What Types of Fluid Are Full Term Newborn Babies Born With
Hygienic Meningitis in the Newborn and Young Baby
Am Fam Doc. 1999 May 15;59(x):2761-2770.
Article Sections
- Abstract
- Illustrative Case
- Evaluation of the Newborn or Infant with Suspected Meningitis
- Etiologies
- Treatment
- Complications
- References
When a toxic newborn or immature infant presents with fever and languor or irritability, information technology is important to consider the diagnosis of meningitis even if the classic localizing signs and symptoms are absent. Cerebrospinal fluid should exist obtained (unless lumbar puncture is clinically contraindicated) to enable initial therapy to be planned. Initial results of cerebrospinal fluid testing may non conclusively differentiate between hygienic and bacterial meningitis, and antimicrobial therapy for all likely organisms should exist instituted until definitive culture results are available. Comprehensive therapy, including antibacterial and antiviral agents, should continue until a crusade is identified and more than specific therapy is initiated, an etiology is excluded or the patient improves considerably and the form of antimicrobial therapy is completed. Group B streptococcus is the about mutual bacterial etiologic agent in cases of meningitis that occur during the start month after birth. Etiologies of hygienic meningitis include viral infection, partially treated bacterial meningitis, congenital infections, drug reactions, postvaccination complications, systemic diseases and malignancy. Long-term sequelae of meningitis include neuromuscular impairments, learning disabilities and hearing loss. Prompt diagnosis and treatment are essential to improved outcome.
When a newborn or young baby presents with fever and sluggishness or irritability, meningitis is a primary business. Bacterial meningitis has an incidence of about 20 to 100 cases per 100,000 alive births during the newborn period.one Aseptic meningitis is even more common. Although most types of aseptic meningitis practise not cause serious sequelae, some types result in significant morbidity and mortality if not properly diagnosed and treated. Physicians should maintain a high alphabetize of suspicion for these treatable causes.
Illustrative Case
- Abstract
- Illustrative Case
- Evaluation of the Newborn or Infant with Suspected Meningitis
- Etiologies
- Treatment
- Complications
- References
A 29-day-old male babe was brought to the role with a history of tympanic fever ranging upwards to 37.7°C (100.0°F) for 2 days. He was eating well and had no other symptoms. His tympanic temperature during the office visit was 36.ix°C (98.5°F), and the physical examination was normal. The child was discharged with a diagnosis of a viral affliction. Ii days later, he adult a tympanic temperature of 39.iv°C (103.0°F). He was mildly anorectic, more irritable and more somnolent. He had no cough, vomiting or diarrhea.
The prenatal history was remarkable for maternal outset-trimester primary genital herpes simplex virus (HSV) infection. The infant's mother tested negative for group B streptococcus. She had no history of intravenous drug use. She had not traveled out of the country and had no known exposure to ticks, cats or undercooked meat. The patient had been delivered by cesarean section because of probable reactivation of maternal genital HSV infection.
Physical examination performed in the emergency department revealed a rectal temperature of 37.5°C (99.6°F); pulse, 174 beats per minute; respiration, xl per minute; and blood pressure, 97/41 mm Hg. The infant was fussy but consolable and in no acute distress. Physical exam was remarkable only for a clear nasal discharge. His lungs were articulate, and the heart exam was normal. He had no jutting fontanelle, rash, petechiae, vesicular lesions, hepatosplenomegaly or neurologic abnormalities.
The cerebrospinal fluid showed a red blood jail cell count of 15 per mL and a white blood cell count of 1,295 per mL, with a differential of 1 percent neutrophils, 32 per centum lymphocytes and 67 percent monocytes. The cerebrospinal fluid glucose level was 35 mg per dL (ane.94 mmol per L), with a serum glucose level of 110 mg per dL (half dozen.one mmol per Fifty) and a cerebrospinal fluid protein measurement of 79 mg per dL (0.79 g per L). His peripheral consummate blood prison cell (CBC) count was 13,600 per mL, with a differential of 32 percent neutrophils, 61 per centum lymphocytes and 2 percent monocytes.
Because of the patient'due south age and the maternal history of genital HSV infection, the infant was admitted to the hospital, and cefotaxime (Claforan), ampicillin and acyclovir (Zovirax) were administered. Clinical improvement was apparent within the first 48 hours. After bacterial cultures were negative for 72 hours, therapy with cefotaxime and ampicillin was discontinued. After cerebrospinal fluid culture for HSV was negative for 7 days and the polymerase chain reaction (PCR) test of the cerebrospinal fluid was negative, therapy with acyclovir was discontinued. Stool culture grew coxsackie B virus. The infant recovered and was reaching appropriate developmental milestones at six months of age.
Evaluation of the Newborn or Infant with Suspected Meningitis
- Abstract
- Illustrative Case
- Evaluation of the Newborn or Baby with Suspected Meningitis
- Etiologies
- Treatment
- Complications
- References
HISTORY
When because the possibility of meningitis in an ill-appearing newborn or infant, the history of the mother and kid may help in the determination of possible causative agents and assessment of the severity of the illness. Symptoms to inquire about in the baby include poor feeding, lethargy or irritability, altered sleep pattern, seizures, rash, vomiting, diarrhea or respiratory difficulty.1 Fever may or may not exist nowadays (Table 1). To help identify the cause of meningitis, it is important to consider the season, the patient's exposure to sick persons and travel history, and typical infectious diseases that may be prevalent in the community at the time.2 In infants younger than three months of historic period, congenital and perinatal diseases may present with abnormal cerebrospinal fluid findings. The mother should be questioned near whatsoever fever or complicating illness occurring during pregnancy or around the time of delivery. In addition, maternal drug-utilise and sexual histories may requite important information. Family unit physicians have a particular advantage in this expanse since they may have cared for both the mother and the babe.
TABLE one
Signs and Symptoms of Meningitis in Infants
| Fever or hypothermia (temperature may also be normal) |
| Poor feeding |
| Irritability or sluggishness |
| Seizures |
| Rash (petechial, vesicular, macular, mucosal) |
| Tachypnea or apnea |
| Jaundice |
| Jutting fontanelle (tardily) |
| Vomiting or diarrhea |
| Altered sleep design |
Concrete EXAMINATION
In the physical examination of a newborn or infant with meningitis, findings may range from completely normal to stupor or even seizures. Important physical findings include lethargy or irritability, fever or hypothermia, petechial, vesicular or macular skin rash, mucosal lesions, tachypnea or apnea1 (Table 1). Meningeal signs (nuchal rigidity) are not typical in this historic period grouping. A bulging fontanelle is frequently absent-minded until late in the course of the illness. The child may be more irritable while being held than while lying withal (paradoxic irritability).
LABORATORY DATA
The most important examination to perform when meningitis is suspected is the lumbar puncture. The cerebrospinal fluid should be tested for cell counts with differential, Gram stain, glucose determination, poly peptide and bacterial cultures. Some fluid should be saved if further diagnostic studies are needed. 7 or more days may be necessary for definitive results of viral cultures. PCR can provide aforementioned-day results for several viruses, including HSV, cytomegalovirus, human being immunodeficiency virus (HIV) and the enteroviruses.3
Other of import laboratory values to obtain during the evaluation include a CBC and bacterial cultures of claret and urine. If possible, the serum glucose level should be obtained before the lumbar puncture, since the process itself may cause serum glucose to be elevated.iv Latex antigen tests for Haemophilus influenzae type b, Streptococcus pneumoniae, Neisseria meningitidis and group B streptococcus may be useful if positive, especially if patients take previously received antibiotics and have negative Gram stains and cultures.4 Stool cultures may also be indicated. Occasionally, a computed tomographic (CT) scan or magnetic resonance imaging (MRI) is indicated to aid identify causative agents. For example, cytomegalovirus, toxoplasmosis, rubella and HSV may prove calcifications, while Staphylococcus aureus, Citrobacter diversus, Proteus mirabilis and other bacteria can cause abscesses.5,six Table 2 summarizes diagnostic tests for suspected meningitis.
Tabular array 2
Diagnostic Tests for Suspected Meningitis
| In most cases | |
| Lumbar puncture to obtain CSF for: | |
| Cell count with differential | |
| Gram stain | |
| Glucose level | |
| Protein level | |
| Bacterial cultures | |
| Claret cultures for bacteria | |
| Serum glucose level | |
| Urine culture | |
| Consider | |
| Latex antigen test of CSF and urine for | |
| Haemophilus influenzae, Streptococcus pneumoniae, Neisseria meningitidis, group B streptococcus | |
| Polymerase chain reaction test of CSF for viruses (HSV, CMV, HIV, Enterovirus) | |
| Viral cultures of CSF, urine, stool, nasopharynx | |
| Serology for infectious etiologies as indicated by history or physical examination (maternal or baby) | |
| Stain for acid-fast bacillus | |
| CT scan of the brain with and without dissimilarity, or MRI | |
When a complete evaluation of the cerebrospinal fluid, including Gram stain, is performed, bacterial meningitis is documented by culture in only 1 to five percentage of patients with normal values.4 Normal cerebrospinal fluid values vary with historic period (Table 3). Although cerebrospinal fluid values may assistance to differentiate bacterial from viral etiologies, civilisation is nonetheless the gold standard. Cerebrospinal fluid values for bacterial and aseptic meningitis may overlap, and all newborns and young infants should receive antibody therapy if cerebrospinal fluid values are aberrant or meningitis is suspected. Antiviral therapy should exist added if the history, physical exam and laboratory findings propose a possible viral etiology.
TABLE 3
Typical Cerebrospinal Fluid Values in Newborns and Immature Infants
| Values | Normal term newborn | Normal infant* | Bacterial meningitis | Viral meningitis |
|---|---|---|---|---|
| White blood cells | < 30 per mL | < x per mL | 200 to 100,000 per mL | 25 to 1,000 per mL |
| Neutrophils | < 60 % | < 10 % | 80 to 100 % | < 50 % |
| Glucose | > sixty % of serum | > fifty % of serum | < 40 % of serum | > 40 % of serum |
| Protein | <seventy mg per Dl (i.7 m per Fifty) | <40 mg per dL (0.4 g per Fifty) | 100 to 500 mg per dL (1 to 5 g per Fifty) | l to 100 mg per dL (0.5 to i g per L) |
Etiologies
- Abstract
- Illustrative Case
- Evaluation of the Newborn or Infant with Suspected Meningitis
- Etiologies
- Treatment
- Complications
- References
Results of cerebrospinal fluid culture split up meningitis into two categories: bacterial, in which bacteria are grown from the cerebrospinal fluid, and hygienic, in which no growth of bacteria by standard culture methods is shown.
BACTERIAL ETIOLOGIES
Typical pathogens vary with age (Table 4). In the first month of life, group B streptococcus is the nearly common etiologic amanuensis. Although it ordinarily presents as sepsis in the neonate, information technology tin can have a late-onset presentation every bit meningitis at i to 12 weeks of age.5 Escherichia coli and Listeria monocytogenes are other pathogens that cause meningitis in the newborn. Afterwards the first month of life, S. pneumoniae and Northward. meningitidis go more common pathogens.1 The widespread utilise of the H. influenzae type b (Hib) vaccine has caused a dramatic subtract in the incidence of this affliction (from 2.9 cases per 100,000 in 1986 to 0.two cases per 100,000 in 1995).7
TABLE iv
Differential Diagnosis of Bacterial Meningitis in Newborns and Young Infants
| < 1 month of age |
| Group B streptococcus |
| Escherichia coli |
| Listeria monocytogenes |
| Streptococcus pneumoniae |
| One to half dozen months of historic period |
| Due south. pneumoniae |
| Haemophilus influenzae |
| Neisseria meningitidis |
| E. coli |
| 50. monocytogenes |
ASEPTIC ETIOLOGIES
In addition to bacterial causes, aseptic meningitis should be considered in infants with abnormal cerebrospinal fluid values. Aseptic meningitis typically follows a shorter, more beneficial course than bacterial meningitis. Etiologies include viral infection, partially treated bacterial meningitis, congenital infections, other less common infectious agents, drug reactions, postvaccination complications, systemic diseases and malignancy2 (Table v).
Tabular array 5
Differential Diagnosis of Aseptic Meningitis
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Amid the viral etiologies, enteroviruses account for approximately 85 pct of cases.2 Enterovirus meningitis usually occurs in the summer and fall, with astute onset of symptoms that last one to two weeks.2 If Enterovirus is a possibility, a sample of cerebrospinal fluid should be sent for this viral civilization.
HSV affects 1,500 to 2,000 neonates each year. Of these, iv percent acquire the virus congenitally, 86 percent during delivery and 10 percent postnatally.eight The chance of an infant becoming infected appears to depend on the timing of maternal seroconversion, with the highest risk occurring when the onset of maternal main herpes is near the time of labor.9 The typical presentation of neonatal HSV infection follows one of three patterns. The first blueprint is localized HSV with herpetic lesions of the skin, heart or oral fissure; if left untreated, 75 percent of these patients progress to more extensive infection.8 The 2nd presentation is generalized herpes sepsis, which resembles bacterial sepsis, with alterations in temperature, and lethargy, respiratory distress, anorexia, vomiting and cyanosis.eight The third presentation is localized central nervous organization infection (meningitis or encephalitis), with irritability, jutting fontanelle, seizures, paralysis or blackout.8 When HSV infection is a possibility, samples of the cerebrospinal fluid should be sent for HSV culture and PCR.
Other sexually transmitted diseases may crusade congenital or perinatal infection and must be considered in the differential diagnosis since they may require specific therapy. Since its emergence in 1982, HIV infection has been increasing in women and children. An estimated 7,000 infected women give nascency to one,000 to 2,000 infected infants each year.10 Infected infants may present with opportunistic infections, pneumonitis or neurologic dysfunction.11 Since antibody tests performed on the infant may likewise detect maternal antibody, these tests cannot definitively diagnose HIV in infants. Newer methods for direct detection, including PCR, tin can identify upwards to 40 per centum of infected infants at birth.11 The incidence of maternal-to-fetal transmission should decrease with increased maternal prenatal treatment with zidovudine (Retrovir).12
Possible infection with cytomegalovirus, syphilis, toxoplasmosis, Lyme disease and tuberculosis may be evaluated with diagnostic tests such equally PCR, specific antibody titers and acid-fast stains. Cytomegalovirus is the most common congenital infection. Approximately twoscore,000 infants built-in in the United States have cytomegalovirus infection, and twenty percent of these infants experience pregnant morbidity or mortality.xiii A diagnosis of built syphilis should be considered in infants with the concrete stigmata of syphilis or in those whose mothers take a known history of inadequately treated syphilis. Each yr in the United States, about 3,000 infants are built-in with congenital toxoplasmosis. Most cases of toxoplasmosis are acquired through ingestion of undercooked meat or oocytes from cat feces. Although built Lyme disease is rare, it may cause neurologic symptoms in twenty per centum of infants and, in areas where Lyme disease is endemic, should be considered if there is a history of maternal exposure to ticks.14 With the increasing prevalence of tuberculosis secondary to HIV illness, tuberculous meningitis may get more than mutual and should be considered as a possible etiology.15
Table 6 summarizes historic clues that may help the physician diagnose treatable causes of aseptic meningitis.
TABLE 6
Historical Findings Supporting the Diagnosis of Treatable Causes of Aseptic Meningitis
| Disease | Maternal affliction | STD chance | Intravenous drug use | Exposure to cat feces or raw meat | Tick bite | Twenty-four hours care exposure | Close-contact exposure | Seasonal |
|---|---|---|---|---|---|---|---|---|
| Cytomegalovirus | 10 | X | 10 | X | ||||
| Enterovirus | X | 10 | X | Ten | ||||
| Herpes simplex virus | X | X | Ten | |||||
| HIV | X | X | X | |||||
| Lyme disease | X | X | Ten | |||||
| Syphilis | Ten | X | ||||||
| Toxoplasmosis | 10 | Ten | ||||||
| Tuberculosis | Ten | Ten |
Treatment
- Abstract
- Illustrative Instance
- Evaluation of the Newborn or Babe with Suspected Meningitis
- Etiologies
- Treatment
- Complications
- References
Since the causative agent is normally not known at presentation, all newborns or infants with meningitis should exist treated aggressively ( Figure 1 ). Patients should be hospitalized, and treatment with intravenous antibiotics should be started. Toxic or unstable patients crave intensive-care monitoring. Although bacterial organisms are frequently associated with a more fulminant class, HSV and Enterovirus may also produce viral septic daze. Antibiotics should be administered until all bacterial cultures have been negative for at least 72 hours. Protocols for treatment of bacterial meningitis have been recently published.16–xviii The increasing prevalence of penicillin-resistant Due south. pneumoniae in certain parts of the country offers new challenges in treatment.
Diagnosis and Treatment of Meningitis in Infants and Newborns
FIGURE 1.
[ corrected] Diagnosis and treatment of meningitis in newborns and infants based on CSF findings. (CSF = cerebrospinal fluid; PCR = polymerase chain reaction; HSV = canker simplex virus; Ab = antibody; PPD = purified protein derivative).
If HSV infection is a possibility, acyclovir should be added to the treatment regimen. Acyclovir, in dosages of 10 to 15 mg per kg every eight hours for 10 days, has been shown to decrease mortality rates from 49 pct to 17 percentage and to reduce neurologic sequelae from 74 percent to 33 percent.8 Empiric acyclovir therapy is indicated in newborns and infants with typical herpetic skin or mouth lesions, presumed viral encephalitis when no other crusade has been identified, sepsis syndrome with negative bacterial cerebrospinal fluid and blood cultures, or sepsis syndrome with either a positive maternal vaginal HSV culture at the fourth dimension of birth or a history of HSV infection in a parent.8
Specific treatment can improve outcomes for other causes of aseptic meningitis (Tabular array 7). Current handling for Enterovirus meningitis is supportive, and nigh infants recover completely. Intravenous immune globulin may play a role in management of severe cases.19 The antiviral drug pleconaril is currently in phase II clinical trials for treatment of adolescents and adults with enteroviral meningitis, and clinical trials for evaluation of treatment of neonatal enteroviral affliction are planned for the near future.20 Treatment for congenital HIV infection is constantly evolving, and infected infants should be managed with the most current antiretroviral regimens.
TABLE seven
Recommended Treatments for Hygienic Meningitis
| Etiology | Handling |
|---|---|
| Cytomegalovirus | Ganciclovir (Cytovene) (clinical research trial) |
| Enterovirus | Immune globulin (possibly pleconaril) |
| Herpes simplex virus | Acyclovir (Zovirax) |
| Human immunodeficiency virus | Multidrug antiretroviral regimens |
| Lyme affliction | Ceftriaxone (Rocephin) |
| Syphilis | High-dose penicillin |
| Toxoplasmosis | Pyrimethamine (Daraprim) and sulfadiazine |
| Tuberculosis | Multidrug antimycobacterial regimens |
Up to ninety percent of symptomatic infants with congenital cytomegalovirus infection experience long-term sequelae.13 Research trials using ganciclovir are bachelor for newborns and young infants with built cytomegalovirus infection.21 Infants with congenital syphilis who are treated early on with high-dose penicillin take a lower risk of long-term sequelae.6 Treatment with investigational protocols using pyrimethamine (Daraprim) and sulfadiazine may meliorate the outcomes in infants with congenital toxoplasmosis infection.6 Congenital Lyme disease can exist treated with ceftriaxone (Rocephin).14 Infection with Mycobacterium tuberculosis requires a prolonged regimen of multiple antimycobacterium drugs, and patients with central nervous system disease may even so experience complications afterward this therapy.15
Figure 1 offers a suggested protocol for the diagnosis and treatment of meningtitis in newborns and young infants, based on results of bacterial and viral laboratory tests.
Complications
- Abstract
- Illustrative Case
- Evaluation of the Newborn or Infant with Suspected Meningitis
- Etiologies
- Treatment
- Complications
- References
Newborns and young infants with meningitis should be observed advisedly for both acute and chronic complications (Table 8). Acute complications include seizures, syndrome of inappropriate antidiuretic hormone (SIADH) and increased intracranial pressure level with focal or general neurologic findings.22 Poor prognostic factors include bacterial rather than viral infection, younger age, focal neurologic findings at admission and the presence of SIADH.4
Table 8
Common Complications of Meningitis
| Acute complications |
| Seizures |
| Syndrome of inappropriate antidiuretic hormone (SIADH) secretion |
| Hemodynamic instability |
| Increased intracranial pressure |
| Subdural effusions |
| Focal neurologic deficits |
| Chronic complications |
| Deafness |
| Seizure disorders |
| Motor deficits |
| Language deficits |
| Behavior disorders |
| Mental retardation |
Long-term sequelae include seizure disorder, hydrocephalus, sensorineural hearing loss, weakness, paralysis, cranial nerve palsy, learning disabilities, blindness, behavior disorders and speech delay.4,16,22 Although these sequelae are more common in patients with bacterial meningitis, they may also occur in patients with aseptic meningitis.22 Shut follow-up is needed after hospital discharge for all patients with meningitis. Hearing should be assessed one to two months later on discharge, using brainstem auditory evoked response testing. Neuromuscular cess at the fourth dimension of discharge should be documented and periodically assessed on an outpatient basis to let early detection of any deficiencies. Learning disabilities, behavior disorders and speech delay, which can be difficult to diagnose in infants and young children, require close monitoring after discharge and at subsequent well-child visits.
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REFERENCES
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