CASE REPORT:

MENINGOENCEPHALITIS
PRESENTER:
MOHD AJIB (090100385)
ESMETH (090100381)
TUTOR:
DR JOHANNES HARLAN SAING SP.A(K)
PAEDIATRICS DEPARTMENT
RSUP H ADAM MALIK MEDAN

INTRODUCTION
Meningitis is a clinical syndrome characterized by

inflammation of the meninges

Encephalitis, an inflammation of the brain
parenchyma
Meningoencephalitis is inflammation of both the
brain and the leptomeninges
CDC: 20,000 cases of viral encephalitis occur in the
US/year.

ETIOLOGY
Most viral infections in childhood are able to cause

encephalitis
Herpes simplex virus (HSV)
herpes zoster, Epstein-Barr virus, mumps, measles and
enteroviruses.
cytomegalovirus, adenovirus, influenza
virus, poliovirus, rubella, rabies, arbovirus (eg California
virus, Japanese B encephalitis, St Louis encephalitis,
West Nile encephalitis, Eastern and Western equine
encephalitis), reovirus (Colorado tick
fever virus), parvovirus B19.

 bacterial:tuberculosis (TB), mycoplasma, listeria, Lyme

disease, Bartonella henselae (cat scratch fever),

leptospira, brucella, legionella, neurosyphilis, all causes
of bacterial meningitis.
Rickettsial: Rocky Mountain spotted fever,
endemic typhus, epidemic typhus, Q fever, human
monocytic ehrlichiosis.
Fungal: cryptococcosis, coccidiomycosis, histoplasmosis,
North American blastomycosis, candidiasis
Parasitic: African
trypanosomiasis, toxoplasmosis, echinococcus, schistoso
miasis

SIGNS AND SYMPTOMS

Typically, children with aseptic meningitis have:

Intense headache
Meningismus
Photophobia, but a clear sensorium

In contrast, amoebae, fungi, and the viruses causing

Eastern equine encephalitis, HSV, or rabies may

cause:

Cerebral or brain stem dysfunction

Seizures
Increased intracranial pressure
Death

Presenting signs and symptoms produced by viruses

are often protean and include:

Fever
Chills
Myalgia
Headache

If the spinal cord is involved, the patient may have:

Symmetrical limb paralysis

Transverse sensory symptoms
Bowel and bladder dysfunction

PATHOPHYSIOLOGY
(VIDEO)*

DIAGNOSIS
History taking
Physical examination
Laboratory findings
Imaging

Typical CSF findings:

Viral meningoencephalitis

Leukocytes

Glucose

> 50% of serum concentration

Protein

Initial predominance of polymorphonuclear neutrophils, followed

by shift to mononuclear cells
Range, 02000 cells/mm3

Mild to moderate increase

Range, usually < 200 mg/dL

Gram stain

Negative

Bacterial meningitis

Leukocytes

Protein

Predominantly neutrophils
Range, 0200,000 cells/mm3
Marked increase
Range, usually > 150 mg/dL

Gram stain

Usually reveals bacteria

MANAGEMENT
Goals: reduce morbidity and prevent complications
Treatment is supportive and includes:

Reducing high intracranial pressure

Providing respiratory support
Treating seizures
Maintaining fluid and electrolyte balance

Immediate parenteral antibiotics for possible diagnosis of

meningitis
There is no specific treatment for other viral causes and the
emphasis of treatment is supportive.
Intravenous broad-spectrum antibiotics may be given to
treat secondary bacterial infections.
Amphotericin is usually given for primary amoebic
meningoencephalitis.

PROGNOSIS
Depends on the age of the patient and the underlying

etiology
The poorest prognosis for viral encephalitis occurs in
patients with untreated herpes simplex encephalitis
and subacute sclerosing panencephalitis.

Case Report

SP
Male
8 years old
DOB: 16th January 2006
Body weight: 19kg
Body length: 113cm

History taking
Chief
Complaint

loss of consciousness

History

Experienced by patient in the past 3 days before

entering hospital. Loss of consciousness preceded
by drowsiness.
Vomit (-), fever (+), experienced 4 days before
admited into hospital. High fever, down with feverlowering drugs.
seizures (+), experieced 1 day before entering
hospital. History of seizures (-)
History of cough (+), 12 hours before entering
hospital.
History of weight loss (+). Complete imunization.
Patient was refered from RSU Binjai, diagnosed
with meningitis.

Status presens
Sens : GCS 8 (E2 V1 M5)
Temp: 37,5
Weight : 19kg
Length : 113cm

Localized status
Head

RC (+/+), pint point pupil, conjunvtiva

palpebra inferior pale (-/-)
Ear : within normal limit
Nose : NGT inserted
Mouth: oxygen mask

Thorax

Symmetrical fusiform
Chest retraction(+) epigastrial, suprasternal
HR: 126 bpm, reg, murmur(-) <N:80-120>
RR: 32x/i , reg, ronchi (-) <N:16-20>

Abdomen Soepel, Normal peristaltic, liver & spleen

unpalpable

Extremite
s

Pulse 126 bpm, reg, adequate

pressure and volume, warm, CRT<3
100/70 mmHg

Urogenital

Male, anus(+), within normal limit

Lab result (4th July 2014)

Parameters

Value

Normal Value

Hemoglobin

11,90 gr%

11,3 14,1 gr%

Hematocrite

36,4 %

37 41%

Erithrocyte(RBC)

4,72 x 106 /mm3

4,40 4,48 x 106 /mm3

Leucocyte(WBC)

3,87 x 103 /mm3

4,5 13,5 x 103 /mm3

Thrombosit(PLT)

290.000 /mm3

150.000 450.000 /mm3

MCV

77,10 fl

81 95 fl

MCH

25,20 pg

25 29 pg

MCHC

32,70 gr%

29 31 gr%

RDW

12,90 %

11,6 14,8 %

51,5 / 24,3 / 22,7 / 1,0 /

37-80/20-40/2-8/1-6/0-1

Complete Blood Count

N/L/M/E/B

0,5

Physiology of Hemostasis (4th July 2014)

Protombin Time
Control

13,60s

Pasien

12,5s

INR

0,92

APTT
Control

35,2

Pasien

30,5

Trombin time
Kontrol

17,3

Pasien

13,5

Hati
AST/SGOT

24 U/L

<38

Carbohidrate
Metabolisme
101,3 mg/Dl

<200

Ureum

11,90 mg/dl

<50

Kreatin

0,3 mg/dl

0,4 0,6

Uric acid

1,1 mg/dl

<7,0

Na

132 mEq/L

135 155

4,4

3,6 5,5

Phospor

4,6

3,4 6,2

Cl

98

96 106

Mg

2,38

1,4 1,7

KGD
Ginjal

Electrolit

Autoimmune
CRP Kualitatif

Positif

Procalcitonin

0,36 ng/mL

<0,05

Analysis of Cerebrospinal fluid (1st July 2014)

Parameter

Value

Normal Value

Color

Clear

Clear

LDH

34 U/L

< 200

Total Protein

20.00 mg/dL

< 45

Total Leukosit

0.068 x 103/uL

<3

Total Eritrosit

0.000 x 106/uL

Glucose

97 mg/dL

40-76

pH

9,0

7-8

MN Sel

66,2 %

PMN Sel

33,8 %

Chemical Chemistry (1st July 2014)

KGD

114,00 mg/dL

<200

Ureum

7,20 mg/dL

<50

Natrium

130 mEq/L

135 155

Kalium

3,6 mEq/L

3,6 5,5

Klorida

99 mEq/L

96 106

CT-Scan
Sulci, gyri and white
matter clear.
Falx cerebri medial.
Lesion not found
hipo/hiperdens in both
hemisfer cerebri.
Ventrikel system dan
sisterna in good
condition.
Sella and parasella in
good condition.
Both mastoid air cell in
good condition.
Visible sinus
paranasalis are clean.
Conclusion: no sign of
SOL, hydrocephalus and
bleeding.

Working diagnosis

Meningoencephalitis

Differential diagnosis

Ensefalitis
Meningitis
Meningoencephalitis

Management
02 11 x/i nasal canul
IVFD NaCL 0,9% 60gtt/I
Inj ceftriaxone 1gr / 6jam / IV
Inj Phenytoin LD 20mg/kg/BB : 380mg in 20cc NaCL 0,9%

(finish in 15 mins)
NGT inserted
Lumbal punksi, kultur LCS
Photo thorax
Rawat RB4 infeksi

Follow-up

July 2nd 2014

S

Fever (+)

GCS 8 (E2 V1 M5), BB: 19kg, TB: 113cm

Head

Eye: Isochoric pupil, inferior palpebra conjunctiva pale (-/-),icteric sclera (-/-),
Ear: within normal limit
Nose: NGT (+)
Mouth: Oxygen mask inserted

Neck

Stiff neck (+), pemb. KGB (-)

Thorax

Symmetrical fusiformis, chest retraction (+) epigastrial, HR: 126 bpm, regular, murmur (-). RR: 32x/i, reguler, ronchi (-)

Abdomen

Soepel, Normal peristaltic, liver & spleen unpalpable

Extremities

Pulse 126 bpm, reg, adequate pressure and volume, warm, CRT<3
100/70 mmHg

Genital

Male, within normal limit.

DD/ - meningitis
-meningoencephalitis
-ensefalitis

Management:
-

30 head elavated midline position

O2 5L/i

IVFD NaCL 0,9% 10 gtt/i

IVFD NaCL 3% 100cc/12jam (finish in 1 hour)

Inj ampicilin 1gr / 6jam / IV

Inj phenitoin LD 50mg / 12jam / IV in 20cc of NaCL 0,9% finish in 20 mins.

July 3rd 2014

S

Fever (+)

GCS 8 (E2 V1 M5), T: 38,1C, BB: 19kg, TB: 113cm

Head

Eye: Isochoric pupil, inferior palpebra conjunctiva pale (-/-),icteric sclera (-/-),
Ear: within normal limit
Nose: NGT (+)
Mouth: Oxygen mask inserted

Neck

Stiff neck (+), pemb. KGB (-)

Thorax

Symmetrical fusiformis, chest retraction (+) epigastrial, HR: 120 bpm, regular, murmur (-). RR: 30x/i, reguler, ronchi (-)

Abdomen

Soepel, Normal peristaltic, liver & spleen unpalpable

Extremities

Pulse 120 bpm, reg, adequate pressure and volume, warm, CRT<3
100/70 mmHg

Genital

Male, within normal limit.

-meningoencephalitis

Management:
-

30 head elavated midline position

O2 5L/i

IVFD NaCL 0,9% 10 gtt/i

IVFD NaCL 3% 100cc/12jam (finish in 1 hour)

Inj ceftriaxone 1gr / 6jam / IV

Inj phenitoin LD 50mg / 12jam / IV in 20cc of NaCL 0,9% finish in 20 mins.

Paracetamol 3 x 250cc

Diet SV 1450 kkcl with 40gr protein

July 4th 2014

S

Fever (+)

GCS 8 (E2 V1 M5), T: 38C, BB: 19kg, TB: 113cm

Head

Eye: Isochoric pupil, inferior palpebra conjunctiva pale (-/-),icteric sclera (-/-)
Ear: within normal limit
Nose: NGT (+)
Mouth: Oxygen mask inserted

Neck

Stiff neck (+), pemb. KGB (-)

Thorax

Symmetrical fusiformis, chest retraction (+) epigastrial, HR: 122 bpm, regular, murmur (-). RR: 29x/i, reguler, ronchi (-)

Abdomen

Soepel, Normal peristaltic, liver & spleen unpalpable

Extremities

Pulse 122 bpm, reg, adequate pressure and volume, warm, CRT<3
100/70 mmHg

Genital

Male, within normal limit.

-meningoencephalitis

Management:
-

30 head elavated midline position

O2 5L/i

IVFD NaCL 0,9% 10 gtt/i

IVFD NaCL 3% 100cc/12jam (finish in 20mins)

Inj ceftriaxone 1gr / 12jam / IV CH3

Inj phenitoin LD 50mg / 12jam / IV in 20cc of NaCL 0,9% finish in 20 mins.

Paracetamol 3 x 250cc

Diet SV 1450 kkcl with 40gr protein

July 6th 2014

S

Fever (+)

GCS 9 (E3 V1 M5), T: 38C, BB: 19kg, TB: 113cm

Head

Eye: Isochoric pupil, inferior palpebra conjunctiva pale (-/-),icteric sclera (-/-)
Ear: within normal limit
Nose: NGT (+)
Mouth: Oxygen mask inserted

Neck

Stiff neck (+), pemb. KGB (-)

Thorax

Symmetrical fusiformis, chest retraction (+) epigastrial, HR: 121 bpm, regular, murmur (-). RR: 30x/i, reguler, ronchi (-)

Abdomen

Soepel, Normal peristaltic, liver & spleen unpalpable

Extremities

Pulse 121 bpm, reg, adequate pressure and volume, warm, CRT<3
100/70 mmHg

Genital

Male, within normal limit.

-meningoencephalitis

Management:
-

30 head elavated midline position

O2 5L/i

IVFD NaCL 0,9% 10 gtt/i

IVFD NaCL 3% 100cc/12jam (finish in 20mins)

Inj ceftriaxone 1gr / 12jam / IV CH3

Inj phenitoin LD 50mg / 12jam / IV in 20cc of NaCL 0,9% finish in 20 mins.

Paracetamol 3 x 250cc

Diet SV 1450 kkcl with 40gr protein

July 7th 2014

S

Fever (+)

GCS 11 (E4 V1 M6), T: 38,1C, BB: 19kg, TB: 113cm

Head

Eye: Isochoric pupil, inferior palpebra conjunctiva pale (-/-),icteric sclera (-/-)
Ear: within normal limit
Nose: NGT (+)
Mouth: Oxygen mask inserted

Neck

Stiff neck (-), pemb. KGB (-)

Thorax

Symmetrical fusiformis, chest retraction (+) epigastrial, HR: 120 bpm, regular, murmur (-). RR: 30x/i, reguler, ronchi (-)

Abdomen

Soepel, Normal peristaltic, liver & spleen unpalpable

Extremities

Pulse 120 bpm, reg, adequate pressure and volume, warm, CRT<3
100/70 mmHg

Genital

Male, within normal limit.

-meningoencephalitis

Management:
-

30 head elavated midline position

O2 5L/i

IVFD NaCL 0,9% 10 gtt/i

IVFD NaCL 3% 100cc/12jam (finish in 20mins)

Inj ceftriaxone 1gr / 12jam / IV CH3

Inj phenitoin LD 50mg / 12jam / IV in 20cc of NaCL 0,9% finish in 20 mins.

Paracetamol 3 x 250cc

Diet SV 1450 kkcl with 40gr protein

Discussion
THEORY

Cases

Risk factor for TTN:

1. Age
2. Community settings
3. Travel

Risk factor in patient:1. 8 years old

2. Crowded area
3. No history of travelling

Clinical sign of TTN:1. Fever

2. Cephalgia
3. Nausea
4. Vomit
5. Stiff neck
6. Fotofobia

Clinical sign in patient:1. Long fever

2. Cephalgia
3. Nausea
4. Vomit
5. Stiff neck
6. Fotofobia

CSS normal protein levels, a slight

increase, or decrease can be found in
meningitis viral.

Examination showed that there was no

increase in the amount of protein CSS
CSS fluid analysis results of the
patients showed clear color with a
increase in glucose levels (97 mg/ 4072 mg / dl)

Giving antibiotics is performed

referring to the epidemiology of
meningitis is most often caused by
infection with H. Influenzae, S.
Pneumonia, N. Meningitidis, Listeria
monocytogenes, S. Agalactiae.

Patients given ceftriaxone antibiotic

therapy

Summary
This paper reports a case of a 8 years old, male

patient diagnosed with meningoencephalitis.

A comprehensive treatment with ventilatory
support, antibiotics and electrolyte correction
indeed. Adequate therapy is absolutely supporting
child healing from disease, and improving his growth
and development progress.

THANK
YOU