Meningitis and encephalitis: SAQ

This preschool child presents with the classic constellation of bacterial meningitis: fever, headache, vomiting, neck stiffness, altered mental state, and a non-blanching petechial rash that places meningococcal disease at the top of the differential. Her delayed capillary refill and irritability suggest early compensated shock, so this is a time-critical resuscitation and empiric-antibiotic scenario. [1]

Question 1 (10 marks)

Outline your immediate assessment and investigation plan for this child, including the timing of lumbar puncture. [1]

Begin with an airway, breathing, circulation assessment and an overall sick-or-well judgement. This child is unwell: she has meningism, a reduced conscious level, and early shock. Measure a full set of vital signs including heart rate, blood pressure, capillary refill, and oxygen saturation. Confirm the non-blanching nature of the rash with the glass test and examine for focal neurology and signs of raised intracranial pressure. [1]

Establish intravenous access immediately and draw a blood culture, full blood count, C-reactive protein, glucose, electrolytes, and a coagulation screen. Give the first dose of empiric antibiotics as soon as access is secured, before imaging or lumbar puncture. [2]

Because her conscious level is reduced, perform neuroimaging before lumbar puncture to exclude raised intracranial pressure, then proceed to lumbar puncture if imaging is reassuring. Send cerebrospinal fluid for cell count and differential, glucose with a simultaneous blood glucose, protein, Gram stain, culture, and meningococcal polymerase chain reaction. The combination of a reduced Glasgow Coma Scale and shock justifies deferring the lumbar puncture until after she is stabilised, but never defers the antibiotics. [2]

Question 2 (10 marks)

Describe your initial management including empiric antibiotics, dexamethasone, and fluid resuscitation. [1]

Start empiric antibiotics immediately. For a child of this age the regimen is a third-generation cephalosporin, cefotaxime 50 mg per kilogram intravenously 6-hourly or ceftriaxone 50 to 100 mg per kilogram intravenously daily, combined with vancomycin 15 mg per kilogram intravenously for penicillin-resistant pneumococcal cover. Give the first dose before lumbar puncture when, as here, the procedure must be delayed. [2]

Give dexamethasone 0.15 mg per kilogram intravenously with or just before the first antibiotic dose. The benefit in preventing hearing loss is greatest for Haemophilus influenzae type b and probable for pneumococcal meningitis, and it is lost if steroids are given after antibiotics. In a child with a petechial rash and shock, meningococcal disease is likely and steroids are still commonly given while the diagnosis is being clarified. [3]

Resuscitate the shock with a 10 mL per kilogram bolus of 0.9 per cent sodium chloride, reassessing after each bolus and repeating to a total of 30 to 60 mL per kilogram titrated to perfusion. Avoid hypotonic fluids because of the risk of hyponatraemia and cerebral oedema. Arrange early transfer to a paediatric intensive care setting, notify public health, and plan contact prophylaxis for close household contacts if meningococcal disease is confirmed. [1]