Pediatric Meningitis and Encephalitis Clinical Presentation

  • Author: Jeffrey Hom, MD, MPH, FACEP, FAAP; Chief Editor: Richard G Bachur, MD   more...
 
Updated: Apr 19, 2011
 

History

  • Bacterial meningitis
    • The younger the child, the less likely he or she is to exhibit the classic symptoms of fever, headache, and meningeal signs.
    • Meningitis in the neonatal period is associated with maternal infection or pyrexia at delivery. The child younger than 3 months may have very nonspecific symptoms, including hyperthermia or hypothermia, change in sleeping or eating habits, irritability or lethargy, vomiting, high-pitched cry, or seizures.
    • Meningismus and a bulging fontanel may be observed but are not needed for diagnosis.
    • A child who is quiet at rest but who cries when moved or comforted may have meningeal irritation (paradoxical irritability).
    • After age 3 months, the child may display symptoms more often associated with bacterial meningitis, with fever, vomiting, irritability, lethargy, or any change in behavior.
    • After age 2-3 years, children may complain of headache, stiff neck, and photophobia.
    • The clinical course may be brief and fulminant with rapid progression of symptoms or may follow a more gradual course with several days of upper respiratory infection progressing to more severe symptoms. The fulminant course is more often associated with N meningitidis infection.
  • Viral meningitis
    • In areas with widespread vaccination of children, enteroviruses are the most common causes of viral meningitis. The onset is variable and may have several days of fever, anorexia, and general malaise. It also may present as a rather abrupt onset of fever, nausea, vomiting, and headache.
    • Additional symptoms are shared with enteroviral infections, such as pharyngitis, conjunctivitis, and myositis.
    • Other causes of viral meningitis also may be associated with encephalitis. Arboviral infections frequently have associated encephalitis and seizures.
    • Adenoviral, mumps, and varicella-zoster infections tend to be more severe than enteroviral infections, and often evidence of encephalitis is present.
    • In areas with low vaccination rates, mumps virus is often the most frequent cause of meningitis.
  • Fungal meningitis occurs in immunocompromised patients and has a variable presentation.
  • Aseptic meningitis may be caused by drugs, usually nonsteroidal anti-inflammatory drugs (NSAIDs), IVIG, and antibiotics. A recent report was of a pediatric patient with a trimethoprim-sulfamethoxazole–induced meningitis. Symptoms were similar to those of viral meningitis. Symptoms may occur within minutes of ingestion of the drug.
  • Encephalitis
    • Diagnosis for the causative viral agent is aided by historical facts. Information such as season of year, travel, activities, and exposure to animals helps with diagnosis.
    • A distinction between viral encephalitis and postinfectious encephalomyelitis is important because management and prognosis are different. With postinfectious encephalomyelitis, the usual presentation is a nonspecific respiratory viral syndrome.
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Physical

Physical examination findings are widely variable based on age and infecting organism. It is important to remember that the younger the child, the less specific the symptoms.

  • In the young infant findings that definitely point to meningitis are rare.
    • The infant may be febrile or hypothermic.
    • Bulging of the fontanel, diastasis of the sutures, and nuchal rigidity point to meningitis but are usually late findings.
  • As the child grows older, the physical examination becomes more reliable.
    • Meningeal signs (eg, headache, nuchal rigidity, positive Kernig and Brudzinski signs) should be sought, and their presence or absence recorded.
    • A definitive diagnosis of meningitis requires examination of CSF via lumbar puncture. Presence or absence of classic meningeal signs and symptoms should not be used as the sole criteria for referring patients for further diagnostic testing.[8]
    • Focal neurological signs may be present in up to 15% of patients and are associated with a worse prognosis.
    • Seizures occur in up to 30% of children with bacterial meningitis.
    • Obtundation and coma occur in 15-20% of patients and are more frequent with pneumococcal meningitis.
    • Encephalitis may present like meningitis or the symptoms of the systemic viral infection may predominate.
  • Encephalitis
    • Physical findings for encephalitis are fever, headache, and decreased neurological function. Decreased neurological functions include altered mental status, focal neurological function, and seizure activities. These findings can help identify the virus type and prognosis.
    • In West Nile virus, the signs and symptoms are nonspecific and include fever, malaise, periocular pain, lymphadenopathy, and myalgia.
    • West Nile virus has some unique physical findings including fine, maculopapular, erythematous rash; proximal muscle weakness; and flaccid paralysis. This rash is commonly found in children.
    • Critically ill patients have neurological dysfunction, such as altered mental status and cranial nerve dysfunction, as the major physical finding.
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Causes

  • Risk factors for bacterial meningitis
    • Age
    • Low family income
    • Attendance at day care
    • Head trauma
    • Splenectomy
    • Chronic disease
    • Children with facial cellulitis, periorbital cellulitis, sinusitis, and septic arthritis have an increased risk of meningitis.
    • Maternal infection and pyrexia at the time of delivery are associated with neonatal meningitis.
  • Use of the Hib and p neumococcal vaccine decreases the likelihood of infection from these agents.
  • Viral meningoencephalitis
    • Immunizations for measles, mumps, and rubella decrease the risk of infection from those agents.
    • It is unclear why some patients with systemic viral illnesses develop meningitis or encephalitis.
  • Fungal meningitis occurs in immunocompromised patients.
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Contributor Information and Disclosures
Author

Jeffrey Hom, MD, MPH, FACEP, FAAP  Assistant Professor, Department of Pediatrics/Emergency Services and Department of Emergency Medicine, New York University School of Medicine

Jeffrey Hom, MD, MPH, FACEP, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Robert Allan Felter, MD, FAAP, CPE, FACPE  Professor of Clinical Pediatrics, Department of Pediatrics, Georgetown University School of Medicine; Medical Director, Pediatric Emergency Medicine and Inpatient Services, Inova Loudoun Hospital

Robert Allan Felter, MD, FAAP, CPE, FACPE is a member of the following medical societies: American Academy of Pediatrics and American College of Physician Executives

Disclosure: Nothing to disclose.

Specialty Editor Board

Garry Wilkes, MBBS, FACEM  Director of Emergency Medicine, Bunbury Hospital; Medical Consultant, St John Ambulance, WA Ambulance Service; Adjunct Associate Professor, Edith Cowan University; Clinical Associate Professor, Rural Clinical School, University of Western Australia

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Grace M Young, MD  Associate Professor, Department of Pediatrics, University of Maryland Medical Center

Grace M Young, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Emergency Physicians

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD  Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston

Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research

Disclosure: Nothing to disclose.

References

  1. Haddy RI, Perry K, Chacko CE. Comparison of incidence of invasive Streptococcus pneumoniae disease among children before and after introduction of conjugated pneumococcal vaccine. Pediatr Infect Dis J. Apr 2005;24(4):320-3. [Medline].

  2. Nigrovic LE, Kuppermann N, Malley R. Children with bacterial meningitis presenting to the emergency department during the pneumococcal conjugate vaccine era. Acad Emerg Med. Jun 2008;15(6):522-8. [Medline].

  3. Nigrovic LE, Malley R, Kuppermann N. Cerebrospinal fluid pleocytosis in children in the era of bacterial conjugate vaccines: distinguishing the child with bacterial and aseptic meningitis. Pediatr Emerg Care. Feb 2009;25(2):112-7; quiz 118-20. [Medline].

  4. O'Brien KL. Wolfson LJ. Wat JP. et al. Burden of disease caused by Streptococcus pneumoniae in children younger than 5 years: global estimates. Lancet. Sept 2009 12;374:893 - 902. [Medline].

  5. Watt JP, Wolfson LJ, O'Brien KL, Henkle E, Deloria-Knoll M, McCall N, et al. Burden of disease caused by Haemophilus influenzae type b in children younger than 5 years: global estimates. Lancet. Sep 12 2009;374(9693):903-11. [Medline].

  6. McIntyre PB, Macintyre CR, Gilmour R. A population based study of the impact of corticosteroid therapy and delayed diagnosis on the outcome of childhood pneumococcal meningitis. Arch Dis Child. Apr 2005;90(4):391-6. [Medline].

  7. Kutz JW, Simon LM, Chennupati SK, Giannoni CM, Manolidis S. Clinical predictors for hearing loss in children with bacterial meningitis. Arch Otolaryngol Head Neck Surg. Sep 2006;132(9):941-5. [Medline].

  8. Amarilyo G, Alper A, Ben-Tov A, Grisaru-Soen G. Diagnostic accuracy of clinical symptoms and signs in children with meningitis. Pediatr Emerg Care. Mar 2011;27(3):196-9. [Medline].

  9. Dubos F, Korczowski B, Aygun DA, Martinot A, Prat C, Galetto-Lacour A, et al. Serum procalcitonin level and other biological markers to distinguish between bacterial and aseptic meningitis in children: a European multicenter case cohort study. Arch Pediatr Adolesc Med. Dec 2008;162(12):1157-63. [Medline].

  10. Dubos F, Martinot A, Gendrel D, Breart G, Chalumeau M. Clinical decision rules for evaluating meningitis in children. Curr Opin Neurol. Jun 2009;22(3):288-93. [Medline].

  11. [Best Evidence] Nigrovic LE, Kuppermann N, Macias CG, Cannavino CR, Moro-Sutherland DM, Schremmer RD, et al. Clinical prediction rule for identifying children with cerebrospinal fluid pleocytosis at very low risk of bacterial meningitis. JAMA. Jan 3 2007;297(1):52-60. [Medline].

  12. Kanegaye JT, Nigrovic LE, Malley R, Cannavino CR, Schwab SH, Bennett JE, et al. Diagnostic value of immature neutrophils (bands) in the cerebrospinal fluid of children with cerebrospinal fluid pleocytosis. Pediatrics. Jun 2009;123(6):e967-71. [Medline].

  13. Neuman MI, Tolford S, Harper MB. Test characteristics and interpretation of cerebrospinal fluid gram stain in children. Pediatr Infect Dis J. Apr 2008;27(4):309-13. [Medline].

  14. Ray B, Rylance G. QUESTION 1. Normal CSF: does it exclude meningitis?. Arch Dis Child. Dec 2009;94(12):988-91. [Medline].

  15. Nigrovic LE, Malley R, Macias CG, Kanegaye JT, Moro-Sutherland DM, Schremmer RD, et al. Effect of antibiotic pretreatment on cerebrospinal fluid profiles of children with bacterial meningitis. Pediatrics. Oct 2008;122(4):726-30. [Medline].

  16. Dubos F, Korczowski B, Aygun DA, Martinot A, Prat C, Galetto-Lacour A, et al. Serum procalcitonin level and other biological markers to distinguish between bacterial and aseptic meningitis in children: a European multicenter case cohort study. Arch Pediatr Adolesc Med. Dec 2008;162(12):1157-63. [Medline].

  17. Greenberg RG, Smith PB, Cotten CM, Moody MA, Clark RH, Benjamin DK Jr. Traumatic lumbar punctures in neonates: test performance of the cerebrospinal fluid white blood cell count. Pediatr Infect Dis J. Dec 2008;27(12):1047-51. [Medline].

  18. Fein D, Avner JR, Khine H. Pattern of pain management during lumbar puncture in children. Pediatr Emerg Care. May 2010;26(5):357-60. [Medline].

  19. Mongelluzzo J, Mohamad Z, Ten Have TR, Shah SS. Corticosteroids and mortality in children with bacterial meningitis. JAMA. May 7 2008;299(17):2048-55. [Medline].

  20. Altman NR. Intracranial infection in children. Top Magn Reson Imaging. Summer 1993;5(3):143-60. [Medline].

  21. Arango CA, Rathore MH. Neonatal meningococcal meningitis: case reports and review of literature. Pediatr Infect Dis J. Dec 1996;15(12):1134-6. [Medline].

  22. Arditi M, Mason EO Jr, Bradley JS, et al. Three-year multicenter surveillance of pneumococcal meningitis in children: clinical characteristics, and outcome related to penicillin susceptibility and dexamethasone use. Pediatrics. Nov 1998;102(5):1087-97. [Medline].

  23. Baraff LJ, Lee SI, Schriger DL. Outcomes of bacterial meningitis in children: a meta-analysis. Pediatr Infect Dis J. May 1993;12(5):389-94. [Medline].

  24. Bonsu BK, Harper MB. Accuracy and test characteristics of ancillary tests of cerebrospinal fluid for predicting acute bacterial meningitis in children with low white blood cell counts in cerebrospinal fluid. Acad Emerg Med. Apr 2005;12(4):303-9. [Medline].

  25. Bonsu BK, Harper MB. Corrections for leukocytes and percent of neutrophils do not match observations in blood-contaminated cerebrospinal fluid and have no value over uncorrected cells for diagnosis. Pediatr Infect Dis J. Jan 2006;25(1):8-11. [Medline].

  26. Bonthius DJ, Karacay B. Meningitis and encephalitis in children. An update. Neurol Clin. Nov 2002;20(4):1013-38, vi-vii. [Medline].

  27. Booy R, Kroll S. Bacterial meningitis in children. Curr Opin Pediatr. Feb 1994;6(1):29-35. [Medline].

  28. Bradley JS, Kaplan SL, Klugman KP, et al. Consensus: management of infections in children caused by Streptococcus pneumoniae with decreased susceptibility to penicillin. Pediatr Infect Dis J. Dec 1995;14(12):1037-41. [Medline].

  29. Buchanan GA, Darville T. Impact of immunization against Haemophilus influenzae type b (HIB) on the incidence of HIB meningitis treated at Arkansas Children's Hospital. South Med J. Jan 1994;87(1):38-40. [Medline].

  30. Chavez-Bueno S, McCracken GH. Bacterial meningitis in children. Pediatr Clin North Am. Jun 2005;52(3):795-810, vii. [Medline].

  31. Dawson KG, Emerson JC, Burns JL. Fifteen years of experience with bacterial meningitis. Pediatr Infect Dis J. Sep 1999;18(9):816-22. [Medline].

  32. Deeks SL, Palacio R, Ruvinsky R, et al. Risk factors and course of illness among children with invasive penicillin-resistant Streptococcus pneumoniae. The Streptococcus pneumoniae Working Group. Pediatrics. Feb 1999;103(2):409-13. [Medline].

  33. Drake R, Dravitski J, Voss L. Hearing in children after meningococcal meningitis. J Paediatr Child Health. Jun 2000;36(3):240-3. [Medline].

  34. Dubos F, Lamotte B, Bibi-Triki F, Moulin F, Raymond J, Gendrel D, et al. Clinical decision rules to distinguish between bacterial and aseptic meningitis. Arch Dis Child. Aug 2006;91(8):647-50. [Medline].

  35. Fiore AE, Moroney JF, Farley MM. Clinical outcomes of meningitis caused by Streptococcus pneumoniae in the era of antibiotic resistance. Clin Infect Dis. Jan 2000;30(1):71-7. [Medline].

  36. Fraser A, Gafter-Gvili A, Paul M. Antibiotics for preventing meningococcal infections. Cochrane Database Syst Rev. 2005;CD004785. [Medline].

  37. Gaur S, Malhotra A, Whitley-Williams P. Rates of Neisseria meningitidis increasing in young adults. Pediatr Ann. Sep 2004;33(9):590-5. [Medline].

  38. Grimwood K, Anderson VA, Bond L, et al. Adverse outcomes of bacterial meningitis in school-age survivors. Pediatrics. May 1995;95(5):646-56. [Medline].

  39. Huttova M, Kralinsky K, Horn J, et al. Prospective study of nosocomial fungal meningitis in children--report of 10 cases. Scand J Infect Dis. 1998;30(5):485-7. [Medline].

  40. Kanegaye JT, Soliemanzadeh P, Bradley JS. Lumbar puncture in pediatric bacterial meningitis: defining the time interval for recovery of cerebrospinal fluid pathogens after parenteral antibiotic pretreatment. Pediatrics. Nov 2001;108(5):1169-74. [Medline].

  41. Kornelisse RF, de Groot R, Neijens HJ. Bacterial meningitis: mechanisms of disease and therapy. Eur J Pediatr. Feb 1995;154(2):85-96. [Medline].

  42. Lipton JD, Schafermeyer RW. Evolving concepts in pediatric bacterial meningitis--Part I: Pathophysiology and diagnosis. Ann Emerg Med. Oct 1993;22(10):1602-15. [Medline].

  43. Lutsar I, Ahmed A, Friedland IR, et al. Pharmacodynamics and bactericidal activity of ceftriaxone therapy in experimental cephalosporin-resistant pneumococcal meningitis. Antimicrob Agents Chemother. Nov 1997;41(11):2414-7. [Medline].

  44. Maxson S, Jacobs RF. Viral meningitis. Tips to rapidly diagnose treatable causes. Postgrad Med. Jun 1993;93(8):153-6, 159-60, 163-6. [Medline].

  45. Negrini B, Kelleher KJ, Wald ER. Cerebrospinal fluid findings in aseptic versus bacterial meningitis. Pediatrics. Feb 2000;105(2):316-9. [Medline].

  46. Nigrovic LE, Kuppermann N, McAdam AJ. Cerebrospinal latex agglutination fails to contribute to the microbiologic diagnosis of pretreated children with meningitis. Pediatr Infect Dis J. Aug 2004;23(8):786-8. [Medline].

  47. O'Meara M, Ouvrier R. Viral encephalitis in children. Curr Opin Pediatr. Feb 1996;8(1):11-5. [Medline].

  48. Oates-Whitehead RM, Maconochie I, Baumer H. Fluid Therapy for Acute Bacterial Meningitis. Cochrane Database Syst Rev. Jul 20 2005;3:CD004786. [Medline].

  49. Oliver LG, Harwood-Nuss AL. Bacterial meningitis in infants and children: a review. J Emerg Med. Sep-Oct 1993;11(5):555-64. [Medline].

  50. Pohl CA. Practical approach to bacterial meningitis in childhood. Am Fam Physician. May 15 1993;47(7):1595-603. [Medline].

  51. Price EH, de Louvois J, Workman MR. Antibiotics for Salmonella meningitis in children. J Antimicrob Chemother. Nov 2000;46(5):653-5. [Medline].

  52. Redman RC 4th, Miller JB, Hood M, DeMaio J. Trimethoprim-induced aseptic meningitis in an adolescent male. Pediatrics. Aug 2002;110(2 Pt 1):e26. [Medline].

  53. Richardson MP, Reid A, Tarlow MJ. Hearing loss during bacterial meningitis [published erratum appears in Arch Dis Child 1997 Apr;76(4):386]. Arch Dis Child. Feb 1997;76(2):134-8. [Medline].

  54. Rorabaugh ML, Berlin LE, Heldrich F. Aseptic meningitis in infants younger than 2 years of age: acute illness and neurologic complications. Pediatrics. Aug 1993;92(2):206-11. [Medline].

  55. Saez-Llorens X, McCracken GH. Bacterial meningitis in children. Lancet. Jun 21 2003;361(9375):2139-48. [Medline].

  56. Saravolatz LD, Manzor O, VanderVelde N, Pawlak J, Belian B. Broad-range bacterial polymerase chain reaction for early detection of bacterial meningitis. Clin Infect Dis. Jan 1 2003;36(1):40-5. [Medline].

  57. Scheifele D, Halperin S, Law B. Invasive Haemophilus influenzae type b infections in vaccinated and unvaccinated children in Canada, 2001-2003. CMAJ. Jan 4 2005;172(1):53-6. [Medline].

  58. Schuchat A, Robinson K, Wenger JD. Bacterial meningitis in the United States in 1995. Active Surveillance Team. N Engl J Med. Oct 2 1997;337(14):970-6. [Medline].

  59. Singhi PD, Singhi SC. Central nervous system infections in children (bacterial, tubercular). Curr Opin Neurol. Apr 1995;8(2):150-5. [Medline].

  60. Sivertsen B, Christensen PB. Acute encephalitis. Acta Neurol Scand. Feb-Mar 1996;93(2-3):156-9. [Medline].

  61. Syrogiannopoulos GA, Mitselos CJ, Beratis NG. Childhood bacterial meningitis in Southwestern Greece: a population- based study. Clin Infect Dis. Dec 1995;21(6):1471-3. [Medline].

  62. van de Beek D, de Gans J, McIntyre P, Prasad K. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. Jan 24 2007;CD004405. [Medline].

  63. Wade T, Booy R, Teare EL. Pasteurella multocida meningitis in infancy - (a lick may be as bad as a bite). Eur J Pediatr. Nov 1999;158(11):875-8. [Medline].

  64. Waler JA, Rathore MH. Outpatient management of pediatric bacterial meningitis. Pediatr Infect Dis J. Feb 1995;14(2):89-92. [Medline].

  65. Walia R, Hoskyns W. Tuberculous meningitis in children: problem to be addressed effectively with thorough contact tracing. Eur J Pediatr. Jul 2000;159(7):535-8. [Medline].

  66. Walling AD, Kallail KJ, Phillips D. The epidemiology of bacterial meningitis. J Am Board Fam Pract. Sep-Oct 1991;4(5):307-11. [Medline].

  67. Whitley RJ, Gnann JW. Viral encephalitis: familiar infections and emerging pathogens. Lancet. Feb 9 2002;359(9305):507-13. [Medline].

  68. Woolley AL, Kirk KA, Neumann AM Jr, McWilliams SM, Murray J, Freind D, et al. Risk factors for hearing loss from meningitis in children: the Children's Hospital experience. Arch Otolaryngol Head Neck Surg. May 1999;125(5):509-14. [Medline].

 
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