Pediatric emergency medicine trisk 1005

Current Evidence. The most common bacterial and viral pathogens are
listed according to age in Table 122.2 . The relative rates of meningitis,
especially bacterial meningitis, remain highest in the neonatal age group.
Clinical Recognition. Most patients present with fever, evidence of
meningeal irritation, and increased ICP from diffuse cerebral edema or
hydrocephalus with CSF obstruction at the basilar cisterns. However,
clinical manifestations may be nonspecific.
Diagnostic testing. Infection of the subarachnoid space can be diagnosed
by sampling the CSF through a lumbar puncture. A CT scan or quick brain
MRI should be performed prior to lumbar puncture to rule out
hydrocephalus. Lumbar puncture in the setting of untreated hydrocephalus
may precipitate life-threatening herniation.
Management. Suspected bacterial meningitis is a medical emergency and
administration of appropriate antibiotic therapy should not be deferred if
lumbar puncture cannot be performed. Placement of an ICP monitor is
controversial even in the presence of a poor neurologic examination or
cerebral edema. Monitoring ICP has not been shown to improve outcomes
in these patients. Maintenance of cerebral perfusion, by avoiding
hypotension, not the direct treatment of elevated ICP, improves outcomes.
The most important prognostic factor for patients with meningitis is prompt
and appropriate antimicrobial treatment.


TABLE 122.2
PEDIATRIC MENINGITIS CAUSATIVE ORGANISMS
Age

Common pathogens

Birth to 90 days

Group B streptococcus
Escherichia coli
Streptococcus pneumoniae
Neisseria meningitidis
Listeria monocytogenes
Herpes simplex virus (HSV)
Enterovirus
Streptococcus pneumoniae
Neisseria meningitidis
Group B streptococcus
Gram-negative rods
Herpes simplex virus
Enterovirus
Streptococcus pneumoniae
Neisseria meningitidis
Enterovirus
Neisseria meningitidis
Streptococcus pneumoniae
Enterovirus
Arboviruses

≥3 months to 3 years

≥3 years to 10 years

≥10 years to 18 years

In exceptional cases where the meningitis is complicated by
hydrocephalus, an external ventricular drain may need to be placed. If the
hydrocephalus is permanent from scarring of the subarachnoid spaces, a

shunt for CSF diversion may need to be considered once the infection has
been treated.

Discitis/Osteomyelitis


Common pathogens encountered in children include Staphylococcus
aureus, Kingella kingae, pneumococci, and salmonella species. The
prevailing hypotheses are that it is thought to arise from a prior site of
infection and spread via three possible routes: hematogenously, by direct
inoculation, or by direct extension. Almost 50% of children will have a
prior prodromal illness related to their disc space infection. In children,
blood vessels are present in the annulus fibrosus and the vessels within the
vertebral body typically are anastomotic. These anatomic variations have
been proposed as a reason explaining preferential localization of bacterial
infections to the intervertebral disc space. Spondylodiscitis in children has a
bimodal age distribution (0 to 2 years and >10 years) mostly affecting the
thoracic and lumbar spine. Diagnosis can often be delayed up to 4 to 6
months secondary to the low incidence and vague presentation in children.
Clinical Recognition. Children most commonly present with back pain,
but nonspecific symptoms may be the only presentation, often without
fevers. Very young children with discitis often may refuse to walk, regress
with ambulatory motor skills, display Gower sign, torticollis or refuse to sit.
Several authors have proposed categories of symptoms for children
presenting with discitis: back pain, hip and leg pain, meningeal symptoms,
abdominal symptoms, or “irritable child” syndrome.
Diagnostic Testing and Imaging. Laboratory values (CBC, ESR, CRP)
and blood cultures should be obtained, but are often normal or only mildly
elevated. Blood cultures will often be positive early in the course of the
illness but given the delay in diagnosis, often only 50% are diagnostic. Very

early in the course, plain radiographs may be negative as it typically takes 2
weeks to a month before disc space narrowing becomes apparent. Initial
evaluation should include an MRI of the entire spine with contrast.
Technetium-99, bone scans will identify the problem 7 to 12 days after
onset of symptoms, but are nonspecific and require distinction between
inflammatory and neoplastic etiology.
Management. Treatment is controversial as most spondylodiscitis
infections have a relatively benign course. If a pathogen is not identified, a
CT-guided biopsy should be considered prior to initiation of antibiotic
treatment unless clinically contraindicated in the unstable or critically ill
patient. More routinely however, a course of intravenous broad-spectrum
antibiotics followed by oral antibiotics for 6 to 8 weeks is prescribed.


Antibiotic choice should be tailored to the pathogen identified by culture.
Surgery should be considered for refractory and progressive infections not
responding to antibiotics. Epidural extension with neurologic compromise
should be treated with emergent decompression and evacuation of the
infection.
Clinical Pitfall. An entity known as chronic recurrent multifocal
osteomyelitis (CRMO), or nonbacterial osteomyelitis (NBO), should be
distinguished from spondylodiscitis or osteomyelitis. It is often associated
with additional inflammatory syndromes, including peripheral arthritis,
sacroiliitis, psoriasis, inflammatory bowel disease or SAPHO (synovitis,
acne, pustulosis, hyperostosis, and osteitis). The etiology is poorly
understood. Young girls are more often affected (5:1) between the ages of 4
to 14 years. Patients are often asymptomatic between episodes, but
symptoms may extend beyond 6 months. Patients may have minor
diagnostic criteria of normal or mildly elevated labs (CRP, ESR),
hyperostosis, other autoimmune diseases, and an associated family history.

Radiographic imaging can mimic osteomyelitis, but other long bones are
typically involved. Bone biopsies are often necessary for diagnosis and
result as sterile but demonstrate evidence of inflammation and/or sclerosis
or fibrosis. Standard therapy involves NSAID use, but alternate medications
such as oral steroids, methotrexate, and bisphosphonates, most commonly
pamidronate, have been reported with positive early results.
Spinal Epidural Abscess
The most common anatomical site for thecal sac encroachment by epidural
abscess is in the cervical spine, followed by the thoracic and lumbar spine.
However, neurologic complications, paraparesis or paraplegia, as a result of
thecal sac compression occurred more frequently in the thoracic and
cervical regions. The most feared complication of primary or secondary
spinal epidural abscess is paralysis. When paraplegia or tetraplegia is
present, the prognosis is very poor.

POSTOPERATIVE COMPLICATIONS
CLINICAL PEARLS AND PITFALLS