Meningitis is an inflammation of the meninges covering the brain and spinal cord. It is a medical emergency that can cause permanent damage to the brain. If suspected in children immediate action is necessary to prevent a serious outcome. If untreated mortality can reach 100 percent and if treatment is delayed or inadequate morbidity can be high. Children are particularly prone to it and when there is suspicion of an infection, treatment should be started promptly even when investigations are not complete.

Cause: Viral and bacterial infections are the main cause of meningitis. Although viral infection is the most common cause of meningitis, they are not as serious as bacterial meningitis and patients often recover on their own. Meningitis caused by fungus is very rare.

The bacteria which cause the infection are generally found in the nose and throat of 10 percent of the population. Under certain conditions they become virulent, enter the blood stream and reach the brain. It can also spread from a sinus or ear infection. Spread from another person can occur through coughing and sneezing.

Bacterial infections cause the maximum damage and most fatalities are due to that. Bacteria causing the infection are pneumococcus, meningococcus, haemophilus and listeria. Among these pneumococcus is the commonest infection affecting infants and children. In infants it is more common during the first month than at any other time. Meningococcus more often affects teenagers and young adults.

Pathology: Normally the infection gets into the blood stream and reaches the meninges of the brain. Some of the studies now indicate that the harmful inflammatory reaction that occurs after the infection reaches the brain is initiated by the interaction of bacterial products with host pattern recognition receptors (PRRs). This leads to the production of certain cytokines that in turn leads to the production of proinflammatory mediators. This attracts neutrophils to the subarachnoid space. Activated neutrophils release cytotoxic agents that cause damage to brain tissue.

Symptoms & Signs: Symptoms are more pronounced in infants and young children. In adults, although many of the symptoms seen in children may be present, generally they are not as severe and may present with fever, headache and stiff neck. Neonatal meningitis remains a devastating disease

Infants:
• Irritable with constant high pitched crying
• Not feeding
• Drowsy or lethargic
• Sometimes cough and difficulty breathing
• Fontanelle may be tense or bulging
• In infants under 3 months fever may not be present
• Generalised rash or tiny red spots
Positive glass test – Tiny red spots or rash when pressed by a clear glass would normally fade. If the spots do not fade and persist under pressure it is a medical emergency. If the skin is dark you may not see the spots. Then look at the palm or sole of the feet. You must never wait for rashes to appear as this happens at later stages.

Older Children: (In addition to above)
• Sudden high fever with cold hands and feet
• Headache
• Stiff Neck
• Nausea and Vomiting
• Sensitive to bright light (Photophobia)
• Skin Rashes
• Seizures and Coma – late signs.

Investigations:
• Blood culture: Blood should be taken for culture as soon as possible to identify the organism causing the infection.
• Lumbar Puncture: This is an important investigation that must be done in any suspected case of meningitis before starting an antibiotic. Gram stain and CSF analysis should identify the organism. In meningitis, it would also show increased WBCs and protein. Sugar content may be lowered.
• CT or MRI Scan: The scan will suggest inflammation of the meninges. The scan can also spot a sinus infection which may be the cause for meningitis.

If a scan is likely to take time, antibiotic therapy should be started without a delay (as soon as the lumbar puncture is done). If a bacteria is not identified by any of the tests it could be viral meningitis.

Treatment:
• Admission to hospital
• Fluids and antibiotics through intravenous drip (as soon as CSF is sent for analysis)
• Steroids to reduce the inflammation
• Close monitoring of the child – (BP, Pulse, Temperature and Neurological state)

The most important thing to remember is “Do not delay starting antibiotic therapy”. Any delay will result in serious complication. With prompt treatment you can expect good recovery even with severe meningitis. Antibiotic therapy may extend for 2 to 3 weeks.

Steroid Therapy:
The addition of dexamethasone is mainly to reduce the subarachnoid space inflammatory response which is a major factor in morbidity and mortality caused by bacterial meningitis. It is recommended for all adults with suspected or proven pneumococcal meningitis, and in infants and children with Haemophilus influenzae type b meningitis. However patients should be observed closely for any adverse outcomes.

The use of dexamethasone in infants and children with pneumococcal meningitis is controversial, and there are insufficient data to support its use in neonates.

Complications:
Most patients will make full recovery with prompt treatment. Complications from meningitis result mainly from delay in recognising the condition and starting treatment late. Delayed treatment increases the risk of permanent brain damage or even death. Any complication that follows is directly related to the degree of brain damage.
It may be constant headaches, memory loss, hearing problems, seizures, motor coordination or problems with gait.

Prevention:
Infants and children should avoid very crowded places. It has been shown that the risk of getting infected increases in overcrowded and smoky places as the bacteria spreads mainly through the respiratory route. The incidence is increased in households where the parents smoke.
Meningitis can be prevented by routine immunisation during childhood. Every parent must make sure that their child is fully up to date with immunisation. It is particularly important to do this before the child starts attending school where they will come in contact with lots of children.

If by chance a child comes in contact with someone who has meningitis, it may be necessary to treat the child with antibiotics prophylactically (or monitor closely). As you would expect there is also a higher risk of infection in patients who have compromised immune system.

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