CASE REPORT

MENINGITIS

Arranged by :

Diana Marlisa (130100069)

Vania G.H.Girsang (130100282)

Supervisor :

dr.Hj.Tiangsa Br Sembiring, SpA (K)

NIP.

PEDIATRIC DEPARTMENT

RUMAH SAKIT UMUM PUSAT HAJI ADAM MALIK

FACULTY OF MEDICINE

UNIVERSITY OF NORTH SUMATERA

MEDAN

2017
Case Report

MENINGITIS
Presentator : Diana Marlisa (130100069)

Vania G.H.Girsang (130100282)

Day/date :

Supervisor : dr.Hj.Tiangsa Br Sembiring, SpA (K)

Introduction

Meningitis is an inflammation of the meningens (the covering of the brain and spinal
cord).1 Meningitis can be caused by infection from viruses and bacteria (germs), parasite and
fungal.2 But usually they develop the infection from viruses and bacteria. Meningitis virus (also
known as Aseptic Meningitis, Serous Meningitis) commonly caused by viruses called
“enteroviruses”.3 Before the effective immunisation was found, poliovirus was the most common
caused. But this time, the other enteroviruses (coxsackievirus and echovirus), California virus,
and Mumps virus are the most responsible for some cases of Aseptic meningitis during
summer.,4
In neonates and new born, some symptoms like letargy and decrease appetite with or
without seizures could be found.5 In infant, child and adult, the symptoms appeared suddenly,
with headache, vomiting, letargi and stiff neck.5 Sometimes fever, flu like syndrome, parotitis,
rash and adenopaty.6 Symptoms usually appear within 1- 2 weeks, after exposure to the virus.
There are no specific treatment for this. Some patient completely recovery from this disease.7
Meningitis bacterial is one of the most potentially serious infections occurring in infants
and older children.3 This infection is associated with acute complication and risk of long term
morbidity. The most common cause of bacterial meningitis in children 1 month to 12 years of
age in the USA is Neisseria meningitides.4 Bacterial meningitis caused by Streptococcus
pneumonia and Haemophilus influenza type b has become much less common in develop
countries since the introduction of universal immunization against these pathogens beginning at
2 month of age.4
 Based on the pattern in Indonesia, meningitis is the cause of death ranked 17th with a
proportion of 0.8% Reflect the select nature of the type of patient studied or seasonal outbreak
of particular pathogens in the various regions of the world. Study inclusion criteria represented 2
categories of children: (1) children with seizure and fever, and (2) children with clinical
suspicion of invasive bacterial disease or meningitis.6 Almost all microbe that are pathogenic to
human beings have the potential to cause Meningitis, but relatively small number of pathogens
(group B streptococcus, Escherichia coli, Listeria monocytogenes, Haemophilus influenza type
b, S. pneumonia and Neisseria meningitis) account for most cases of bacterial meningitis in
neonates and children.4
Viral meningitis can occur at any age but is common in young children. In the largest
reported study, a 1996 birth cohort of 12.000 children in Finland, the annual incidence of
presumed viral meningitis was 219 per 100.000 in infants under 1 year and 27.8 per 100.000
overall in children under 14. In a smaller retrospective study, the incidence of aseptic meningitis
in people aged 16 and over lower at 7.6 per 100.000.7
Initial empiric theraphy for bacterial meningitis is based on the patient’s age, risk factors,
and clinical features. In patients with suspected bacterial meningitis, empiric theraphy should not
be delayed for more than one hour while awaiting diagnostic testing or transfers.8 Although no
prospective comparative trials have been perfomed, observational studies have found that
delayes in theraphy of as little as two to six hours are associated with adverse outcomes. Fluid
management includes treatment for possible dehydration or hyponatremia from the syndrome of
inappropriate antidiuretic hormone. After the results of the Gram stain, culture, and susceptibility
test are available, specific theraphy targeting the pathogen should be administered.9
Enteroviruses are the most common etiologic pathogens in persons with aseptic
meningitis and do not require specific antimoicrobial theraphy.10 HSV aseptic meningitis usually
a self limited infection that must be distinguished from HSV encephalitis based on clinical and
radiographic features; theraphy with acyclovir (Zovirax) can be lifesaving in patients with HSV
encephalitis. Varicella – zoster virus infection may cause aseptic meningitis in the absence of
cutaneous manifestation. Although it has not been studied in clinical trials, therapy with
acyclovir at 10 mg per kg every eight hours is suggested based on expert opinion. Central
nervous system Lyme disease is treated with ceftriaxone for 14 to 28 days, and central nervous
system syphilis is treated with intravenous penicillin for 10 to 14 days. 14
 The mortality rate in adults with bacterial meningitis in develop countries is 21 percent; it
is higher in patients with pneumococcal disease than in those with meningococcal disease.
Neurologic sequelae include hearing loss in 14 percent of patients and hemiparesis in 4 percent.
Risk factors for adverse outcomes include advanced age, alteration of mental status on
admission, bacteremia, and a CSF white blood cell count of less than 1.000 per µL (1.00 × 10 9
per L). The mortality rate in children with bacterial meningitis is 3 percent; the incidence of
stroke in children with bacterial meningitis is 3 percent.7
In aseptic meningitis, motor incoordination, convulsive total or partial deafness, and
behavioral disturbances may follow viral Central Nervous System (CNS) infections. Most
children completely recover from viral infection CNS, although the prognosis depends on the
severity of the clinical illness, the specific cause and the age of the child. If the clinical illness is
severe, and the substantial parenchymal involvement is evident, the prognosis is poor, with
potential deficits being intellectual, motor, psychiatric, epileptic, visual or auditory in nature.14
Infection caused by S. pneumonia or H. influenza type b must be considered in
incompletely vaccinated individuals or those in developing countries. Those with certain
underlying immunologic (HIV infection, IgG subclass deficiency) or anatomic (splenic
dysfunction, cochlear defects or implants) disorders also may be at increased risk of infection
caused by these bacteria.9 The clinical picture of acute bacterial meningitis mainly depends on
the patient’s age. The classic manifestations (fever, chills,vomiting, photophobia, and severe
headache) noted in older children and adults are rarely present in infants. In general, the younger
the patient, the more subtle and atypical are the sign and symptoms. In general, meningitis
caused by a virus is less serious than meningitis caused by bacteria.3
The aim of this paper is to report the case of meningitis in a 5 months old boy.
CASE

Main complaint : Decreasing awareness

MA, a 5 months old boy, was admitted to Adam Malik General Hopital with decreased
awareness since 1 weeks ago. He had seizures since 7 days before admitted to the hospital,
occurred 5 times a day, < 15 minutes in duration. When the seizures occurred , the eyes were
wide , both arm and legs were stiffened, and there was unconscious.
He had been fever since 7 days ago before admitted to the hospital. Fever down with
antipiretic agent. He had been diarrhea since 8 days ago, frequence 8 times a day, more water
from dregs, mucus was found,blood was not found. Coughing was found since 7 days ago. Urine
output was normal.
Patient birth followed a normal full term pregnancy and normal delivery, birth weight
was 2000 gr, birth length was 50 cm. He had been immunited with BCG , DPT 2 times
incomplete impression. Feeding history : 0-3 months give breast milk ± 8 times a day, 3 months
until now give cerelac 2 times a day and formula milk 8 times a day.
Prescription drug is O2 1-2 l bpm, IVFD RL 36 gtt/bpm macro, Ing ranitidine 8 mg/ 8
hours, paracetamol drips 70 mg / 8 hour . History of previous disease was the patient referral
from tanjung balai hospital with diagnose ensefalopati dengue.

PHYSICAL EXAMINATION
Physical examination
Presence Status: alertness : GCS 9 (E5V3M4) Temperature: 40 ⁰C
Body weight : 6630 gr Body length : 67 cm

Anemis, ikteric, dyspnoe , cyanosis , edema no were found

Localization Status:
Head: Eye: Light Reflexes (+ / +), pupil were isochoric, pale at lower eyelid conjunctiva

(-/-), Ear / Nose / Mouth: within nomal limits / O2 nasal

Canule / NGT was found

Thorax: Symmetrical Fusiform, no retraction
HR: 152 x / bpm, regular, no murmur was found
 RR: 42 x / bpm, regular, no ronchi was found
Abdomen: soepel, peristaltic was normal, liver / lien: were not palpable
Extremities: Pulse: 152 x / bpm, regular, P / V adequate, capillary refill time < 3 seconds
Anogenital: Male, within normal limits

LABORATORY FINDING (01 June 2017)

Types of Checking Results Normal value

Blood Count
Hemoglobin 10.8 g / dL 10.5-13.1 g / dL
Erythrocyte 4.08 x 106 / mm3 3.60 - 5.20 x106 / mm3
Leukocyte 3.150 / mm3 6000-17.500 / mm3
Hematocrit 33% 35-43%
Differential Count
Neutrophil 45.20% 25.00 - 60.00%
Lymphocytes 32.90% 25.00 - 50.00%
Monocyte 16.50% 1.00 - 6.00%
Eosinophils 5.40% 1.00 - 5.00%
Basofil 0.00% 0.00 - 1.00%
Blood gas analysis
PH 7,360 7,35 - 7,45
PCO2 30 mmHg 36- 42 mmHg
PO2 191,0 mmHg 85 - 100 mmHg
Bicarbonate (HCO3) 16.9 U / L 22- 26 U / L
Total CO2 17.8 U / L 19 - 25 U / L
Excess Bases (BE) -7.4 U / L (-2) - (+2)
O2 Saturation 100% 95 - 100%
Carbohydrate metabolism
Glucose ad random 469 mg / dL 40 - 60 mg / dL
Electrolyte
Sodium 144 mEq / L 135- 156 mEq / l
 Potassium 2.4 mEq / L 3,6 - 5,5 mEq / L
Chloride 106 mEq / L 95 - 106 mEq / L

Differential Diagnosis:

 Meningitis
 Meningoensefalitis
 Ensefalitis

Working Diagnosis:
• Meningitis

Therapy :
• O2 1-2 l / min
• IVFD RL 36 gtt / min macro
• Ranitidine injection 5 mg / 8 hours// IV
• Paracetamol drips 70 mg / 8 hours

Plan:
- Head CT scan
- Complete blood count, AGDA, electrolyte
- Lumbal puncture
 FOLLOW UP

June 2, 2017

S : Decreased Awareness (+), fever (+), diarrhea (+)

O : Alertness : GCS 10 (E2M5V3) T = 37.5 ⁰C

Head = fontanella still open
Eyes = Light reflex + / +, pupil were isochoric, pale at lower eyelid conjunctiva(-/-)
E / N / M = within normal limits / PCH (-), O2 nasal canule was found /

within normal limits

Thorax = Symmetrical Fusiform, no retraction , HR: 104x /bpm, regular, no murmur

was found . RR: 24x /bpm, regular, no ronchi was found

Abdomen = Soepel, peristaltic was normal, Hepar / Lien: were not palpable
Extremities = warmer acral, P / V enough, Capillary refill time <3 seconds

A : DD / CNS infection ec - Meningitis + GE without dehydration

- Meningoencephalitis
- Dengue encephalopathy

P : O2 nasal canule 0.5 lpm

Head Elevation 30⁰ midline position
IVFD NaCl 0.9% tpm micro
Inj. Ceftriaxone 400 mg / 12 hours / IV
Inj. Paracetamol 80 mg / 8 hours / IV
Diet formula milk 80 cc / 3 hours / NGT

LABORATORY FINDING (June 2, 2017)

Types of Checking Results Normal Value

Blood Count
Hemoglobin 10.6 g / dL 10.5 - 13.1 g / dL
Erythrocyte 4.01x106 / mm3 3.60 -5.20 x106 / mm3
Leukocyte 8.430 / mm3 6000 - 17.500 / mm3
 Haematocrit 32% 35 - 43%
Platelets 184,000 229,000 - 553,000
Differential Count
Neutrophils 41.60% 25.00 - 60.00%
Lymphocytes 38.0% 25.00 - 50.00%
Monocyte 15.50% 1.00 - 6.00%
Eosinophils 4,70% 1,00 - 5,00%
Basofil 0.20% 0.00 - 1.00%
Absolute neutrophil 3.50x103 / mm3 1.9 - 5.4x103 / mm3
Absolute lymphocyte 3.20x103 / mm3 3.7-10,7x103 / mm3
Absolute monocyte 1.31x103 / mm3 0,1-0,8x103 / mm3
Eosinophil absolute 0.40x103 / mm3 0.20-0,50x103 / mm3
Absolute basophil 0,02x103 / mm3 0-0,1x103 / mm3
Carbohydrate metabolism
Glucose ad random 69 mg / dL 40 - 60 mg / dL
Electrolyte
Calcium 7.20 mg / dl 8.4-10.2 mg / dl
Sodium 140 mEq / L 135- 156 mEq / l
Potassium 2.8 mEq / L 3,6 - 5,5 mEq / L
Chloride 103 mEq / L 95 - 106 mEq / L

Immunoserology
Virus
IgM Anti Dengue Negative
Anti Dengue IgG Negative
Autoimmune
Quantitative CRP 0.7 mg / dl <0.7
Another test

Procalcitonin 4,65 ng/dl <0,05

June 3, 2017

S : fever (+), decreased awareness (+)

O : Aletness : GCS 13 (E4V4M5) T = 38⁰C BB = 7.7 kg

Head = fontanela still open. Eyes : Light reflex + / +, pupil isochoric,

Pale at lower eyelid conjunctiva (- / -)

Thorax = Symmetrical fusiform, no retraction

HR: 120x / bpm , regular, murmur

RR: 28x / min, regular, no ronchi was found -

Abdomen = Soepel, peristaltic (+) N, H / L: not palpable

Extremities = pulse: 120x / bpm ,regular, P / V adequate, capillary refill time < 3

seconds

A : CNS infection ec DD / Meningitis + GE without dehydration

Meningoencephalitis

P : O2 nasal canule 1 lpm

IVFD kaen 3B 32 cc / hr

Inj. Ceftriaxone 400 mg / 12 hours / IV

Inj. PCT 10 cc / 6 hours / IV

Diet formula milk 50 cc / 3 hours / OGT

June 4, 2017
S : fever (+), decreased awareness (+)
O : Alertness : GCS 13 (E4V4M5) T = 35⁰C
Head = fontanella still open. Light reflex + / + eye, pupil isochoric, pale at lower
eyelid conjunctiva (-/-)
Thorax = Symmetrical Fusiform,no retraction was found
HR: 122x /bpm, regular, no murmur was found
RR: 22x / bpm, regular, no ronchi was found
Abdomen = Soepel, peristaltic was normal, H / L: ttb
Extremities = pulse: 122x /bpm, regular, P / V enough, warm acral
A : CNS infection ec DD / Meningitis + GE without dehydration
Meningoencephalitis
P : O2 nasal canule 1 lpm
IVFD Kaen 3B 32 cc / hr
Inj. Ceftriaxone 400 mg / 12 hours / IV
Inj. PCT 10cc / 6 hours / IV
Diet milk formula 80 cc / 3 hours / OGT

LABORATORY FINDING (June 4, 2017)

Types of Checking Results Normal Value

Liver Function Test
Albumin 2.4 g / dl 3.5-5.0 g / dl

June 5, 2017

S : Fever (+), decreased awareness (+)

O : Alertness : GCS 13 (E4M5V4) T = 37.5⁰C

Head = fontanella still open . Light reflex + / + eye, pupil ischoric,

 Pale at lower eyelid conjunctiva (-/-)

Thorax = Symmetrical Fusiform, no retraction was found

HR: 122x /bpm, regular, no murmur was found

RR: 20x /bpm, regular, no ronchi was found

Abdomen = Soepel, peristaltic was normal , H / L: not palpable

Extremities = pulse: 122x / bpm, regular, P / V adequats

A : CNS infection ec DD / Meningitis + GE without dehydration

Meningoencephalitis

P : O2 nasal canule 1 lpm

IVFD Kaen 3B 32 cc / hr

Inj. Ceftriaxone 400 mg / 12 hours / IV

Inj. PCT 10cc / 6 hours / IV

Diet milk formula 80 cc / 3 hours / OGT

LABORATORY FINDING (5 June 2017)

Types of Checking Results Normal Value

Blood Count
Hemoglobin 10.7 g / dL 10.5 - 13.1 g / dL
Erythrocyte 4,04x106 / mm3 3,60 -5,20 x106 / mm3
Leucocytes 14.600 / mm3 6000 - 17.500 / mm3
Haematocrit 32% 35 - 43%
Platelets 466.000 229.000 - 553.000
Differential count
Neutrophils 20.50% 25.00 - 60.00%
 Lymphocytes 58.70% 25.00 - 50.00%
Monocyte 16.40% 1.00 - 6.00%
Eosinophils 2.20% 1.00 - 5.00%
Basofil 0.20% 0.00 - 1.00%
Neutrophil absolute 2.99x103 / mm3 1.9 - 5.4x103 / mm3
Absolute lymphocyte 8.57x103 / mm3 3,7-10,7x103 / mm3
Absolute monocyte 2.69x103 / mm3 0.1-0,8x103 / mm3
Eosinophil absolute 0.32x103 / mm3 0.20-0,50x103 / mm3
Absolute basophil 0,03x103 / mm3 0-0,1x103 / mm3
Liver
Albumin 3.3 g / dl 3.5-5.0 g / dl
Electrolyte
Calcium 7.90 mg / dl 8.4-10,2 mg / dl
Sodium 139 mEq / L 135- 156 mEq / l
Potassium 3.3 mEq / L 3,6 - 5,5 mEq / L
Chloride 107 mEq / L 95 - 106 mEq / L

June 6, 2017

S : Fever (+), decreased awareness (+)

O : Alertness : GCS 13 (E4M5V4) T = 37.5⁰C

Head = fontanella still open. Light reflex + / + eye, pupil isochoric,

Pale at lower eyelid conjunctiva (- / -)

Thorax = Symmetrical Fusiform, no retraction was found

HR: 102x / bpm, regular, no murmur was found

RR: 22x /bpm, regular,no ronchi was found

Abdomen = Soepel, peristaltic was normal, H / L: within

 Extremities = pulse: 102x / bpm, regular, P/ V enough, warm acral

A : CNS infection ec DD / Meningitis + GE without dehydration

Meningoencephalitis

P : O2 nasal canule 1 lpm

IVFD Kaen 3B 32 cc / hr

Inj. Ceftriaxone 400 mg / 12 hours / IV

Inj. PCT 10cc / 6 hours / IV

Diet milk formula 80 cc / 3 hours/ OGT

Discussion

Meningitis is a syndrome of fever, headache, and meningismus with inflammation in the

meningens especially subarachnoid space as evidenced by Cerebrospinal fluid (CSF)
pleocytosis.1,3,4,7, Meningens is the collective term for the fibrous membranes that envelop the
brain and spinal cord, providing protection to delicate tissues of the central nervous system. The
meningens is the group of three membrans : the dura mater, the arachnoid mater, and the pia
mater, with the dura mater the outermost layer and pia mater the innermost layer.2 Normally, the
cerebrospinal fluid is clear, and contain some cell (until 4/µl) and contain a little protein
(albumin ratio CSF and albumin serum = 6,5 ± 1,9 × 10-3).2,7 Pleocytosis is an increased cell
count in cerebrospinal fluid.11 Infection process or neoplastic process in cerebrospinal fluid can
change the composition the normal CSF.8,9

The time to presentation (acute, subacute or chronic) and tempo of the illness differ based
on the etiology and guide appropriate initial management and treatment.9 The incidence of
bacterial meningitis in the first febrile seizures aged 6-18 months is still quite high, especially at
6-12 months of age, the seizure > 15 minutes is significantly associated with bacterial meningitis,
it is recommended to examine lumbar puncture in each child less than 18 months who suffered
first febrile seizures especially if the seizures more than 15 minutes. 12 Usually presents within
hours to days, whereas chronic meningitis is by definition longer than 4 weeks in duration. 9 A
wide range of bacteria cause purulent meningitis (bacterial mengitis). In the neonatal period,
which includes premature and term babies up to 3 months of life, group B streptococci cause
most bacterial meningitis in develop countries. Causes of bacterial meningitis in infants aged 2
months to 5 years of Streptococcus pneumonia, Neisseria meningitis, Haemophillus influenza. 13
 Viral meningitis and bacterial meningitis are both characterized by acute onset of fever,
headache, photophobia, neck stiffness, and often accompanied by nausea and vomiting. To
distinguish bacterial and viral meningitis identified by lumbar puncture examination.14
Symptoms of meningitis include fever, headache, meningism with or without consciousness,
lethargy, malaise, seizures, and vomiting, for disease severity can be seen from the low GCS
(Glass Glow Coma Scale) value.13 The disturbance of consciousness experienced may be
decreased awareness or irritability. Also found prominent crowns, stiff neck, or meningeal
stimulation such as Bruzinski and Kernig, but in children aged less than 1 year may not
encounter signs of meningeal stimulation, and found seizures.13 There may also be an increase in
intracranial pressure.13

Diagnosis is confirmed by examination of cerebrospinal fluid and the identification of

bacteria, viruses, or fungi with culture or antigen detection. Blood culture and full blood count is
an initial evaluation because 70-85% of neonates with meningitis have a positive blood culture.
The highest incidence of positive blood culture in early sepsis and meningitis.15 Blood glucose
and electrolyte examination is performed if indicated.13 Examination of lumbar puncture is
important for diagnosis.13 However, in severe cases, lumbar punctures should be delayed and
initiated by empiric antibiotics (2-3 days delay does not alter diagnostic values except for germ
identification, if antibiotics are sensitive).13 If strong suspicion of meningitis, although there is a
sign of increased intracranial pressure, lumbar puncture can still be done, but with caution.13
Absolute contraindication performs lumbar puncture if there is an increased sign of intracranial
pressure due to lesion urging space.13

Lumbar puncture in bacterial meningitis::

 Obtain cloudy liquid or opalescence with None (-) (+) and Pandy (+) / (++).
 Number of cells 100-10.000 / mm3 with predominant count of polymorphonuclear,
protein 200-500 mg / dl, glucose <40 mg / dl, gram staining, culture and resistance test.
In the early stages the number of cells can be normal with predominant lymphocytes.
 When a previous antibiotic has been obtained, the picture may be nonspecific.13

Table 1. Comparison of the character of cerebrospinal fluid in different types of meningitis16

Normal Bacterial Viral TB Fungal

Macroscopic Clear, Murky Clear/opalescent Clear/opalescent Clear
colorless
Pressure Normal Increased Normal or Increased Normal or
increased increased
Cell 0-5/mm3 100- 5-100/mm3 5-1000/mm3 20-
60.000/mm3 500/mm3
Neutrofil nothing >80% <50% <50% <50%
Glucose 75% blood Low (<40% Normal Low (<50% Low (<80%
glucose blood blood glucose) blood
glucose) glucose)
Protein <0,4 g/L 1-5 g/L >0,4-0,9 g/L 1-5 g/L 0,5-5 g/L
Others Gram positive Positive PCR Positive culture gram
<90%;Positive culture < 50% 50-80% negative;
culture positive
<80%;Positive culture 25-
 blood culture 50%
<60%

Bacterial Meningitis Score for children :

 Gram stain of CSF positive ( 2 points )

 CSF protein more than 80 mg/dl ( 1 point )
 Blood absolute neutrophil count 10.000 cells/cubic mm or more ( 1 point )
 Incidence of seizures with illness ( 1 points )
 Spinal fluid neutrophil count >=1000 cells per cubic mm ( 1 point )

Risk of bacterial meningitis :

 0 point : Aseptic meningitis very likely
 1 point : Aseptic meningitis less likely
 2-6 points : bacterial meningitis more likely 17

Meningitis with negative CSS cultures will give the impression of having previous treatment
with antibiotics or enterovirus infection.15 CT scan with contrast or head MRI in severe cases or
suspected complications such as subdural empyema, hydrocephalus, and brain abscess). On
electroencephalography examination can be found general slowdown.13 The principle of
management is with empirical therapy, then adjusted to the results of culture and resistance
test.13 Antimicrobial therapy in bacterial meningitis should consist of ampicillin and cefotaxime
or ampicillin and gentamicin, unless it is likely to be staphylococcus, which is an indication for
vancomycin.15
Empirical antibiotic therapy:

Age 1 - 3 months:

 Ampicillin 200-400 mg / kgBW / day IV divided into 4 doses + cefotaxime 200 - 300 mg
/ kgBW / day IV divided into 4 doses, or
 Ceftriaxone 100 mg / kgBW / day IV divided into 2 doses

Age> 3 months:

 Cefotaxime 200 - 300 mg / kgBW / day IV divided into 3 - 4 doses, or

 Ceftriaxone 100 mg / kgBW / day IV divided by 2 doses, or
 Ampicillin 200 - 400 mg / kgBW / day IV divided into 4 doses + chloramphenicole 100
mg / kgBW / day divided into 4 doses

If there is already a culture result then the antibiotic is adapted to the culture result.
 Dexametasone 0.6 mg / kgBW / day IV divided into 4 doses for 4 days, dexametasone
injection was given 15 - 30 minutes before or at the time of administration of antibiotics.
 The duration of treatment depends on the germs, generally for 10 - 14 days.13
 Supportive:

 The critical period of treatment of bacterial meningitis is day 3 and 4. Vital signs and
neurological evaluation should be done regularly. To prevent vomiting and aspiration,
the patient should be firstly empowered at the beginning of the illness.
 Head circumference should be monitored daily in children with large open crown.
 Increased intracranial pressure, seizures and fever should be well controlled. Fluid
restriction or higher head position is not always done in every child with bacterial
meningitis.13

Monitoring and Prognosis :

To monitor the side effects of high-dose antibiotic use serial peripheral blood tests, liver
function tests and renal function tests if indicated. For the growth of the patient, for hearing loss
as a symptom of bacterial meningitis present in 30% of patients, therefore the auditory function
test should be done immediately after returning home.13 Other residual symptoms such as mental
retardation, epilepsy, blindness, spasticity, and hydrocephalus. 13

Summary

It has been reported the case of Meningitis in 5 months 23 days boys. The diagnosis was
established from history taking (anamnesis), physical examination and laboratory finding.
During hospitalization, patient got empiric antibiotic (ceftriaxone) and paracetamol for suportif
to decrease the fever, and diet to maintain the nutrition (SGM milk or breast milk)

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