig and
inflammation Brudzinski sign
Increased Bulging fontanel, diastasis of Headache, bulging fontanel,
intracranial sutures, convulsions, diastasis of sutures in
pressure opisthotonus infants, papilledema, mental
confusion, altered state of
consciousness
Focal Hemiparesis, ptosis, facial Hemiparesis, ptosis,
neurologic nerve palsy deafness, facial nerve palsy,
signs optic neuritis
Laboratory Diagnosis:

1.Lumbar Puncture
Contraindications
Skin infection over site
Increased ICP with papilledema
Focal neurologic deficits
Suspected mass lesion
Hematologic problems
Significant cardiopulmonary
compromise and shock
 Pressure Cell Count Glucose Protein
CSF (mm H20) (white blood (mg/100 ml) (mg/100 ml)
Findings cells/mm3)

Normal values 90-180 0-5 lymphocytes 50-75 (at least 15-40

50% of
simultaneous
serum glucose)
Bacterial meningitis 200-300 100-5,000; neutrophils Reduced, < 40 100-1,000
usually >80%
Tuberculous meningitis 180-300 Usually < 500 Reduced, < 40 100-200, but
lymphocytes up to 1,000 if
CSF block is
present
Cryptococcal meningitis 180-300 10-200 lymphocytes Reduced, <40 50-200

Viral meningitis 90-200 10-300 lymphocytes; Normal; 50-100

may be >1,000 in occasionally
echoviral and mumps slightly reduced
meningitis and in in mumps
lymphocytic meningitis and
choriomeningitis; early LCM
echoviral meningitis
may show up to 80%
neutrophilic
predominance

Viral encephalitis 180-300 0-500 lymphocytes Normal 50-100

Laboratory Diagnosis:
2. Neuroimaging

Contrast enhanced CT image Subdural effusion, cerebritis

of a 3-month-old baby brain and developing abscess
show brain edema and formation in a patient with
subdural empyema bacterial meningitis
Patient’s laboratory
results:
CSF Analysis:
Clear, colorless fluid
OP 130
WBC = 320/cumm, all neutrophils
RBC = 0
Protein = 90
Sugar = 40% of blood sugar
Gram stain = (+) gram-negative coccobacilli
Culture (-)
CBC:
Hgb 11, RBC 4.3, WBC 12,000 with lymphocytic
predominance
Diagnosis:

Acute Bacterial Meningitis

(Hemophilus)
Pneumonia
Treatment:
Bacterial meningitis is a medical
emergency; delay in treatment
may lead to increased sequelae or
death
Drug of choice must be
bactericidal for pathogen involved
Must achieve adequate levels in
the CSF
Initial regimen should cover most
likely pathogens for specific age
groups, and reach bactericidal
levels in the CSF
Treatment:

Knowledge of local susceptibility

patterns is essential
Antibiotics should be guided by
the bacteriologic results
Duration of treatment: 10 -14
days
Empiric Therapy for
Bacterial Meningitis:
Patient Likely etiology Antimicrobial choice
group
Primary Alternative
0-2 mos E. coli Ampicillin or Ampicillin +
Gram (-) bacilli Penicillin + Cefotaxime or
Aminoglycoside Ceftriaxone
S. pneumoniae
2mos – 5 yrs H. influenzae Ampicillin or Cefotaxime or
S. pneumoniae Chloramphenico Ceftriaxone
l
N. meningitidis
>5 yrs S. pneumoniae Penicillin G Chloramphenico
N. meningitidis l

Task Force on Meningitis

Philippine Society of Microbiology and Infectious Diseases
Tuberculous
Meningitis
Subacute to chronic
Staging of symptoms
Stage I: early nonspecific
Stage II: altered consciousness, minor focal
signs, meningism, abnormal involuntary
movements
Stage III: stupor or coma, seizures, severe
neurologic deficits and/or abnormal
movements
Prognosis is related directly to
the clinical stage of diagnosis
 Pressure Cell Count Glucose Protein
CSF (mm H20) (white blood (mg/100 ml) (mg/100 ml)
Findings cells/mm3)

Normal values 90-180 0-5 lymphocytes 50-75 (at least 15-40

50% of
simultaneous
serum glucose)
Bacterial meningitis 200-300 100-5,000; neutrophils Reduced, < 40 100-1,000
usually >80%
Tuberculous meningitis 180-300 Usually < 500 Reduced, < 40 100-200, but
lymphocytes up to 1,000 if
CSF block is
present
Cryptococcal 180-300 10-200 lymphocytes Reduced, <40 50-200
meningitis
Viral meningitis 90-200 10-300 lymphocytes; Normal; 50-100
may be >1,000 in occasionally
echoviral and mumps slightly reduced
meningitis and in in mumps
lymphocytic meningitis and
choriomeningitis; early LCM
echoviral meningitis
may show up to 80%
neutrophilic
predominance

Viral encephalitis 180-300 0-500 lymphocytes Normal 50-100

Late Neurologic
Sequelae:

Visual impairment
Strabismus
Hearing loss or impairment
Locomotion/neuromotor deficits
Epilepsy
Mental or psychomotor retardation
Hydrocephalus
Microcephaly
Hydrocephalu
s
 Microcephaly

Cerebral Atrophy
Viral Meningitis

Majority due to enteroviruses

Higher incidence during summer to fall
months
Other viruses associated with meningitis in
children:
HSV types 1 and 2
Mumps
Adenoviruses
Polioviruses
Lymphocytic choriomeningitis virus
Epstein-Barr virus
HIV
St. Louis encephalitis virus
Tick-borne encephalitis virus
 Pressure Cell Count Glucose Protein
CSF (mm H20) (white blood (mg/100 ml) (mg/100 ml)
Findings cells/mm3)
Normal values 90-180 0-5 lymphocytes 50-75 (at least 50% 15-40
of simultaneous
serum glucose)
Bacterial meningitis 200-300 100-5,000; neutrophils Reduced, < 40 100-1,000
usually >80%
Tuberculous meningitis 180-300 Usually < 500 Reduced, < 40 100-200, but up
lymphocytes to 1,000 if CSF
block is present
Cryptococcal meningitis 180-300 10-200 lymphocytes Reduced, <40 50-200

Viral meningitis 90-200 10-300 lymphocytes; may Normal; 50-100

be >1,000 in echoviral and occasionally
mumps meningitis and in slightly reduced in
lymphocytic mumps meningitis
choriomeningitis; early and LCM
echoviral meningitis may
show up to 80%
neutrophilic predominance

Viral encephalitis 180-300 0-500 lymphocytes Normal 50-100

Viral Meningitis

Management:
– No specific antiviral therapy
necessary
– Treatment is supportive with IV
fluids
– Outcome is usually a full recovery
Viral Encephalitis

Distinguished from viral meningitis by

the extent and severity of cerebral
dysfunction
Two clinical presentations:
Fever and malaise without meningeal
signs
With meningeal signs plus cerebral
dysfunction (altered consciousness,
personality changes, seizures, and
paresis) and cranial nerve
abnormalities
Viral Encephalitis

Causes:
Epidemic
Arbovirus
Poliovirus
Echovirus
Coxsakie virus
Sporadic
Herpes simplex
Varicella-Zoster
Mumps
 Pressure Cell Count Glucose Protein
CSF (mm H20) (white blood (mg/100 ml) (mg/100 ml)
Findings cells/mm3)

Normal values 90-180 0-5 lymphocytes 50-75 (at least 15-40

50% of
simultaneous
serum glucose)
Bacterial meningitis 200-300 100-5,000; neutrophils Reduced, < 40 100-1,000
usually >80%
Tuberculous meningitis 180-300 Usually < 500 Reduced, < 40 100-200, but
lymphocytes up to 1,000 if
CSF block is
present
Cryptococcal meningitis 180-300 10-200 lymphocytes Reduced, <40 50-200

Viral meningitis 90-200 10-300 lymphocytes; Normal; 50-100

may be >1,000 in occasionally
echoviral and mumps slightly reduced in
meningitis and in mumps meningitis
lymphocytic and LCM
choriomeningitis; early
echoviral meningitis
may show up to 80%
neutrophilic
predominance
Viral encephalitis 180-300 0-500 lymphocytes Normal 50-100
Viral Encephalitis

Treatment:
Acyclovir 10 mg/kg IV infusion every 8
hours for at least 10 days
Supportive therapy
Prognosis:
Mortality rate varies with etiology
Permanent cerebral sequelae more
likely in infants
Thank
you!