VIRAL MENINGITIS
6 year old female referred to the Emergency Department by primary care physician with a prescription reading "Rule Out Meningitis." The patient had been seen earlier in the Pediatrician's office for headache, fever to 103 and complaints of neck pain (when prompted). The symptoms initially began 3 days prior and had been gradually worsening.
No history of recent travel or trauma. No known sick contacts. Patient denies sore throat or photophobia.
Vaccines up to date.
Upon initial assessment in the ED, patient found to by uncomfortable appearing but alert. Generally non-focal examination except for overall appearance and complaint of some neck pain with maximal flexion of the neck. Negative Kernig's and Brudzinski's signs.
Vital signs: T 38.6 HR 126 BP 108/62 RR 22 O2 100%
Initial workup consisted of labs, IVF, pain control and observation.
Upon re-evaluation, patient appeared to be deteriorating clinically, with worsening headache and neck pain. At this time, LP was performed.
Labs:
CBC - WBC 8.8 (67% N, 21% L)
CSF - WBC 230 (55% N, 31% L); RBC 0; Glucose 64; Protein 24; Gram Stain with few WBCs and no organisms.
What is the appropriate treatment and disposition?
Recent literature has attempted to determine who can be considered "low-risk" when diagnosed with meningitisand therefore be discharged home from the hospital, and who would benefit from admission and IV antibiotics. Some of the literature is presented on the right of this page.
Based on the BMS score described in 2002 and then validated in 2007, this child would have fallen into the "low-risk" category and may have been discharged home after a dose of ceftriaxone in the ED with close follow-up the following day.
Conclusion:
This patient was ultimately diagnosed with enterovial meningitis.
EVIDENCE
Summary:
Examined all CSF samples in children aged 2 months to 17 years who underwent LP for suspected meningitis.
1617 samples: 44 cases of bacterial meningitis.
5 had CSF WBC = 3 or less
6 had CSF WBC = 4-30
Rest had CSF WBC > 30
NPV if CSF has 30 WBC or less - 99.3%
PPV if CSF has > 30 WBC - 22.3%
Recommendation - Give antibiotics and admit for: Ill appearing; CSF WBC>30, age<6 months; CSF glucose <40; CSF protein>45; positive gram stain; peripheral band count>500; CSF to blood glucose ratio<40%
They conclude that you cannot base decision to treat for menigitis on CSF WBC alone and must way in other factors as meningitis can be seen in the setting of no CSF pleocytosis.
Development and Validation of a Multivariable Predictive Model to Distinguish Bacterial from Aseptic Meningitis in Children in the Post-HA Flu Era. Pediatrics 2002.
Summary:
Derived a Bacterial Meningitis Score (BMS) and vaildated it (using 2/3 of population for derivation and 1/3 for vaildation)
696 children admitted for suspected meningitis (29 days to 19 years).
125 (18%) had bacterial meningitis
Predictors of bacterial meningitis: postive gram stain; CSF protein>80; peripheral absolute neutrophil count>1000; presence of seizures; CSF absolute neutrophil count>1000
BMS Score: Positive gram stain = 2 points; all others = 1 point each
BMS of 2 or greater, sensitivity = 87%
BMS of 1 or greater, sensitivity = 100%
Conclusion: Outpatient management may be considered for children with BMS = 0 (low-risk group)
Summary:
Multicenter retrospective cohort study.
To validate the BMS in 20 centers over a 4 year period.
Included those aged 29 days to 9 years with a diagnosis of meningitis; Had an LP in the ED; CSF pleocytosis (>10 cells), corrected 1:500 for RBCs, or positive CSF culture; no previous antibiotics.
Defined bacterial meningitis: Positive CSF cuture; CSF pleocytosis with positive blood culture; CSF pleocytosis with positive latex agglutination testing.
3295 patients. 121 with bacterial meningitis (3.7%)
1714 patients defined as "very low risk" using BMS. 2 of these with bacterial meningitis (0.1%) Both of these children were age < 2 months.
Sensitivity = 98.3%
Specificity = 99.9%
Conclusions: Admit to hospital if BMS is 1 or more OR if age is less than 2 months. This gives sensitivity and NPV of 100%.
Author does recommend treatment with long-acting antibiotics for those discharged home.
