Clinical scenario 3: Jenna

Jenna, a four month old girl, presents with a one day history of fever, fussiness and poor feeding. She is irritable and difficult to console but is breathing comfortably on her own and maintaining a good airway. She does not like to be moved. Vital signs:

RR 36min, HR 120/min, BP 90/58 mmHg.

Temperature 39.2° C and SaO2 98% in room air.

Her fontanelle appears full and her neck appears slightly stiff. CRT < 2 seconds.

The following seven questions refer to Jenna’s clinical scenario.

Question 11

Which ONE of the following is the most likely diagnosis?
URTI
Meningitis
UTI
Encephalitis
Not possible to determine
Check answer

Explanation

This child has features suggestive of meningitis, given her irritability and full fontanelle. The diagnosis of meningitis may be more difficult in the very young as history and examinations can be non-specific. Note that young infants with meningitis may not have neck stiffness. Features include:

  • fever or hypothermia
  • bulging fontanelle or acute increase in head circumference.
  • irritability
  • high pitched cry
  • lethargy
  • altered mental state
  • seizures
  • apnoea
  • poor feeding
  • vomiting.

A high menu of suspicion for meningitis must exist in sick, febrile or hypothermic newborns, with or without the above features.

Question 12

What is your approach to her management? Place the appropriate options in the order in which you would perform them, but choose only those that are necessary for Jenna.

A) Lumbar puncture and bloods for FBC, UEC, CRP, Blood culture
B) Attend to airway, breathing and circulation
C) Dexamethasone
D) Empiric antibiotics
E) Head CT

B, A, C
B, C, E
B, C, D
E, B, A
C, D, A
Check answer

Explanation

B, A, C – Attend to airway, breathing and circulation, Lumbar puncture and bloods for FBC, UEC, CRP, Blood culture, and dexamethasone. Then commence antibiotics.

This requires a judgment call as to how unwell the child is. Any child first needs to have their airway, breathing and circulation assessed and resuscitated as required. In the case of the child who is not particularly unwell, such as here, it is better to perform an LP before administration of antibiotics.

If the child is unstable or particularly unwell, empiric antibiotics should be commenced and an LP delayed until it safe to perform. Antibiotics are imperative for treatment of meningitis and should not be delayed for logistical delays in performing an LP.


For children over three months, there is evidence that early administration of dexamethasone before commencement of antibiotics has beneficial effects on hearing impairment in HIB and non-HIB meningitis.

For children less than three months, it is less clear as there are potential adverse effects and thus it is not recommended. A head CT is not routinely indicated for suspected meningitis unless there are focal neurological signs or the child is comatose.

Question 13

A lumbar puncture is performed. Place the following five steps in the correct order for performing a lumbar puncture.

A) Positioning of child
B) Insertion of needle and collection of fluid
C) Clean area
D) Parental consent
E) Local anesthetic patch
E, A ,C, B, D
A ,C, B, D, E
C, B, D, E, A
B, D, E, A ,C
D, E, A ,C, B
Check answer

Explanation

D-E-A-C-B

Parental consent, local anesthetic patch, positioning of child, clean area, and insertion of needle and collection of fluid.

It is important to gain consent for an LP. A full explanation of the procedure should be given, including a fact sheet. Local anaesthetic cream is usually placed on the lower back unless the LP is being performed as a matter of extreme urgency. Injection of local anaesthetic is also used but may obscure landmarks.

In many units, inhaled nitrous oxide or a mild sedative such as oral midazolam may be given to an older child. Oral sucrose should be considered in a neonate. The child needs to be positioned on their side with their legs curled up under their chin.

A nurse is required to assist with positioning and to keep the child still. An LP is a sterile procedure. The skin over the lower back is cleaned with iodine or chlorhexidine. Sterile drapes are placed around the site. The needle is inserted into the spinal space between L3-L4 or L4-L5. This is located by palpating the posterior-superior iliac crest and drawing an imaginary line between the two crests that intersect with L4. The needle is inserted with the bevel facing up and aiming cephalad towards the umbilicus, advancing slowly.

Since penetration of the dura is not always obvious. The stylet can be removed from time to time during insertion to look for CSF. A “pop” is sometimes heard as the needle enters the subarachnoid space. CSF should be collected in 3-4 separate numbered tubes with approximately ten drops in each tube. The stylet should then be replaced and the needle removed.

A dressing should be placed over the site.

As with all procedures in paediatrics it is important to be able to describe the procedure in lay terms for the parents.

Reference:

See lumbar puncture fact sheet

Question 14

Which of the following are the TWO most likely complications of an LP?

Introduction of infection and traumatic tap
Traumatic tap and unsuccessful procedure
CSF leak, and nerve involvement - paralysis
Unsuccessful procedure and introduction of infection
Nerve involvement - paralysis and CSF leak
Check answer

Explanation

All of these are potential complications. By far the most common is a traumatic e.g: blood stained tap (making immediate interpretation more difficult) and an unsuccessful procedure.

Other complications include dermoid from introduction of skin tissue during procedure, headache (hard to determine at this age) and coning (less risk with open anterior fontanelle)

Clinical scenario: Jenna continued

The preliminary CSF results show:

Question 15

Which ONE of the following is the most likely cause of the meningitis demonstrated by this CSF result?
Viral
Bacterial
Tuberculosis
Traumatic tap
Fungal
Check answer

Explanation

The presence of polymorphonuclear (PMN) cells should always be assumed to be abnormal and usually suggests bacterial meningitis. PMNs are often 100-10,000 while the lymphocyte count is <100. Protein is usually >1.0g/L but may be normal. Glucose is usually decreased but may be normal.

PMNs may also occur in the early phase of viral meningitis, although lymphocytosis is more commonly seen. PMNs are usually <100, while lymphocytes are 10-1000. Protein may be 0.4-1g/L or may be normal. Glucose is usually normal.

In tuberculous (TB) meningitis, the total WCC is usually < 500 x 106/L and lymphocytes predominate. Characteristically, the CSF glucose is low and CSF protein raised but normal values do not exclude TB meningitis.


The most accurate method is to compare the red cell count:white cell count in the blood versus the CSF (in anaemic children with a blood pleocytosis (high white cells) this ratio won’t be 500:1). Please see NSW health guidelines for bacterial meningitis.

Question 16

Which ONE of the following is the most common cause of bacterial meningitis in this age group?
Haemophilus influenza
Listeria monocytogenes
Group B streptococcus
Streptococcus pneumoniae
Neisseria meningitidis
Check answer

Explanation

The correct answer is: Neisseria meningitides.

Question 17

Which ONE of the following treatments would you commence?
IV cefotaxime
IV ampicillin and gentamicin
IV cefotaxime and vancomycin
IV benzylpenicillin
IV flucloxacillin
Check answer

Explanation

Three months – 15 years: Neisseria meningitidis (Meningococcus) is the most common organism. Haemophilus influenzae is now rare with Hib vaccination. Cefotaxime or ceftriaxone should be used empirically.

In addition, it is recommended that dexamethasone should be given in cases of acute bacterial meningitis where children are older than three months and antibiotics have not been used.

In the 0-3 month age group, the most likely organisms are Group B streptococcus, Escherichia coli and Listeria monocytogenes. Ampicillin (or benzyl penicillin) + cefotaxime should be used empirically.
*NB: Ceftriaxone is contraindicated in neonates.

Streptococcus pneumoniae (Pneumococcus) is a possible aetiological agent at any age. If S. pneumoniae is suspected, vancomycin should be used, in conjunction with a third generation cephalosporin. This includes:

  • CSF with Gram positive diplococci resembling streptococci seen on Gram stain
  • CSF, which is negative by gram stain, but the clinical presentation and/or other CSF findings are highly suspicious for bacterial meningitis
  • High clinical suspicion of bacterial meningitis, but a lumbar puncture is contra-indicated.

For more information, please see

NSW Health guideline: Infants and Children - Acute Management of Bacterial Meningitis

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