Sequence of Management of Suspected Infantile Meningitis! - USMLE Forums
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  #1  
Old 08-08-2011
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Kids Sequence of Management of Suspected Infantile Meningitis!

A 10 month old boy is brought to the ER for vomiting. He has a history of a 3 day fever sore throat and pain. He was treated for otitis with Amoxicillin but now his temperature is 103, BP 90/50. He is lethargic drowsy with pupils that do not focus and with full tense fontanelles and tense tympanic membranes.
What is the most appropriate next step in management?
A. IV Ampicillin with LP
B. LP and then IV Ampicillin
C. IV Ceftriaxone and Vancomycin followed by LP
D. LP followed with IV Ceftriaxone and Vancomycin
E. CT scan and then IV Ceftriaxone and Vancomycin
F. MRI and then IV Ceftriaxone & Vancomycin
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  #2  
Old 08-08-2011
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I think its D
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Old 08-08-2011
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I also think that D is the best option in children.
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Old 08-08-2011
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Originally Posted by cool_atomic View Post
I also think that D is the best option in children.
So you look over the suspected intercranial HTN and dont do anything pre LP....Does anyone know the specific reason
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Old 08-08-2011
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Default It's choice F

Patient has an increased ICP ,, in which LP is not an option


It's F MRI should demonstrate the dissemination of infection to the soft tissue of the brain and ear
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Old 08-08-2011
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Originally Posted by dr-ahmed View Post
Patient has an increased ICP ,, in which LP is not an option


It's F MRI should demonstrate the dissemination of infection to the soft tissue of the brain and ear
Y would u go to MRI before a CT for suspected ICP
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Old 08-08-2011
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Default It's the logic that makes the next step

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Originally Posted by Kais_MD View Post
Y would u go to MRI before a CT for suspected ICP

Well ,,,from my own point of view ,, we used previously to do CT scan to confirm increased ICP before going for the LP

But now we have high index of suspicion + clear evidence of increased ICP (tense fontanelles) ,, So the next logic best step is to look for the site of infection dissemination via an MRI ,,, this patient most probably have spread of infection to both his ear and venous sinuses ,,

I'd like to know what do u think about it too ?
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Old 08-08-2011
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Originally Posted by Kais_MD View Post
So you look over the suspected intercranial HTN and dont do anything pre LP....Does anyone know the specific reason
In infant , their fontanells are open , so its ok to do LP , they wont get herniation ..

After 1 year of age and in adult , we give emperic Rx first , then CT ...
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Old 08-08-2011
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Originally Posted by usmlekzz View Post
In infant , their fontanells are open , so its ok to do LP , they wont get herniation ..

After 1 year of age and in adult , we give emperic Rx first , then CT ...
to my mind the right choice is D.Under age 1 there is no an increased risk of herniation
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Old 08-08-2011
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Originally Posted by usmlekzz View Post
In infant , their fontanells are open , so its ok to do LP , they wont get herniation ..

After 1 year of age and in adult , we give emperic Rx first , then CT ...
USMLE KZ is right....in infants below 1 year the fontanelles havent closed so the risk of herniation is very rare...>So you can safe do an LP first and then antibiotics later....
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Old 08-08-2011
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Ok..I didnt know that!! Thanks usmle.....
Then it will be C isnt it?
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Old 08-08-2011
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Originally Posted by podebrad View Post
Ok..I didnt know that!! Thanks usmle.....
Then it will be C isnt it?
iTs D because LP is indicated first to eliminate any false negatives...Unless you cant do an LP right away because it doesnt yield anything.then you give antibiotics first...
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Old 08-08-2011
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Default didn't know that

Quote:
Originally Posted by usmlekzz View Post
In infant , their fontanells are open , so its ok to do LP , they wont get herniation ..

After 1 year of age and in adult , we give emperic Rx first , then CT ...
Well I didn't know that ,, then I guess LP would be safe as an initial step and may be Ct or MRI can be warranted later
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E. CT scan and then IV Ceftriaxone and Vancomycin
u cant do lp in a confused child u have to do ct bf lp
and mx must be ab 1st not ct then ab (vip to start rx 1st)
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Originally Posted by miss patho View Post
E. CT scan and then IV Ceftriaxone and Vancomycin
u cant do lp in a confused child u have to do ct bf lp
and mx must be ab 1st not ct then ab (vip to start rx 1st)
nope..>kaplan and world specifically states that on an infant below 1 year of age its ok...becuase there is virtually no risk of herniation which is why the ct is done in the first place...above 1 year yes its warranted..
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Old 08-08-2011
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Default Encephalitis vs meningitis

I do not have good info on encephalitis in children. But my concern in this patient are the AMS ("lethargic drowsy") and one focal neurologic finding ("pupils that do not focus"). So I would be concerned for encephalitis. I would do the MRI or CT not just to look for increased ICP but also to make the diagnosis of encephalitis or to rule it out. CT is the best initial test for encephalitis according to MTB, but MRI is superior according to UpToDate.

After the imaging, I would immediately give the patient a third-gen cephalosporin that penetrates the BBB well (like ceftriaxone or cefutaxime) and vanc. But in this case with a moderate to high likelihood of viral encephalitis (the most common etiology for encephalitis), I would add acyclovir to the empiric regimen.

In general, the AB Rx should start before the LP, so those answers are always wrong. However, it is debatable if the imaging or the ABx should come first; what do you guys think?
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