Approach to the Patient with Child Fever – Part Two

Many trusts now automatically screen patients toward the end of the antenatal period for flora of GBS. This is because GBS is a key cause of bacterial meningitis in the neonate (alongside E.coli, staph aureus and listeria). The mortality rate of neonatal sepsis remains 50% according to some literature. Bundy LM, Noor A. Neonatal Meningitis. [Updated 2021 Jun 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK5322.

Brudzinski’s sign, worth a google to see the images of the procedure, is an involuntary flexion of the hip and knee joints in response to passive forward flexion of the neck toward the thorax. Alongside Kernig’s sign, it is one of an examiner’s favourite screening tools for OSCEs. Murphy’s sign is used in the acute abdomen, Osler nodes are found in endocarditis on the hand. JLV is a co-founder of MedGuide and no sign named after him (yet!!).

The most common cause of meningococcal septicaemia in adults is neisseria meningitidis. This a circular diplococcus bacteria. Its worth noting that the meningococcal septicaemia state is when this organism is found in the blood, but meningococcal meningitis is when the bacteria is found in the cerebrospinal fluid to confirm meningitis occurring.

Meningism includes - fever, neck stiffness, non-blanching purpuric rash, photophobia and headache. If you add altered level of consciousness and acute onset, you have quite a good safety net of screening questions to identify meningitis in a history.

The parameters of a CSF analysis, and the surface anatomy of its acquisition, is bread and butter medical school knowledge. Make sure you know the appearance, glucose, blood, white cell and protein count for bacterial, viral, tuberculosis and fungal CSF infiltrates.

Bacterial meningitis and bacterial endocarditis ceftriaxone IV dose - as per the paediatric BNF (August 2021) states - For Child 1 month–11 years (body-weight up to 50 kg) give 80–100 mg/kg once daily, 100 mg/kg once daily dose should be used for bacterial endocarditis; maximum 4 g per day. As such, with a 30kg weight, the 7 year old female receives (30*100) = 3000mg or 3g per day IV ceftriaxone.

Dexamethasone is given as adjunct therapy (and should never solely replace antimicrobial agents) due to its ability to decrease nervous system adverse effects of meningitis. It is known to be protective against development of cerebral palsy, hearing loss and other neurological deficits.

Remember, simplistically speaking, a neutrophilic leukocytosis is suggestive of a bacterial infection response. Conversely a lymphocytic leukocytosis is more suggestive of a viral response.