Background: Acute meningitis is life-threatening inflammation of the tissue layers that surround the brain and spinal cord. Most cases of meningitis are caused by a viral infection, but bacterial, parasitic and fungal infections are other causes [1]. Some cases of meningitis improve without treatment in a few weeks. Others can be life-threatening and require emergency antibiotic treatment. Bacterial meningitis is serious and can be fatal within days without prompt antibiotic therapy [2]. Delayed treatment increases the risk of permanent brain damage or death. Symptoms develop over the course of a few hours to days and include headache, sensitivity to light and neck stiffness. A fever is often present. Acute meningitis that is caused by a virus tends to be less severe than that caused by a bacterium and it tends to go away on its own. Acute viral meningitis is more common than acute bacterial meningitis.

Signs and Symptoms

Early meningitis symptoms may mimic the flu (influenza). Symptoms may develop over several hours or over a few days.

Possible Signs and Symptoms in Anyone Older than the Age of 2 Include

Sudden high fever, Stiff neck, Severe headache that seems different from normal, Headache with nausea or vomiting, Confusion or difficulty concentrating, Seizures, Sleepiness or difficulty awaking, Sensitivity to light, No appetite or thirst, Skin rash (sometimes, such as in meningococcal meningitis) [3].

Signs and Symptoms in Newborns and Infants May Show

High fever, Constant crying, Excessive sleepiness or irritability, Difficulty awaking from sleep, Inactivity or sluggishness, Poor feeding, Vomiting, A bulge in the soft spot on top of a baby's head (fontanel), Stiffness in the body and neck, Infants with meningitis may be difficult to comfort and may even cry harder when held [4].

Several strains can cause acute bacterial meningitis, most commonly:

• Streptococcus Pneumoniae (Pneumococcus): The most common cause of bacterial meningitis in infants, young children and adults in the United States. It more commonly causes pneumonia or ear or sinus infections. A vaccine can help prevent this infection [5]

• Neisseria Meningitidis (Meningococcus): Another leading cause of bacterial meningitis. These bacteria commonly cause an upper respiratory infection but can cause meningococcal meningitis when they enter the bloodstream. This is a highly contagious infection that affects mainly teenagers and young adults. It may cause local epidemics in college dormitories, boarding schools and military bases. A vaccine can help prevent infection. Even if vaccinated, anybody who has been in close contact with a person with meningococcal meningitis should receive an oral antibiotic to prevent the disease [6]

• Haemophilus Influenzae (Haemophilus): Haemophilus influenzae type b (Hib) bacterium was once the leading cause of bacterial meningitis in children. Hib vaccines greatly reduce the number of cases [7]

• Listeria Monocytogenes (Listeria): These bacteria can be found in unpasteurized cheeses, hot dogs and lunchmeats. Pregnant women, newborns, older adults and people with weakened immune systems are most susceptible. Listeria can cross the placental barrier and infections in late pregnancy may be fatal to the baby

• Viral Meningitis: Enteroviruses are the most common cause of viral meningitis, which are most common in late summer and early fall. Viruses such as herpes simplex virus, HIV, mumps virus, West Nile virus and others also can cause viral meningitis [8]

Acute fungal meningitis is rare. It is not considered contagious and typically occurs only in people whose immune systems are weakened, such as those who have acquired Human Immunodeficiency Syndrome (AIDS), are undergoing cancer treatment, or have had an organ transplant.

Objective

To evaluate clinical features and laboratory findings in children below age of 10 years presented with acute meningitis.

Patients and Methods: 

This descriptive study was carried out at the emergency department of child’s central Teaching Hospital, from January to August 2017.

The nature and target of this study were explained to the patient’s family and Verbal consent was taken. Ethical approval was given by the Scientific Council of pediatrics/Iraqi Board for Medical Specializations.

Inclusion Criteria

Children below age of 10 years with clinically suspected acute meningitis that had done Lumber Puncture for CSF analysis.

Exclusion Criteria

• Neonatal period

• Traumatic LP

• Patients who did not do LP for any cause (e.g. increased intracranial pressure, severe cardiopulmonary compromise, bleeding tendency, family refusal etc.)

Study Sample

Included one hundred eight patients who were admitted to the emergency room and treated as meningitis. The cases were classified according to age distribution into:

• Infants less than 1 year

• Children 1-10 years

History was taken regarding; name, age, gender, signs and symptoms, duration of illness, history of antibiotic use, medical history, family history, surgical history.

Full clinical examination was performed including identifying the level of consciousness, neck stiffness, full fontanel, neurological deficit, vital signs and fundoscopy. Definite diagnosis was established on clinical basis and laboratory findings:

CSF analysis for (Appearance, glucose, protein, total WBC count and differential_culture). CSF gram stain was not available in hospital at the time of study.

For definite diagnosis of bacterial meningitis, CSF shows:

• CSF glucose was considered low when it was <40mg/dL CSF protein was considered high when it was >100 mg/dL

• CSF pleocytosis (PMNs or Lymphocytes) predominance was considered when it was >50% of total WBC count in CSF [9]

Beside Blood test for (complete blood count, C-reactant protein).

Features supportive of a provisional diagnosis of viral meningitis include [10]:

• CSF WBC of <500 cells/microL with a mononuclear predominance

• Normal CSF glucose CSF protein <100 mg/dL Negative CSF Gram stain

• Enterovirus disease in the community or close contact with an individual with an enterovirus compatible disease process

• Improvement in symptoms following lumbar puncture

Partially treated bacterial meningitis was considered if there is a history of antibiotic use before LP, negative CSF culture and CSF WBC>5 cells/mm³ with neutrophil predominance [11], but mononuclear cells may predominate if pretreated for extended period of time, protein usually (100-500), glucose is normal or decreased [12].

Statistical Analysis

Data processed using computer program are Microsoft Word 2010 for descriptive statistic including range, means, standard deviation were calculated and EPI-info Version 6 for analytic statistic was used. The level of significance was set to 5%. P<0.05 was considered significant while p>0.05 was considered as non-significant [13].

The study was done for a total of 108 patients. The mean age was 2.67 years. There were 41 (37.96%) patients below 1 year (30 males, 11 females) and 67 (62.03%) patients from 1-10 years (39 males, 28 females). P value between the two age groups was significant (p<0.001) (Table 1).

Table 1: Age Distribution and Type of Meningitis According to Sex

Males were sixty-nine (63.89%), females were thirty-nine (36.11%) with male: Female ratio of 1.7:1 and P value <0.001 which is significant.

Concerning clinical types of meningitis subdivided according to infectious cause and antibiotic use into viral, bacteria and partially treated. Sixty-one patients (56.48%) used antibiotics before diagnosis; forty-seven patients (43.52%) did not use any antibiotics. Group of patients that used antibiotics showed laboratory finding of bacterial meningitis considered partially treated. Males were predominant in viral and partially treated bacterial meningitis. In bacterial meningitis, males and females are affected equally (Table 2).

Table 2: Types of Meningitis in Relation to Age Groups

Concerning symptoms of meningitis in relation to age, fever was the most common symptom in both age groups <1 year and >1year in (92.68%) and (98.5%) respectively. Difference was not significant (0.67). Vomiting was a presenting symptom in (51.21%) of patients below 1 year and (62.68%) of patients between 1 year and 10 years (Table 3 and 4).

Table 3: Signs and Symptoms of Meningitis in Relation to Clinical Types

Table 4: Signs and Symptoms of Meningitis in Relation to Age Groups

P value also was not significant (0.28). Convulsions presented in (51.21%) of patients <1 year and (58.2%) of patients >1 year. P value was not significant (0.5). Photophobia and headache occurred only in children above 1 year in (23.88%) and (43.28%) respectively. While poor feeding and lethargy occurred in both age groups but significantly in patients <1 year (Tables 5).

Table 5: Mean Values of CSF and Blood Tests in Relation to the Types of Meningitis

The mean age of diagnosis with meningitis was (2.67) years. This approximates the results found by Raghad [14] (mean age was 2.84 years) and by Husain et al. [15] (mean age was 3 years).

The majority of patients were above 1 year (62.04%) with significant difference with the other group (p<0.001). This is consistent with Raghad D. study (57% of patients were above 1 year). It differs from Nori [16] and Nashwan [17] studies which found the majority of patients were below 1 year, may be due to the exclusion of neonatal age group in the study.

Males were affected more significantly than females, with male: female ratio of 1.7:1, which agree with Nori [16] Nashwan [17] and Farag et al. [11]

The study shows (35.18%) of patients had viral meningitis, 65% had bacterial meningitis, (50%) of them constitute partially treated bacterial meningitis and (14.81%) had bacterial meningitis. This approximates the results of Farag et al. [11] who found that viral meningitis represents (34.8%) of patients and bacterial meningitis (65.2%), (The study considered bacterial and partially treated bacterial meningitis as one group). Also it approximates the results of Nori [16].

In this study bacterial meningitis and partially treated meningitis occur more commonly in children >1 year. This approximates the results of Farag et al. [11].

Fever was the most common presenting symptom in all types of meningitis (92.1% of viral meningitis, 98.14% of partially treated bacterial meningitis, 100% of bacterial meningitis). Vomiting followed by convulsions are the next most common symptoms. This consistent to Raghad D. Headache and photophobia were significantly more in cases above 1 year that agrees with Jabeen et al. [18].

In cases below 1 year, bulging fontanel (78.04%) and irritability (65.85%) were the most common signs with significant difference with the other group. The results were similar to that of Raghad D.

The most common signs in patients above 1 year were neck stiffness (65.67%) followed by Kernig’s sign (32.83%) and irritability (22.83%) with significant difference with the other group Similar results were found by Raghad D. This may be due to the fact that in children, particularly in those younger than 12-18 months, Kernig and Brudzinski signs are not consistently present [5].

Fever, vomiting and convulsions are the most common symptoms of meningitis. Bulging fontanel and irritability were the most common signs in infants with acute meningitis, while headache, neck stiffness, Kernig’s sign and irritability were most common in older age group. Pretreatment with antibiotic before LP rendered the CSF culture sterile with predominance of lymphocytes in CSF cytological examination, but little or no effect on CSF glucose and protein. No single clinical feature is diagnostic.

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