Meningitis without a petechial rash in children in the Hib vaccine era
Section snippets
Background
Bacterial meningitis remains an important cause of mortality and morbidity in children.1., 2. Dexamethasone may reduce morbidity in children with meningitis.3 A meta-analysis of controlled trials of dexamethasone showed decreased morbidity in children with Haemophilus and possibly pneumococcal meningitis. However, its role is less clear in children with meningococcal meningitis. Furthermore, the timing of the first steroid dose appears to contribute to its degree of efficacy.4 Some experts thus
Aims
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To determine the causes of meningitis in children immunised with Hib vaccine, presenting without a non-blanching rash
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Review use of dexamethasone as an adjunct to antimicrobial treatment in this group
Method
We identified children admitted to the Paediatric wards at Birmingham Heartlands Hospital between January 1998 and August 2002, with a cerebrospinal fluid (CSF) white cell count (WCC) of more than 10 WCC/mm3. Children were identified by the Microbiology Result Database. If CSF was blood stained an adjustment was made; counting anything more than 1 WBC per 500 red blood cells as raised.26 The case notes of those children identified were reviewed. Children were excluded if they had a
Results
One hundred and forty-seven children were identified with a total CSF WCC of more than 10 white cells. Thirty-nine children were excluded as they had either a non-blanching rash on presentation, or did not have a discharge diagnosis of meningitis. One hundred and eight children were therefore identified for inclusion in the study. The microbiological results of these children are shown in Table 1.
Case notes were available for review for 62 children. The median age of the children was 7 years (2
Discussion
In our group of children the most common cause of meningitis without a non-blanching rash was enterovirus. A lumbar puncture was vital in establishing the diagnosis, with CSF being the only positive diagnostic test in 31/62 children. Lumbar puncture thus altered the management of the disease; antibiotics, if started, could be discontinued and there were shorter admission times. This has been shown to be the case in other published studies,15., 16. which includes adult data.17 A lumbar puncture
Conclusion
The most common cause of meningitis without a rash in British children given Hib vaccine is enterovirus. Enteroviral PCR should be readily available and performed routinely on all CSF samples. A lumbar puncture is required to establish the diagnosis and can therefore lead to reduced inpatient times and length of antibiotic course. The use of dexamethasone should be individualised to those with possible Hib meningitis.
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2005, British Medical Bulletin