Managing children with raised intracranial pressure: part one (introduction and meningitis)

Authors: Paul S, Smith J, Green J, Smith-Collins A, Chinthapalli R.

Intracranial pathologies in children need urgent identification and management. This article is presented in two parts, with part one describing intracranial pressure and outlining the features and management of meningitis. Part two, to be published in February 2014, outlines the features and management of brain tumours and intracranial bleeds. Each condition is accompanied by an illustrative case study to give an idea of what nurses might encounter in a child presenting with raised intracranial pressure.

Comparison of Clinical Features in Patients with Persistent and Nonpersistent Cryptococcal Meningitis: Twelve Years of Clinical Experience in Four Centers in China

Authors: Xu XG, Pan WH, Bi XL, Fang W, Chen M, Zhu Y, Zhou J, Zhou N, Pan B, Li M, Liao WQ, Qi ZT.

BACKGROUND and AIMS: Cryptococcal meningitis (CM) has gradually increased in the recent 20 years in the whole world. Although the mortality decreased significantly in recent years, it was still high, especially in patients with persistent infection. Therefore, we compare differences of clinical features between persistent and nonpersistent CM patients.
METHODS: We conducted a retrospective review of medical records of patients diagnosed with CM from January 2000 to December 2011 in four centers in China, including demographic features, underlying diseases, clinical presentations, laboratory data, and so on.
RESULTS: Of 106 CM patients enrolled, 16 were identified as persistent cases. Among all variables, persistent CM patients were more like to be human immunodeficiency viruses (HIV) infection (P < 0.05), stiff neck (P < 0.01), a serum hemoglobin < 90 g/L (P < 0.01), a serum potassium concentration <2.7 mg/L (P < 0.01), an intracranial pressure (ICP) >400 mmH2 O (P < 0.01), and a latex agglutination cryptococcal antigen titer of cerebrospinal fluid (CSF LACT) >1:1024 (P < 0.01) than nonpersistent ones. A multivariate analysis showed that HIV infection (OR 7.49), stiff neck (OR 11.7), a serum potassium <2.7 mmol/L (OR 9.45), and an ICP >400 mmH2 O (OR 6.83) were closely correlated with persistent CM.
CONCLUSIONS: Although it is difficult to deal with persistent CM nowadays, some cases could be predicted early enough in the future, so as to be treated appropriately and have relatively good outcomes.

Fever and bulging fontanelle mimicking meningitis in an infant diagnosed with benign intracranial hypertension

Authors: Goldberg EM.

A previously healthy 7-month-old male presented to the emergency department with fever and a bulging anterior fontanelle. A computed tomographic scan of the head suggested mild communicating hydrocephalus. Lumbar puncture was performed, which revealed a normal cerebrospinal fluid (CSF) cell count and glucose concentration, but a markedly elevated opening pressure. DNA polymerase chain reaction for herpes simplex virus performed on CSF was negative; CSF bacterial cultures were without growth. DNA polymerase chain reaction for human herpes virus 6 was strongly positive in serum. Fever and bulging fontanelle resolved within 24 hours. A presumptive diagnosis of transient intracranial hypertension of infancy was made, a form of benign idiopathic intracranial hypertension that mimics the presentation of serious intracranial pathology.

Clinical aspects of tuberculous meningitis in children

Authors: Caliman-Sturdza OA, Mihalache D, Luca CM, Dorobăţ C.

The aim of the study was to investigate the particularities of the clinical manifestation and evolution of tuberculous meningitis at children.

MATERIAL AND METHOD: The study was made between January 2000 and December 2008 in Clinic of Infectious Diseases IaSi and Emergency County Hospital ,,Sf. Ioan cel Nou" Suceava on a group of 169 children with tuberculous meningitis.

RESULTS: The majority (78.1%) of patients had poor socio-economic conditions and 22.4$ had a family TB contact. The onset of the symptoms was atypical in infants and small children with fever associated with digestive, neurological or pulmonary manifestations. The admission in hospital was delayed in 56.8% of patients and 39.05% had a severe general status with coma. The positive diagnosis was based on cytological and biochemical features of CSF, results of QuantilFERON. TB Gold, pulmonary images, family TB contact and evolution under anti-tuberculous therapy. We observed a high rate of complications represented by hydrocephaly (28.9%). 18 patients died (4 infants), the cause of dead being meningeal coma or complications.

CONCLUSION: The diagnosis of tuberculous meningitis at children remains a problem because of the atypical clinical manifestation, the delay of initiating the therapy causing high mortality and frequent complications.


Diagnostic accuracy of clinical symptoms and signs in children with meningitis

Authors: Amarilyo G, Alper A, Ben-Tov A, Grisaru-Soen G.

BACKGROUND: The diagnostic accuracy of the classic symptoms and signs of meningitis in infants and children has not been established.

METHODS: All children aged 2 months to 16 years with clinically suspected meningitis were eligible for this prospective cohort study at 2 large medical centers between February 2006 and October 2007. Exclusion criteria were severe chronic disease, severe immune deficiency, or idiopathic intracranial hypertension. The emergency department physician obtained information on clinical symptoms and signs and cerebrospinal fluid analysis. Meningitis was defined as white blood cell count of 6 or higher per microliter of cerebrospinal fluid.

RESULTS: A total of 108 patients with suspected meningitis were enrolled. Meningitis was diagnosed in 58 patients (53.7%; 6 bacterial and 52 aseptic). Sensitivity and specificity were 76% and 53% for headache (among the verbal patients) and 71% and 62% for vomiting, respectively. Photophobia was highly specific (88%) but had low sensitivity (28%). Clinical examination revealed nuchal rigidity (in patients without open fontanel) in 32 (65%) of the patients with meningitis and in 10 (33%) of the patients without meningitis. Brudzinski and Kernig signs were present in 51% and 27% of the patients with meningitis, respectively, and had relatively high positive predictive values (81% and 77%, respectively). Bulging fontanel in patients with open fontanel was present in 50% of the patients with meningitis but had a positive predictive value of only 38%.

CONCLUSIONS: Classic clinical diagnostic signs have limited value in establishing the diagnosis of meningitis in children and should not be the sole determinants for referral to further diagnostic testing and lumbar puncture.


Neurointensive care of patients with severe community-acquired meningitis

Authors: Edberg M, Furebring M, Sjölin J, Enblad P.

BACKGROUND: Reports about neurointensive care of severe community-acquired meningitis are few. The aims of this retrospective study were to review the acute clinical course, management and outcome in a series of bacterial meningitis patients receiving neurointensive care.

METHODS: Thirty patients (median age 51, range 1-81) admitted from a population of 2 million people during 7 years were studied. The neurointensive care protocol included escalated stepwise treatment with mild hyperventilation, cerebrospinal fluid (CSF) drainage, continuous thiopentotal infusion and decompressive craniectomy. Clinical outcome was assessed using the Glasgow outcome scale.

RESULTS: Twenty-eight patients did not respond to commands on arrival, five were non-reacting and five had dilated pupils. Twenty-two patients had positive CSF cultures: Streptococcus pneumoniae (n=18), Neisseria meningitidis (n=2), β-streptococcus group A (n=1) and Staphylococcus aureus (n=1). Thirty-five patients were mechanically ventilated. Intracranial pressure (ICP) was monitored in 28 patients (intraventricular catheter=26, intracerebral transducers=2). CSF was drained in 15 patients. Three patients received thiopentothal. Increased ICP (>20 mmHg) was observed in 7/26 patients with available ICP data. Six patients died during neurointensive care: total brain infarction (n=4), cardiac arrest (n=1) and treatment withdrawal (n=1). Seven patients died after discharge, three due to meningitis complications. At follow-up, 14 patients showed good recovery, six moderate disability, two severe disability and 13 were dead.

CONCLUSION: Patients judged to have severe meningitis should be admitted to neurointensive care units without delay for ICP monitoring and management according to modern neurointensive care principles.



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