Elsevier

Journal of Infection

Volume 49, Issue 4, November 2004, Pages 297-301
Journal of Infection

Meningitis without a petechial rash in children in the Hib vaccine era

https://doi.org/10.1016/j.jinf.2003.10.011Get rights and content

Abstract

Aims. (1) To determine the causes of meningitis in children immunized with Hib vaccine, presenting without a non-blanching rash; (2) to review the use of dexamethasone in this group.

Method. Retrospective review of all children with more then 10 white cells/mm3 in their cerebrospinal fluid (CSF), admitted between January 1998 and August 2002. Children were excluded if they had a non-blanching rash on admission or if their discharge diagnosis was not meningitis. Local guidelines recommended dexamethasone to be given before antibiotics for children with meningitis and no rash.

Results. One hundred and eight children were identified. Causes of proven meningitis were: viral 41 (enterovirus 40), bacterial 22. CSF culture or PCR was the only diagnostic test in 31 children. Dexamethasone was given to 16 children. Length of admission was shorter in children with viral compared with bacterial meningitis (4 vs 8 days; P<0.0001).

Summary. Viral meningitis is the commonest cause of meningitis without rash. Enteroviral PCR was the most useful test and needs to be widely available. Confirmation of enteroviral meningitis allowed early discharge. Few children were given dexamethasone, but only 5/108 may have benefited.

Conclusions. The most common cause of meningitis without a rash in British children is enterovirus. The use of dexamethasone in children with meningitis without a rash should be reconsidered or, at least, individualised.

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

  • To determine the causes of meningitis in children immunised with Hib vaccine, presenting without a non-blanching rash

  • 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.

References (27)

  • D. Garner et al.

    Effectiveness of vaccination for Haemophilus Influenzae type B

    Lancet

    (2003)
  • D. Talan et al.

    Analysis of emergency department management of suspected bacterial meningitis

    Ann Emerg Med

    (1989)
  • L.E. Ferguson et al.

    Neisseria meningitidis: presentation, treatment and prevention

    J Pediatr Health Care

    (2002)
  • P.I. Kaaresen et al.

    Prognostic factors in childhood bacterial meningitis

    Acta Paediatr

    (1995)
  • E.R. Wald et al.

    Dexamethasone therapy for children with bacterial meningitis

    Pediatrics

    (1995)
  • P. McIntyre et al.

    Dexamethasone as adjunctive therapy in bacterial meningitis. A meta-analysis of randomised clinical trials since 1988

    JAMA

    (1997)
  • V. Quagliarello et al.

    Bacterial meningitis: pathogenesis, pathophysiology and progress

    N Engl J Med

    (1992)
  • K.A. Nathavitharana et al.

    Current trends in the management of bacterial meningitis

    Br J Hosp Med

    (1993)
  • H.S. Jafari et al.

    Dexamethasone therapy in bacterial meningitis

    Pediatr Ann

    (1994)
  • A. Schuchat et al.

    Bacterial meningitis in the United States in 1995

    N Engl J Med

    (1997)
  • J.B. Robbins et al.

    Prevention of systemic infections, especially meningitis, caused by Haemophilus Influenzae type b

    JAMA

    (1996)
  • R. Kneen et al.

    The role of lumbar puncture in children with suspected central nervous system infection

    BMC Pediatr

    (2002)
  • D. Addy

    When not to do a lumbar puncture

    Arch Dis Child

    (1987)
  • Cited by (5)

    View full text