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Suggest Treatment For Infective Meningitis
Question: hi, if a patient is diagnosed with meningitis, is there a need to put the patient on Phenytoin as a prophylaxis for Seizures? kindly provide me also with a guideline, publication or an article supporting the answer. i have added the details of the admission below for your kind reference
This is 13 years old male member presented to the Emergency Department on the 28th of May 2015 with complaints of Headache, Vomiting, Fever, body Pain and Loss of Appetite for the last 7 days.
History of Present Illness:
The condition started 2 weeks prior to admission when he had Fever and he presented to Iranian Hospital where he was diagnosed as URTI and was given medications and sent home. Since then he was refusing to eat and only requesting for high sugar drinks. 2 days prior to admission he developed a Severe Headache which was bilateral and has vomited many times (As per Family). He was still having on and off Fever with Body Pain. There was no Abdominal pain, no Diarrhea, no Cough and no Changes in Micturition. There was also no changes in Vision or any history of Weakness. Patient was started on Perfalgan, Ranitidine, Metoclopramide and Ceftriaxone.
Past Medical History:
The patient has no similar condition before and no History of Chronic Diseases.
On Examination:
Patient looks unwell
Heart Rate: 102/min
Blood Pressure: 107/87 mmHg
Respiratory Rate: 26/min
Temperature: 37.5 C
Saturation: 97% in RA
Not pale, Jaundiced or Cyanosed
Lying flat in bed
Chest shows normal vesicular breathing and no added sound
Normal S1, S2
Abdomen is soft with no tenderness, scar, visible vein or organomegally
Patient is oriented to time, place and person
Positive Neck Stiffness
Normal power with no weakness
There is no papilledema
Kernig’s sign negative
Brudzinski sign negative
Lab Investigations on admission:
Test Result Test Result
Hemoglobin 13.0 ESR 76
Hematocrit 37.10 Glucose Random 158
RBC 4.5 HbA1c 5.9
MCV 82.4 eAG 122.6
MCH 28.9 Bilirubin – Total 0.47
MCHC 35.0 Bilirubin - Direct 0.24
RDW 12.7 Bilirubin - Indirect 0.23
Platelets 356 Total Protein 7.0
WBC 24.6 Albumin 3.7
Neutrophils 87.9 Globulin 3.3
Lymphocytes 4.6 A/G Ratio 1.1
Monocytes 7.3 ALP 132
Eosinophils 0.1 AST 23
Basophils 0.1 ALT 10
CRP 148.6 GGT 14
On 29.05.2015:
The patient is afebrile today with Blood pressure of 109/63, and pulse of 72/min. The patient looks ill and still complaining of headache. He is dehydrated and sweating. Throat shows signs of dehydration on examination (coated tongue) and there are[ no signs of congestion. Neurological consultation was done and advised for Widal Test which was negative. Chest X-Ray, CBC, Urine Analysis and culture, ESR, CRP and blood cultures. And then after the Widal test, Chest X-Ray and CBC were normal a CT Scan Brain with contrast was done. CT Scan revealed increased Leptomeningeal enhancement in the right fronto-temporal region and the basal cisterns, consistent with meningitis and right fronto-temporal subdural effusion with mass effect and midline shift (6mm) to the left and hence treatment for Meningitis begun. Patient was started on Manitol, Phenytoin, risek, Topomax, dexamethasone, Metoclopramide and Ceftiaxone. Patient was shifted to Isolation Room after the confirmation from the CT Scan.
CT Brain with Contrast:
There is increased Leptomeningeal enhancement in right Fronto-Temporal region and the basal cisterns. A cresentric extra-axial collection with hypodense contents is seen in the right frontal location and extending into temporal region. It measures 7.5mm in maximum thickness, 10.6cm in transverse and 10.8cm in maximum craniocaudal extent. Mass effect is seen with partial effacement of frontal horn of right lateral ventricle and midline shift of 6mm to the left.
Brain parenchyma shows normal attenuation pattern with well-preserved grey white matter differentiation.
No significant parenchymal lesion is seen. Rest of the ventricular spaces are normal
Brain stem and cerebellum appear normal
Note is made of left frontal, ethmoid and left maxillary sinusitis
Impression
CECT Findings are suggestive of increased Leptomeningeal enhancement in the right fronto-temporal region and the basal cisterns, consistent with meningitis and right fronto-temporal subdural effusion with mass effect and midline shift (6mm) to the left.
On 30.05.2015:
The patient is feeling better as per the family. There are no irritability symptoms. His blood pressure is 115/78 mmHg, pulse is 86/min, respiratory rate is 20/min and temperature is 35.6 C. there are no new complaints and the patient is continuing on the medications.
Lab Investigations on 30.05.2015:
Test Result Test Result
Hemoglobin 13.0 Platelets 399
Hematocrit 36.30 WBC 24.4
RBC 4.5 Neutrophils 92.8
MCV 81.0 Lymphocytes 3.6
MCH 29.0 Monocytes 3.5
MCHC 35.8 Eosinophils 0.0
RDW 13.0 Basophils 0.1
On 31.05.2015:
The patient is irritable today with excessive crying and increased irritability. He was better in the last 2 days. CT Brain non contrast was done for follow up and there is a slight increase in thickness to measure 8mm compared to 7.5mm before. Blood pressure is 105/74, pulse is 78/min. today the patient is irritable, with positive photophobia and neck rigidity
CT Scan Brain:
The collection became more hypodense with CT density ranges between 19-33 HU.
Slight increase in the Thickness to measure about 8mm compared to 7mm
Also noted minimal increase in the midline shift that is measuring about 7mm compared to 6mm in the previous study.
On 01.06.2015:
Patient looks very ill today and he is crying and screaming. His blood pressure is 107/66, temperature is 35.3, pulse is 51/min and respiratory rate is 23/min. patient is conscious, irritable and with neck rigidity. The patient developed right divergent squint today with decreased conscious level (Stupor) which goes with manifestation of increased intracranial pressure. Rest of examination is normal.
This is 13 years old male member presented to the Emergency Department on the 28th of May 2015 with complaints of Headache, Vomiting, Fever, body Pain and Loss of Appetite for the last 7 days.
History of Present Illness:
The condition started 2 weeks prior to admission when he had Fever and he presented to Iranian Hospital where he was diagnosed as URTI and was given medications and sent home. Since then he was refusing to eat and only requesting for high sugar drinks. 2 days prior to admission he developed a Severe Headache which was bilateral and has vomited many times (As per Family). He was still having on and off Fever with Body Pain. There was no Abdominal pain, no Diarrhea, no Cough and no Changes in Micturition. There was also no changes in Vision or any history of Weakness. Patient was started on Perfalgan, Ranitidine, Metoclopramide and Ceftriaxone.
Past Medical History:
The patient has no similar condition before and no History of Chronic Diseases.
On Examination:
Patient looks unwell
Heart Rate: 102/min
Blood Pressure: 107/87 mmHg
Respiratory Rate: 26/min
Temperature: 37.5 C
Saturation: 97% in RA
Not pale, Jaundiced or Cyanosed
Lying flat in bed
Chest shows normal vesicular breathing and no added sound
Normal S1, S2
Abdomen is soft with no tenderness, scar, visible vein or organomegally
Patient is oriented to time, place and person
Positive Neck Stiffness
Normal power with no weakness
There is no papilledema
Kernig’s sign negative
Brudzinski sign negative
Lab Investigations on admission:
Test Result Test Result
Hemoglobin 13.0 ESR 76
Hematocrit 37.10 Glucose Random 158
RBC 4.5 HbA1c 5.9
MCV 82.4 eAG 122.6
MCH 28.9 Bilirubin – Total 0.47
MCHC 35.0 Bilirubin - Direct 0.24
RDW 12.7 Bilirubin - Indirect 0.23
Platelets 356 Total Protein 7.0
WBC 24.6 Albumin 3.7
Neutrophils 87.9 Globulin 3.3
Lymphocytes 4.6 A/G Ratio 1.1
Monocytes 7.3 ALP 132
Eosinophils 0.1 AST 23
Basophils 0.1 ALT 10
CRP 148.6 GGT 14
On 29.05.2015:
The patient is afebrile today with Blood pressure of 109/63, and pulse of 72/min. The patient looks ill and still complaining of headache. He is dehydrated and sweating. Throat shows signs of dehydration on examination (coated tongue) and there are[ no signs of congestion. Neurological consultation was done and advised for Widal Test which was negative. Chest X-Ray, CBC, Urine Analysis and culture, ESR, CRP and blood cultures. And then after the Widal test, Chest X-Ray and CBC were normal a CT Scan Brain with contrast was done. CT Scan revealed increased Leptomeningeal enhancement in the right fronto-temporal region and the basal cisterns, consistent with meningitis and right fronto-temporal subdural effusion with mass effect and midline shift (6mm) to the left and hence treatment for Meningitis begun. Patient was started on Manitol, Phenytoin, risek, Topomax, dexamethasone, Metoclopramide and Ceftiaxone. Patient was shifted to Isolation Room after the confirmation from the CT Scan.
CT Brain with Contrast:
There is increased Leptomeningeal enhancement in right Fronto-Temporal region and the basal cisterns. A cresentric extra-axial collection with hypodense contents is seen in the right frontal location and extending into temporal region. It measures 7.5mm in maximum thickness, 10.6cm in transverse and 10.8cm in maximum craniocaudal extent. Mass effect is seen with partial effacement of frontal horn of right lateral ventricle and midline shift of 6mm to the left.
Brain parenchyma shows normal attenuation pattern with well-preserved grey white matter differentiation.
No significant parenchymal lesion is seen. Rest of the ventricular spaces are normal
Brain stem and cerebellum appear normal
Note is made of left frontal, ethmoid and left maxillary sinusitis
Impression
CECT Findings are suggestive of increased Leptomeningeal enhancement in the right fronto-temporal region and the basal cisterns, consistent with meningitis and right fronto-temporal subdural effusion with mass effect and midline shift (6mm) to the left.
On 30.05.2015:
The patient is feeling better as per the family. There are no irritability symptoms. His blood pressure is 115/78 mmHg, pulse is 86/min, respiratory rate is 20/min and temperature is 35.6 C. there are no new complaints and the patient is continuing on the medications.
Lab Investigations on 30.05.2015:
Test Result Test Result
Hemoglobin 13.0 Platelets 399
Hematocrit 36.30 WBC 24.4
RBC 4.5 Neutrophils 92.8
MCV 81.0 Lymphocytes 3.6
MCH 29.0 Monocytes 3.5
MCHC 35.8 Eosinophils 0.0
RDW 13.0 Basophils 0.1
On 31.05.2015:
The patient is irritable today with excessive crying and increased irritability. He was better in the last 2 days. CT Brain non contrast was done for follow up and there is a slight increase in thickness to measure 8mm compared to 7.5mm before. Blood pressure is 105/74, pulse is 78/min. today the patient is irritable, with positive photophobia and neck rigidity
CT Scan Brain:
The collection became more hypodense with CT density ranges between 19-33 HU.
Slight increase in the Thickness to measure about 8mm compared to 7mm
Also noted minimal increase in the midline shift that is measuring about 7mm compared to 6mm in the previous study.
On 01.06.2015:
Patient looks very ill today and he is crying and screaming. His blood pressure is 107/66, temperature is 35.3, pulse is 51/min and respiratory rate is 23/min. patient is conscious, irritable and with neck rigidity. The patient developed right divergent squint today with decreased conscious level (Stupor) which goes with manifestation of increased intracranial pressure. Rest of examination is normal.
Brief Answer:
May be given eptoin for prophylaxis in some cases
Detailed Answer:
Hello XXXXXXX
I have gone through your question and understand your concerns.
After reviewing all history and reports possibility of infective meningitis is one possibility. Other possibility may be lymphoma or leukemia, sarcoidosis.
Present condition requires neurosurgery opinion for intervention as symptoms and signs of raised intracranial pressure is there.
antibiotics should be continued.
Csf analysis when feasible with no risk of herniation may be done but not at present condition.
Prophylaxis eptoin is usually not given but some physician prefer to give prophylaxis if cortical or subdural collection are present.
In present case eye deviation may be a manifestation of seizure and so treatment to be continued.
possibility of tubercular meningitis should also be considered.
hope you found the answer helpful.
do get back to me for further queries.
Regards
Dr Neeraj Kumar
Neurologist
May be given eptoin for prophylaxis in some cases
Detailed Answer:
Hello XXXXXXX
I have gone through your question and understand your concerns.
After reviewing all history and reports possibility of infective meningitis is one possibility. Other possibility may be lymphoma or leukemia, sarcoidosis.
Present condition requires neurosurgery opinion for intervention as symptoms and signs of raised intracranial pressure is there.
antibiotics should be continued.
Csf analysis when feasible with no risk of herniation may be done but not at present condition.
Prophylaxis eptoin is usually not given but some physician prefer to give prophylaxis if cortical or subdural collection are present.
In present case eye deviation may be a manifestation of seizure and so treatment to be continued.
possibility of tubercular meningitis should also be considered.
hope you found the answer helpful.
do get back to me for further queries.
Regards
Dr Neeraj Kumar
Neurologist
Above answer was peer-reviewed by :
Dr. Shanthi.E
Answered by
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