Presentation of Meningitis and Ventriculitis in Children

The classic presentation of meningitis including fever, headache, vomiting, photophobia, and nuchal rigidity, which is seen in adults, may not be seen in children, especially infants. The severity of symptoms may vary depending on the infecting organism and can range from mild to severe.

Symptoms and Signs of Acute Bacterial Meningitis

The presentation of bacterial meningitis may vary with the age of the child.

• May only be signs of sepsis in the neonate: Neonatal meningitis may be very difficult to recognize. Specific symptoms and signs may not be present; and if a diagnosis of sepsis is entertained, then it is imperative that meningitis is ruled out. Fever is often absent, and cardiovascular or respiratory compromise may be the only obvious signs. The anterior fontanelle may be full, or tense and bulging, but this is not a reliable sign, especially if the infant is dehydrated, and it may occur only late in the illness.
• Infants show signs of infection as well as somnolence and seizures: Infants from 3 months to 1 year of age may present with fever, vomiting, irritability, somnolence, and seizures. A full, tense fontanelle may be present only late in the illness, and nuchal rigidity may be absent. Any unexplained febrile illness in a child of this age should prompt consideration of meningitis in the differential diagnosis.
• Signs of meningitis after 1 year of age: In general, a diagnosis of meningitis should be considered in any patient with fever and unexplained alteration of consciousness. Children older than 1 year of age may present with more classical signs and symptoms of meningitis. The illness usually begins with fevers, chills, vomiting, photophobia, and severe headache. Occasionally, seizures will be present. Irritability, delirium, and lethargy may develop. As the inflammatory response in the leptomeninges increases, nuchal rigidity develops. Petechial or purpural rashes are characteristically seen in meningococcal infection.
• Fulminant meningitis: Some patients present with fulminant meningitis, progressing from mild headache to comatose over a period of several hours. Seizures are common. In these patients, the peripheral white blood cell (WBC) count may be low, due to overwhelming infection, and the CSF WBC count may not be as high as anticipated. In such patients, even immediate initiation of appropriate therapy may not be successful.

Patterns of evolution

• Headache and photophobia evolving into altered consciousness with nuchal rigidity: Meningitis usually begins with fevers, chills, vomiting, photophobia, and severe headache. Occasionally, seizures will be present. Irritability, delirium, and lethargy may develop. As the inflammatory response in the leptomeninges increases, nuchal rigidity develops. Petechial or purpural rashes are characteristically seen in meningococcal infection. With progression, coma, and eventually death may occur.

Time for evolution

• Hours to days: The time course for evolution of meningitis symptoms and signs may cover several days, but in some patients, progression from mild headache to comatose may occur over a period of several hours. Seizures are common. In these patients, the peripheral WBC count may be low, due to overwhelming infection, and the CSF WBC count may not be as high as anticipated. In such patients, even immediate initiation of appropriate therapy may not be successful.

Symptoms and Signs of Tuberculous Meningitis

• Lethargy, nuchal rigidity, and seizures in the setting of systemic tuberculosis: TB meningitis presents with fever, nuchal rigidity, lethargy, and seizures, most often in the setting of acute systemic tuberculosis. Hyponatremia may be caused by prolonged vomiting or cerebal salt-wasting.
• Signs of elevated ICP and cranial neuropathies due to basal meningitis: Infants may present with a bulging fontanelle due to acute hydrocephalus caused by basal meningitis. Cranial nerve palsies, most commonly involving cranial nerve six, are caused by the thick basal exudate along the brainstem. Loss of vision due to optic nerve involvement or hydrocephalus may occur (29).
• Movement disorders: Movement disorders, including chorea, hemiballismus, athetosis, tremors, myloclonic jerks, and ataxia have been described (29).
• Paraplegia: Paraplegia due to tuberculous radiculomyelitis or intramedullary tuberculomas is a common finding. Infarcts in the internal capsule, basal ganglia, and thalami are common in TB meningitis.
• TB meningitis in children occurs in the setting of systemic tuberculosis and presents with fever, nuchal rigidity, lethargy, and seizures. CSF may show low glucose, elevated protein, and moderately elevated WBC counts (50–500 cells/mm3) with a mononuclear predominance.

Patterns of evolution

• Acutely ill with hydrocephalus and altered level of consciousness: Patients with TB meningitis often present acutely ill. They may develop acute hydrocephalus, hyponatremia, and seizures, and progress to coma or death.

Time for evolution

• Rapid: The patient’s condition may deteriorate rapidly, especially in the face of acute hydrocephalus or hyponatremia.

Symptoms and Signs of Viral Meningitis

• Viral illness followed by lethargy: Signs of a systemic viral infection are usually present, and then lethargy develops.
• Concurrent infection common: Lethargy may follow. The diagnosis of meningitis may initially be very difficult, particularly in the setting of a concurrent infection, such as otitis media, or an upper respiratory infection, which may occur in patients with meningitis.

Patterns of evolution

• Insidious development of lethargy after initial viral illness: The onset of symptoms in viral meningitis is more insidious than in bacterial meningitis, usually beginning with an unexplained febrile illness, and poor feeding leading to vomiting.

Time for evolution

• Insidious

Symptoms and Signs of Fungal Meningitis

• Fungal meningitis presentation: The diagnosis of fungal meningitis should be suspected in patients in whom tuberculous meningitis is suspected but laboratory features are atypical (66). Cryptococcal meningitis is generally seen in patients with advanced immunodeficiency syndromes and may present in a more indolent manner, with more subtle headache and low-grade or no fever. In patients with HIV infection, it must be distinguished from tuberculous meningitis. In cryptococcal meningitis, headache is often the predominant symptom, and nuchal rigidity may be absent. This is due to increased ICP and it may require therapeutic lumbar punctures (21). C. albicans may cause meningitis, particularly in neonates with multiple courses of antibacterial therapy for other infections. Coccidioides meningitis may be seen in endemic areas including the southwestern United States or Mexico. In immunosuppressed patients, Aspergillus and mucormycosis may also cause meningitis.
• Meningitis in the setting of systemic disease: Fungal meningitis presents as part of a systemic disease, with typical symptoms of headache, photophobia, low-grade fever, and nuchal rigidity.
• Seizures less common: Seizures are less common in fungal meningitis than in other forms of meningitis.

Patterns of evolution

• Hydrocephalus: Patients with fungal meningitis may develop acute hydrocephalus but are less likely to develop seizures than patients with meningitis from other causes. Cryptococcal meningitis is the most lethal fungal infection in patients seropositive for HIV.

Time for evolution

• Gradual: The evolution of fungal meningitis may be more gradual, depending on the extent of systemic illness, but with the development of acute hydrocephalus, there may be rapid deterioration.

Symptoms and Signs of Ventriculitis

• Meningitis symptoms dominate: Ventriculitis most commonly is not distinguished from meningitis, except in the case of shunt or post-craniotomy infection. In patients with post-craniotomy infection, fever, headache, and nuchal rigidity are common.
• Fever may not be present: Especially in the case of shunt infection, fever may not be present, and patients may present only with signs and symptoms of shunt malfunction.

Patterns of evolution

• Altered level of consciousness, seizures: Patients with ventriculitis may develop progressive lethargy, coma, seizures, and even death. In patients with rupture of a brain abscess into the ventricles, the mortality rate is very high. With loculations within the ventricular system, the ICP rises may be difficult to treat.

Time for evolution

• Variable: The time for evolution of symptoms is highly dependent on the etiologic agent, ranging from very insidious progression with more indolent organisms, to rapid progression in gram-negative rod infections.

Intervention

Stabilization

• ABCs: Resuscitation should include the standard airway, breath, circulate paradigm. Intubation and ventilation should be performed as required. Intravascular volume status should be assessed, and adequate hydration should be ensured. Blood pressure should be maintained in the normal range through adequate hydration and pressors as needed.
• Electrolytes managed: The serum sodium level should be monitored and kept within the normal range.
• Rapid introduction of antibiotics: Once the diagnosis is suspected, antibiotics should be started immediately. Ideally, the lumbar puncture should be performed prior to administration of antibiotics, but a delay in the lumbar puncture should not delay administration of antibiotics, particularly in the critically ill patient.

Admission Orders

• HOB, positioning, and activity: Once the initial evaluation is complete, the critically ill patient should be admitted to the ICU, placed on isolation precautions, and positioned with the head of bed elevated 30 degrees, on bed rest.
• VS: Vital signs are monitored as indicated by ICU policy, but the patient will likely need continuous EKG, arterial line for blood pressure monitoring, and strict intake and output monitoring.
• BP parameters: A normal pressure range should be maintained. Do not allow hypotension, especially in cases of increased ICP.
• IVF and rate: Adjust as needed to maintain intravascular volume. Monitor serum sodium level and adjust IV fluid accordingly
• CSF drainage parameters: If the patient has a lumbar drain or external ventricular drain, keep the ICP less than 20 mm Hg. EVD is preferred in cases of possible obstructive hydrocephalus.