CASE PRESENTATION ON

CSOM with
MENINGITIS
By
14421T0020
Pharm D IV yr

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 DEMOGRAPHIC DETAILS

IP.No : 0041276 Admns dt : 25/12/17

Pt name : XXX Ward : 10-Paediatrics
Age/sex : 11yrs/Mch Unit : 01

A 11yr old Mch brought by the parents with C/o

 C/o abdominal pain , headache , fever – since previous day
 C/o vomitings – 5 episodes , since previous day
Vomitings – non- projectile , non-bilious , contains partially
digested food & water.

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• The present illness started with abdominal pain , then headache
was started severe , more at the nape of neck & then vomitings
were started.
• H/o fever – high grade
• H/o chills +
• No H/o rash & rigor
• H/o ear pain 1wk before and taken treatment locally
• H/o fever after onset of ear pain for 2 days & relieved by taking
medication
• No H/o loose stools
H/o Past illness :
No H/o similar complaints in the past
H/o surgery for hydrocele – 5yrs back
H/o frequent pneumonia & 1episode of febrile seizures
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Ante natal H/o : taken regular IFA tablets
Birth H/o : LSCS /term /AGA /cried immediately after birth ,
birth wt : 2.7kgs
Post natal H/o : No H/o previous NICU admns
Developmental H/o : normal , child studying 5th class
Immunization H/o : immunised as per schedule
Family H/o :

No H/o TB , asthma,
epilepsy

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 LAB INVESTIGATIONS
S.No PARAMETERS LAB VALUES NORMAL RANGE
1. Haemoglobin 12.3gm/dL 11.5-15.5gm/dL
2. PLT 4.02 lakhs/cumm 1.5-4.5lakhs/cumm
3. WBC 17 x 10 3/µL 5-14.5 x 103 / µL
4. BUN 25mg/dL 5-20mg/dL
5. Sr.Creatinine 0.6mg/L 0.12-1.06mg/L
6. Sr.Electrolytes- Na+ 139mmol/L 136-145mmol/L
K+ 4.2 mmol/L 3.5-5.5mmmol/L
Cl- 103mmol/L 95-105mmmol/L
Ca+2 8.7mg/dL 8.5-10.2mg/dL
7. Bilirubin - Total 1.5mg/dL 0.3-1.0mg/dl
Direct 0.5mg/L 0-0.4mg/dl
8. SGOT 50 IU/L 0-60Iu/L
SGPT 41 IU/L 0-50Iu/L
ALP 105 U/L 75-375Iu/L
9. CT Scan Normal 5
 OTITIS MEDIA
Otitis media is the inflammation of the middle ear.
 It can be classified into 4 types on the basis of aetiology , duration ,
symptomology & physical findings.They are
1.Acute OM
2. OM with Effusion
3. Chronic Supperative OM
4.Adhesive OM
 OM is commonly associated with following symptoms :
a.Otalgia
b.Fever
c.Otorrhea
d.Anorexia
e.Irritability
f.Vomiting & diarrhoea 6
CHRONIC SUPPURATIVE OTITIS MEDIA :
CSOM is a chronic inflammation of middle ear that persists for at least
6wks & is associated with otorrhoea through a perforated tympanic
membrane.
Etiology :
80-90% cases – children younger than 6yrs.
Peak onset of OM is in 6-18 Months age group & then upto 10yrs age.

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Pathophysiology:
The most important factor in middle ear disease is eustachian tube (ET)
dysfunction ,in which mucosa at the pharyngeal end of ET is part of
mucociliary system of the middle ear.
Interference with mucosa (edema,tumor,-ve tympanic pressure)

Infectious processes from nasopharynx to middle ear

Otitis media
 Esophageal contents regurgitate into nasopharynx & middle ear
through ET can create a direct mechanical disturbance of middle ear
mucosa and cause middle ear inflammation.

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Signs & Symptoms : Complications:
• Otalgia 1. Intratemporal:
• Otorrhea • Hearing loss
• Headache • TM perforation
• Fever • Tympanosclerosis
• Irritability • Mastoiditis
• Loss of appetite • Labyrinthitis
• Vomiting & Diarrhoea • Facial paralysis
• Hearing loss • Cholesterol granuloma
• Tinnitus • Infectious ecematoid dermatitis
• Vertigo 2. Intracranial :
• Tearing/perforation of eardrum  Meningitis
Diagnosis:  Brain abscess
 Pneumatic otoscopy  Otitic hydrocephalus
 Tympanometry  Subdural empyema 9
 MENINGITIS
Meningitis is the inflammation of lining that surrounds & protects the
brain and spinal cord i.e., meninges.
It is a neurologic emergency that requires prompt recognition , diagnosis
& management to prevent neurologic deficits && death.
Etiology : 1.CNS infections
2.Neurosurgery
3.Trauma
4.Local / hematogenous spread
5.Ventriculo atrial (or) ventriculo peritoneal shunts
Pathophysiology :

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Signs & Symptoms : Complications:
• Headache  Hearing loss
• Neck stiffness(nuchal rigidity)  Recurrent seizures
• Fever  Homeostatic imbalance
• Nausea  Vision loss
• Altered mental status  Learning &behavioural
• +ve Kernig’s sign problems
• +ve Brudzinski’s sign  Problems associated with
• Seizures memory & concentration
• Photophobia
Diagnosis :
 Glass gow coma scale score
 Increased WBC,proteins
 Decreased glucose
 Cloudy CSF
 Increased Intracranial pressure
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 TREATMENT
CSOM
Analgesics + Antibiotics
Analgesics :
ACETAMINOPHEN
IBUPROFEN
Antibiotics :
 AMOXYCLAV-high dose
Amoxicillin-80-90mg/kg/day
Clavulanate-6.4mg/kg/day
 CEFTRIAXONE-50mg/kg/day
 CEFUROXIME-30mg/kg/day
MENINGITIS
• PENICILLIN-G
0.3million units/kg
• CEFTRIAXONE:80-100mg/kg/d
• AMPICILLIN:300mg/kg
• CEFOTAXIME:225-300mg/kg
• LINEZOLID:600mg BD
• TMP-SMX:10-20mg/kg
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 PLAN
DAY : 1
O/E
afebrile,drowsy,arousable,responding ,
coherent
HR : 86/min
RR : 26/min
PV : Normal
CRT <2sec
SpO2 -94% with RA
BP : 100/60 mm Hg
CVS : S1S2 + ,systolic murmurs
RS : B/L AE + , no added sounds
P/A : soft ,liver-3cm below RCM ,
no spleenomegaly 14
CNS : Day-1 Mch 11yrs 23kgs
CN - I : not treated
Rx
CN - II : B/L pupils NSRL
1.IVF – ½ DNS 42ml/hr
CN- III,IV,VI : extraocular
movement present 8PM-8AM @500ml
CN-VII : no facial asymmetry 2.Inj.CEFTRIAXONE
CN-V : facial sensation present 100mg/kg/day-1.1gm IV BD
CN-VIII : responding to sounds 3.Inj.AMIKACIN
CN-IX,X : gag reflex not tested 170mg IV BD
CN-XI :turning head to each side 4.T.PARACETAMOL
CN-XII : tongue bite normal 3/4th PO QID
Motor reflexes : normal
5.Inj.ONDANSETRON
Meningeal signs : neck rigidity+
2cc IV BD
Brudzinski’s sign +
6.Inj .PANTOP 30mg IV OD
Cerebellar region : not tested
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 D2 D3,4&5 D6 D7&8 D9 D10&11 D12,13&14

C/o headache + - - - - - -
H/o fever - - - - - - -
Accepting orally , passing N N N N N N N
urine & stools
O/E : PR (beats/min) 96 92 86 92,94 92 94,92 86
RR (/min) 28 26 26 28,24 26 24 24
CRT (<2sec) + + + + + + +
CVS – S1 S2 , no murmurs + + + + + + +
PV , RS – B/L AE N N N N N N N
P/A – soft ,no organomegaly + + + + + + +

CNS
Tone – Normal in all limbs
Power – 3/5 in all limbs + + + + + + +
Pupils-B/L NSRL,Reflexes -N

TREATMENT :
I.DEXAMETHASONE(DXM) CST CST CST CST CST CST
DAY 9: as D1 as as as D9 as as
1.Inj.CEFTRIAXONE + D2 D2 D2 D9 D9 &
2.T.PANTOP 1/2T BD DXM Stop
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3.T. PCT 2/3 T SOS T.PCT
 DRUG CHART
S.no DRUGS DOSE FQ ROA Day 1 D D D
2 -8 9- 11 12-14
1. IVF-1/2DNS 42ml/hr 8P - 8A IV + + - -

2. I.CEFTRIAXONE 1.1gm BD IV + + + +

3. Inj.AMIKACIN 170mg BD IV + + - -

4. T.PARACETAMOL 3/4th QID PO + + + -

5. I.ONDANSETRON 2cc SOS IV + + - -

6. I.PANTOPRAZOLE 30mg OD IV + + - -

7. Inj.DEXAMETHAS - - - - + - -
ONE
8. T.PANTOPRAZOLE 1/2T OD PO - - + +
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 CRITICAL EVALUATION
Clinical condition : CSOM with Meningitis
Drugs : Appropriate
Doses : Dose for Dexamethasone was not mentioned
Dosage forms : Appropriate
Duration : Appropriate
Frequency : Frequency for Dexamethasone was not mentioned
Drug of choice : Paracetamol + Ceftriaxone , Amoxyclav
Guidelines : American Academy of Paediatrics
DRUG INTERACTIONS :
DRUG SEVERITY COMMENT
INTERACTION
PARACETAMOL + minor Concurrent use leads to decreased
Food peak ACETAMINOPHEN levels 18
 PATIENT COUNSELLING
Regarding Disease :
Chronic supperative otitis media is a disease caused to the
middle ear , i.e., pain is commonly noticed in ear.
Meningitis is a disease to the brain ,caused due to otitis media.
Regarding Drugs :
1.Inj.CEFTRIAXONE :
It is used to treat the disease.
It is given by nurse in injection form , 2 times a day.
It may cause rashes , stool changes.
2.Inj. AMIKACIN :
It is used to kill the micro organisms.
It is given by nurse in injection form , 2 times a day.
It may cause drowsiness , headache , tremors.
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3.Tab.PARACETAMOL :
It is used to treat fever & pain in ear.
It is given in tablet form , taken 4 times a day.
It may cause nausea , vomiting , rashes.
4.Inj.ONDANSETRON :
It is given to treat vomitings.
It is given by nurse in injection form ,whaen ever necessary.
It may cause headache , sedation , constipation.
5.Inj.PANTOPRAZOLE :
It is given to decrease the acid production in stomach.
It is given by nurse in injection form , 1 time a day.
It may cause abdominal pain , rashes , loose stools.
6.Inj.DEXAMETHASONE :
It is given to decrease the disease progression.
It is given by nurse in injection form.
It may cause abdominal distension , drowsiness. 20
Life style modifications :
• Take Vitamin A & zinc rich foods like carrots , tomatoes , sweet
potatoes .
• Prefer coconut oil / olive oil for foods.
• Use pure water for drinking and cooking (avoid chloride , well water)
• Include peppers ,green leafy vegetables ,berries etc i.e., foods rich in
Vitamin C.
• Avoid processed & frozen foods.
• Place a warm cloth next to the affected ear or use a heating pad
• Keep an ice bag near the affected ear for some time to reduce
swelling.
• Lie down, on your side, placing the infected ear on a dry pillow. After
a short while, the fluid will probably drain out, due to the force
of gravity.
• Avoid milk, corn, wheat, citrus , eggs, chocolate and peanut butter.
• Avoid over-consumption of sugar. 21
 REFERENCES

1.Clinical Pharmacy & Therapeutics by Roger Walker & Cate

Whittlesea , 5th edition , pg.no:584-586
2. https://emedicine.medscape.com/article/994656-
overview#showall
3. https://www.nhs.uk/conditions/meningitis/complications/
4. https://www.nhs.uk/conditions/meningitis/complications/
5. https://www.mtatva.com/en/disease/otitis-media-treatment-diet-
and-home-remedies/
6.http://www.ndhealthfacts.org/wiki/Ear_Infections_(Otitis_media)
7.www.micromedexsolutions.com

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