case report

Serous meningitis
by :
Ira Mendrofa Astinal Eka sari 080100005 080100009

Supervisor : dr. H. Hakimi, Sp.A(K)

Department of Pediatrics H. Adam Malik General Hospital Faculty of Medicine North Sumatera University Medan 2012

INTRODUCTION
Incidence of bacterial meningitis infection in Indonesia

is not known with certainty. In the U.S. in 1994, found as many as 8.7 cases per 100,000 pediatric patients under 5 years old, and 2.2 cases per 100,000 patients over the age of 5 years. According to data from the Hospital Surabaya Dr.Soetomo year 1986-1992 is estimated incidence of infection of 60-80 cases per year. In Jakarta in 1980, found meningitis infection in 1.9% of inpatients

DEFINITION

SEROUS MENINGITIS

inflammation of the arachnoid lining of the brain and often caused by specific bacteria such as Mycobacterium tuberculosa

Etiology
New born Group B streptococci Escherichia coli K1 and other gram negative enteric bacilli. Listeria monocytogenes Enterococci S. pneumonie Neisseria meningitis H. Influenza type b

Infants and children

Children older than 5 years

S. pneumonie N. meningitis

Pathogenesis
causative agent The invasion of the CNS through the bloodstream Migrate to the subarachnoid layer

Inflammatory response in piamater, arachnoid, cerebrospinal fluid, and ventricular

Cont....
Exudate spreads across the cranial nerves and spinal nerves

neurological damage

Risk Factors
Male gender. Premature babies and low birth weight (LBW) Processes that allow the infection during pregnancy and birth,

for example premature rupture of membranes (PROM), parturition length, and infections in the last trimester of pregnancy. Low leukocyte bactericidal activity, serum complement deficiency, low properdin serum, low concentrations of IgM and IgA in the infant's body. IGA congenital deficiency, IgG, and IgM in infants. Malignancy in the RES system, leukemia, multiple myeloma, lymphoma, which led to decrease in immunoglobulin production, making it easier to infection. Antibiotics, radiation, and immunosuppressants.

Clinical Symptom
Fever

Headache

Lose consiusness

Vomiting

Photophobia

Clinical Symptom
Neck stiffness

Brudzinskis signs

Confusion

Kernigs sign

Diagnosis
Anamnesis : prodromal symptoms of

headache, anorexia, nausea / vomiting, fever subfebris, accompanied by behavioral changes and impairment of consciousness, sub-acute onset, a history of TB or a focus of infection is very supportive Physical examination : Examination of meningeal stimulation with a stiff neck examination. In patients with meningitis usually have a stiff neck in a positive

Differential Diagnosis
Aseptic meningitis

Tuberculous meningitis
Brain abscess Brain tumor Meningismus Lead encephalatomy

Treatment
Age <1 month of : Ampicillin (50-100 mg / kg every 6

hours) + gentamicin (2-5 mg / kg every 8 hours), or cefotaxime (50 mg / kg every 6-8 hours) can be used in patients with suspected gram-negative bacilli. Age 1-3 months : Ampicillin (50-100 mg / kg every 6 hours + cefotaxim (75 mg / kg every 6-8 hours) or ceftriaxone (50 mg / kg every 12 hours) or vancomycin (15 mg / kg every 6 hours) can be added in patients with suspected meningitis pneumococus (eg gram staining). Ages 3 months-21 years : cefotaxime (75 mg / kg every 6-8 hours, maximum 2 g per day) or ceftriaxone (50 mg / kg every 12 hours, maximum of 4 g per day) + vancomycin (15 mg / kg every 6 hours, maximum 1 g per day), or rifampicin (10 mg / kg every 12 hours, maximum 600 mg per day) may consider granting dexametason.

Prognosis
Meningitis patients with decreased consciousness

and seizures have an increased risk of neurological impairment or death Poor prognosis occurs in patients with cerebral infarction, cerebral edema, Dissemenated intravascular coagulation, and endotoxic shock

OBJECTIVE

To report a case of Serous Meningitis in a 2 years 11 month old boy

Boy

2 years 11 month old boy

11 kg

95 cm

FY

March 1st 2012

Loss Lonsiusn ess

Infection Unit Pediatric Dept RSHAM

experienced since 1 day before admitted

Anamnesis
Fever has been found since 2 days ago Is a high fever, fever up and down and recovered

with a febrifuge Headaches since 2 weeks ago Vomiting since 2 weeks ago, with a frequency of 1-2 times / day Cough with phlegm since 2 weeks ago, a history of contact with an infected person coughs old grandmother Rigid body experienced by patients from 1 day ago

Physical Examination
Sens: soporocoma (GCS5E1V1M3), BW= 11 Kg, BL= 95 cm, BW/BL= 78,5%, Temp. = 37,90C Anemic (-), edema (-), cyanosis (-), icteric (-), dyspnoe (+) Head : Eye: Light reflexes (+/+), isochoric pupil, pale inferior conj. palpebra (-/-) Edema palpebra (-/-). Nose: nasal flare (+), E/M : N Neck : Lymph node enlargement (-)

Physical Examination
Thorax : Symmetrical fusiform, retraction (-), HR= 100 bpm, regular, murmur (-), RR= 26 bpm, regular, ronchi (-/-)

Abdominal : Soepel, peristaltic (+), liver and spleen not palpable

Extremities : Pulse =100 bpm, regular, adequate pressure/volume, CFT <3, warm, Physiological reflex : APR/KPR : +/+; Pathological reflex :Babinsky (+/+), Oppenheim (+/+), Chaddock (+/+), Gordon (+/+); Meningeal Refleks : + .

Diagnosis
Working Diagnosis:

Encephalitis
Differential Diagnosis:

Encephalitis
Meningitis Meningoencephalitis

Management
O2 1/2-1 L/i

IVFD D5% NaCl 0,9% 32 gtt/i micro

Inj. Cefotaxime 500 mg/12 hour IV Inj. Ampicillin 600 mg/6 hour IV Paracetamol 3x150 mg Diazepam 5,5 mg if needed Diet SV 1260 kcal with 30 gram protein

CT-SCAN
Appear hypodense lesion in the right posterior horn of the lateral periventrikel / lobe occipitalis. Visible dilatation of the lateral ventricles, third ventricle, IV ventricle. Sulci, gyri and fissures good Sylvii Falx middle cerebral Differentiation of both gray and white Satter Sisterna magna prominent Both intact ocular bulbus. Both ethmoid sinuses. Other paranasalis sinus has not been established

Follow Up March 2nd 2012

Subjective
Loss consiusness (+)

Objective
Sens: sopocoma (GCS5 E1V1M5), Temp: 36oC Body weight: 11 kg, Body length: 95 cm, BW/BL: 78,5% Head : Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear and Mouth: within normal limit; Nose: nasal flare (+) Neck : Lymph node enlargement (+) o/t regio colli the left and right, mobile, no tenderness Thorax : Symmetrical fusiform , retraction (-), HR: 150 bpm, regular, murmur (-) RR : 30 bpm, regular, ronchi (-/-) Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargement Extremities : Pols : 150 bpm, regular, adequate pressure/volume, CFT<3, warm Genital : Male, within normal limit

Assessment
DD :

Planning/Treatment

Encephalitis - Meningitis Meningoenc ephalitis

O2 1/2-1 L/i IVFD D5% NaCl 0,9% 32 gtt/i micro Inj. Cefotaxime 500 mg/12 hour IV Inj. Ampicillin 600 mg/6 hour IV Paracetamol 3x150 mg Diazepam 5,5 mg if needed Diet SV 1260 kcal with 30 gram protein

Follow Up March 3rd 2012

Subjective
Loss consiusness (+) Fever (+)

Objective
Sens: sopocoma (GCS5 E1V1M5), Temp: 38oC Body weight: 11 kg, Body length: 95 cm, Head : Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear: cerumen prop; Mouth: within normal limit; Nose: nasal flare Neck : Lymph node enlargement (+) o/t regio colli the left and right, mobile, no tenderness Thorax : Symmetrical fusiform , retraction (-), HR: 120 bpm, regular, murmur (-) RR : 28 bpm, regular, ronchi (-/-) Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargement Extremities : Pols : 120 bpm, regular, adequate pressure/volume, CFT<3, warm Genital : Male, within normal limit

Assessment
DD : - Encephalitis - Meningitis Meningoencep halitis -OMSK Dextra

Planning/Treatment

O2 1/2-1 L/i IVFD D5% NaCl 0,9% 32 gtt/i micro Inj. Cefotaxime 500 mg/12 hour IV Inj. Ampicillin 600 mg/6 hour IV Paracetamol 3x150 mg Diet SV 1260 kcal with 30 gram protein Diazepam 5,5 mg if needed Inj. Phenitoin MD 30mg/12 hour IV (in 20 cc NaCl 0,9%, out in 20 minutes) Suction Reguler

Follow Up March 4th - 5th 2012

Subjective Loss consiusness (+) Fever (+) Objective Sens: sopocoma (GCS9 E4V2M3), Temp: 38oC Body weight: 11 kg, Body length: 95 cm, Head : Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear: cerumen prop; Mouth: within normal limit; Nose: nasal flare Neck : Lymph node enlargement (+) o/t regio colli the left and right, mobile, no tenderness Thorax : Symmetrical fusiform , retraction (-), HR: 120 bpm, regular, murmur (-) RR : 36 bpm, regular, ronchi (-/-) Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargement Extremities : Pols : 120 bpm, regular, adequate pressure/volume, CFT<3, warm Genital : Male, within normal limit Assessment DD : - Encephalitis - Meningitis Meningoencepha litis -OMSK Dextra Planning/Treatment

Laboratory Finding : Gastric fluid : Enterobacter aerogenes

O2 1/2-1 L/i IVFD D5% NaCl 0,9% 32 gtt/i micro Inj. Cefotaxime 500 mg/12 hour IV Inj. Ampicillin 600 mg/6 hour IV Paracetamol 3x150 mg Diet SV 1260 kcal with 30 gram protein Diazepam 5,5 mg if needed Inj. Phenitoin MD 30mg/12 hour IV (in 20 cc NaCl 0,9%, out in 20 minutes) Suction Reguler

Follow Up March 6th - 7th 2012

Subjective Loss consiusness (+) Fever (+) Objective Sens: sopocoma (GCS9 E4V2M3), Temp: 37,7oC Body weight: 11 kg, Body length: 95 cm, Head : Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear: cerumen prop; Mouth: within normal limit; Nose: nasal flare Neck : Lymph node enlargement (+) o/t regio colli the left and right, mobile, no tenderness Thorax : Symmetrical fusiform , retraction (-), HR: 100 bpm, regular, murmur (-) RR : 32 bpm, regular, ronchi (-/-) Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargement Extremities : Pols : 100 bpm, regular, adequate pressure/volume, CFT<3, warm Genital : Male, within normal limit Assessment DD : - Encephalitis - Meningitis Meningoencepha litis -OMSK Dextra -Susp. TB paru Planning/Treatment

Laboratory Finding : Gastric fluid : Enterobacter aerogenes

O2 1/2-1 L/i IVFD D5% NaCl 0,9% 32 gtt/i micro Inj. Cefotaxime 500 mg/12 hour IV Inj. Ampicillin 600 mg/6 hour IV Paracetamol 3x150 mg Diet SV 1260 kcal with 30 gram protein Diazepam 5,5 mg if needed Inj. Phenitoin MD 30mg/12 hour IV (in 20 cc NaCl 0,9%, out in 20 minutes) Suction Reguler

Follow Up March 8th 2012

Subjective
Loss consiusness (+) Fever (+)

Objective
Sens: sopocoma (GCS9 E4V2M3), Temp: 38oC Body weight: 11 kg, Body length: 95 cm, Head : Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear: cerumen prop; Mouth: within normal limit; Nose: nasal flare Neck : Lymph node enlargement (+) o/t regio colli the left and right, mobile, no tenderness Thorax : Symmetrical fusiform , retraction (-), HR: 106 bpm, regular, murmur (-) RR : 30 bpm, regular, ronchi (-/-) Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargement Extremities : Pols : 106 bpm, regular, adequate pressure/volume, CFT<3, warm Genital : Male, within normal limit Laboratory Finding : Hb/Ht/WBC/PLT 9.40% / 28.50% / 12.75 103/mm3 / 536 103/mm3 Eletrolit Ca/Na/K/Cl/Mg 7.8/121/4.1/94/2.10

Assessment
Serous meningitis + Susp. TB paru

Planning/Treatment
O2 1/2-1 L/i IVFD D5% NaCl 0,9% 32 gtt/i micro Inj. Cefotaxime 500 mg/12 hour IV Inj. Ampicillin 600 mg/6 hour IV Paracetamol 3x150 mg Diet SV 1260 kcal with 30 gram protein Diazepam 5,5 mg if needed Inj. Phenitoin MD 30mg/12 hour IV (in 20 cc NaCl 0,9%, out in 20 minutes) INH 1x500mg (H1) Rifampicin 1x150mg (H1) Pyrazinamid 1x300mg (H1) Etambutol 1x250mg (H1)

Follow Up March 9th Subjective Objective

13th 2012
Assessment Planning/Treatment O2 1/2-1 L/i IVFD D5% NaCl 0,9% 30 gtt/i micro Inj. Cefotaxime 500 mg/12 hour IV Inj. Ampicillin 600 mg/6 hour IV Paracetamol 3x150 mg Diet SV 1260 kcal with 30 gram protein Diazepam 5,5 mg if needed Inj. Phenitoin MD 30mg/12 hour IV (in 20 cc NaCl 0,9%, out in 20 minutes) INH 1x500mg (H2-5) Rifampicin 1x150mg (H2-5) Pyrazinamid 1x300mg (H25) Etambutol 1x250mg (H2-5)

convulsions (-), fever (+), spastic (+)

Sens: sopocoma (GCS9 E4V2M3), Temp: 38oC Body weight: 11 kg, Body length: 95 cm, Head : Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear: cerumen prop; Mouth: within normal limit; Nose: nasal flare Neck : Lymph node enlargement (+) o/t regio colli the left and right, mobile, no tenderness Thorax : Symmetrical fusiform , retraction (-), HR: 106 bpm, regular, murmur (-) RR : 30 bpm, regular, ronchi (-/-) Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargement Extremities : Pols : 106 bpm, regular, adequate pressure/volume, CFT<3, warm Genital : Male, within normal limit

Serous meningitis + Susp. TB paru

Laboratory Finding : pH/pCO2/pO2/HCO2/O2 7,372/46,7mmHg/78,4mmHg/26.5m mol/L / 93.6%

Follow Up March 14th - 17th 2012

Subjective Objective Assessment Planning/Treatment
Lose consiusness (+), fever (+), spastic (+)

Sens: sopocoma (GCS9 E4V2M3), Temp: 38,3oC Body weight: 11 kg, Body length: 95 cm, Head : Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear/Mouth: within normal limit; Mouth: within normal limit; Nose: nasal flare Neck : Lymph node enlargement (+) o/t regio colli the left and right, mobile, no tenderness Thorax : Symmetrical fusiform , retraction (-), HR: 145 bpm, regular, murmur (-) RR : 35 bpm, regular, ronchi (-/-) Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargement Extremities : Pols : 145 bpm, regular, adequate pressure/volume, CFT<3, warm Genital : Male, within normal limit Laboratory Finding : Hb/Ht/WBC/PLT 7.8% / 24.20% / 9.53 103/mm3 / 224 103/mm3

Serous meningitis + Susp. TB paru

O2 1/2-1 L/i IVFD D5% NaCl 0,9% 30 gtt/i micro Inj. Cefotaxime 500 mg/12 hour IV Inj. Ampicillin 600 mg/6 hour IV Paracetamol 3x150 mg Diet SV 1260 kcal with 30 gram protein Diazepam 5,5 mg if needed Inj. Phenitoin MD 30mg/12 hour IV (in 20 cc NaCl 0,9%, out in 20 minutes) INH 1x500mg (H6-9) Rifampicin 1x150mg (H6-9) Pyrazinamid 1x300mg (H69) Etambutol 1x250mg (H6-9) Blood Transfusion

Follow Up March 18th - 21th 2012

Subjective
Lose consiusness (+), fever (+),

Objective Sens: sopocoma (GCS9 E4V2M3), Temp: 38,2oC Body weight: 11 kg, Body length: 95 cm, Head : Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear/Mouth: within normal limit; Mouth: within normal limit; Nose: nasal flare Neck : Lymph node enlargement (+) o/t regio colli the left and right, mobile, no tenderness Thorax : Symmetrical fusiform , retraction (-), HR: 126 bpm, regular, murmur (-) RR : 30 bpm, regular, ronchi (-/-) Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargement Extremities : Pols : 126 bpm, regular, adequate pressure/volume, CFT<3, warm Genital : Male, within normal limit Laboratory Finding : Hb/Ht/WBC/PLT 9.13% / 27.60% / 9.46 103/mm3 / 432 103/mm3 Eletrolit Ca/Na/K/Cl/Mg 6.9/118/3.8/86

Assessment Serous meningitis + OMSK Dextra

Planning/Treatment IVFD D5% NaCl 0,9% 30 gtt/i micro Inj. Meropenem 200 mg/8 hour IV Inj. Phenitoin MD 30mg/12 hour IV (in 20 cc NaCl 0,9%, out in 20 minutes) Prednison 3x4 mg Aspilet 1x80 mg INH 1x500mg (H10-13) Rifampicin 1x150mg (H1013) Pyrazinamid 1x300mg (H1013) Etambutol 1x250mg (H10-13) Diet SV 1260 kcal with 30 gram protein

Follow Up March 22th - 25th 2012

Subjective
Lose consiusness (+), fever (+),

Objective Sens: sopocoma (GCS9 E4V2M3), Temp: 37,7oC Body weight: 11 kg, Body length: 95 cm, Head : Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear/Mouth: within normal limit; Mouth: within normal limit; Nose: nasal flare Neck : Lymph node enlargement (+) o/t regio colli the left and right, mobile, no tenderness Thorax : Symmetrical fusiform , retraction (-), HR: 108 bpm, regular, murmur (-) RR : 34 bpm, regular, ronchi (-/-) Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargement Extremities : Pols : 108 bpm, regular, adequate pressure/volume, CFT<3, warm Physiological reflex : APR/KPR : +/+ Pathological reflex : Babinsky (+/+), Oppenheim (+/+), Chaddock (+/+), Gordon (+/+) Meningeal Refleks : + Laboratory Finding : Hb/Ht/WBC/PLT 10.9% / 33.20% / 11.62 103/mm3 / 91 103/mm3

Assessment Serous meningitis + OMSK Dextra

Planning/Treatment O2 1/2-1 L/i IVFD D5% NaCl 0,9% 30 gtt/i micro Inj. Meropenem 200 mg/8 hour IV Phenytoin 2x30 mg Prednison 3x4 mg Aspilet 1x80 mg INH 1x500mg (H14-17) Rifampicin 1x150mg (H1417) Pyrazinamid 1x300mg (H1417) Etambutol 1x200mg (H14-17) Diet SV 1450 kcal with 20 gram protein 225cc/6hour/NGT

Follow Up March 26th - 29th 2012

Subjective
Lose consiusness (+), fever (-),

Objective

Assessment

Planning/Treatment O2 1/2-1 L/i IVFD D5% NaCl 0,9% 30 gtt/i micro Inj. Meropenem 200 mg/8 hour IV Phenytoin 2x30 mg Prednison 3x4 mg Aspilet 1x80 mg INH 1x500mg (H18-21) Rifampicin 1x150mg (H1821) Pyrazinamid 1x300mg (H1821) Etambutol 1x200mg (H18-21) Diet SV 1450 kcal with 20 gram protein 225cc/6hour/NGT

Serous Sens: sopocoma (GCS10 E4V2M4), meningitis + Temp: 36,8oC OMSK Dextra Body weight: 11 kg, Body length: 95 cm, Head : Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear/Mouth: within normal limit; Mouth: within normal limit; Nose: nasal flare Neck : Lymph node enlargement (+) o/t regio colli the left and right, mobile, no tenderness Thorax : Symmetrical fusiform , retraction (-), HR: 108 bpm, regular, murmur (-) RR : 34 bpm, regular, ronchi (-/-) Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargement Extremities : Pols : 108 bpm, regular, adequate pressure/volume, CFT<3, warm

Follow Up March 30th - April 3rd 2012

Subjective Objective Sens: sopocoma (GCS10 E4V2M4), Temp: 37,8oC Body weight: 11 kg, Body length: 95 cm, Head : Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear/Mouth: within normal limit; Mouth: within normal limit; Nose: nasal flare Neck : Lymph node enlargement (-), stiff neck (+) Thorax : Symmetrical fusiform , retraction (), HR: 100 bpm, regular, murmur (-) RR : 29 bpm, regular, ronchi (-/-) Abdomen : Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargement Extremities : Pols : 100 bpm, regular, adequate pressure/volume, CFT<3, warm Laboratory Finding : Hb/Ht/WBC/PLT 10.8% / 31.50% / 9.76 103/mm3 / 391 103/mm3 Assessment Serous meningitis + OMSK Dextra Planning/Treatment O2 1/2-1 L/i IVFD D5% NaCl 0,9% 30 gtt/i micro Inj. Meropenem 200 mg/8 hour IV Phenytoin 2x30 mg Prednison 3x4 mg Aspilet 1x80 mg Asetazolamid 1x65 mg Lasix 1x15 mg INH 1x500mg (H22-26) Rifampicin 1x150mg (H2226) Pyrazinamid 1x300mg (H22-26) Etambutol 1x200mg (H2226) Oralit 160cc/time diarrhea Diet SV 1450 kcal with 26 gram protein Chest physiotherapy 3x/week

Fever(+), Spastic (+),

Discussion
Theory Meningitis is characterized by fever, lose consciousness, convulsions, anorexia, myalgia, arthralgia, tachycardia. Case This patient was lose consciousness from 1 day before in the hospital, having history fever, fever decreased with fever medicines, headache is felt 2 weeks before in the hospital Physiological reflex : APR/KPR : +/+; Pathological reflex :Babinsky (+/+), Oppenheim (+/+), Chaddock (+/+), Gordon (+/+); Meningeal Refleks : +

Physical examination : Examination of meningeal stimulation with a stiff neck examination. In patients with meningitis usually have a stiff neck in a positive

Analysis of cerebrospinal fluid : Color : Liquid Protein : slightly higher Glucose : N/ Treatment : appropriate antibiotic treatment (Ampicillin + cefotaxime) + a combination of anti-tuberculosis

Analysis of cerebrospinal fluid : Color : Liquid Protein : 84 mg/dL Glucose : 20 mg/dL The pateint was given all recommended therapies