Current Evidence The most common bacterial and viral pathogens are listed according to age in Table 122.2 The relative rates of meningitis, especially bacterial meningitis, remain highest in the neonatal age group Clinical Recognition Most patients present with fever, evidence of meningeal irritation, and increased ICP from diffuse cerebral edema or hydrocephalus with CSF obstruction at the basilar cisterns However, clinical manifestations may be nonspecific Diagnostic testing Infection of the subarachnoid space can be diagnosed by sampling the CSF through a lumbar puncture A CT scan or quick brain MRI should be performed prior to lumbar puncture to rule out hydrocephalus Lumbar puncture in the setting of untreated hydrocephalus may precipitate life-threatening herniation Management Suspected bacterial meningitis is a medical emergency and administration of appropriate antibiotic therapy should not be deferred if lumbar puncture cannot be performed Placement of an ICP monitor is controversial even in the presence of a poor neurologic examination or cerebral edema Monitoring ICP has not been shown to improve outcomes in these patients Maintenance of cerebral perfusion, by avoiding hypotension, not the direct treatment of elevated ICP, improves outcomes The most important prognostic factor for patients with meningitis is prompt and appropriate antimicrobial treatment TABLE 122.2 PEDIATRIC MENINGITIS CAUSATIVE ORGANISMS Age Common pathogens Birth to 90 days Group B streptococcus Escherichia coli Streptococcus pneumoniae Neisseria meningitidis Listeria monocytogenes Herpes simplex virus (HSV) Enterovirus Streptococcus pneumoniae Neisseria meningitidis Group B streptococcus Gram-negative rods Herpes simplex virus Enterovirus Streptococcus pneumoniae Neisseria meningitidis Enterovirus Neisseria meningitidis Streptococcus pneumoniae Enterovirus Arboviruses ≥3 months to years ≥3 years to 10 years ≥10 years to 18 years In exceptional cases where the meningitis is complicated by hydrocephalus, an external ventricular drain may need to be placed If the hydrocephalus is permanent from scarring of the subarachnoid spaces, a shunt for CSF diversion may need to be considered once the infection has been treated Discitis/Osteomyelitis Common pathogens encountered in children include Staphylococcus aureus, Kingella kingae, pneumococci, and salmonella species The prevailing hypotheses are that it is thought to arise from a prior site of infection and spread via three possible routes: hematogenously, by direct inoculation, or by direct extension Almost 50% of children will have a prior prodromal illness related to their disc space infection In children, blood vessels are present in the annulus fibrosus and the vessels within the vertebral body typically are anastomotic These anatomic variations have been proposed as a reason explaining preferential localization of bacterial infections to the intervertebral disc space Spondylodiscitis in children has a bimodal age distribution (0 to years and >10 years) mostly affecting the thoracic and lumbar spine Diagnosis can often be delayed up to to months secondary to the low incidence and vague presentation in children Clinical Recognition Children most commonly present with back pain, but nonspecific symptoms may be the only presentation, often without fevers Very young children with discitis often may refuse to walk, regress with ambulatory motor skills, display Gower sign, torticollis or refuse to sit Several authors have proposed categories of symptoms for children presenting with discitis: back pain, hip and leg pain, meningeal symptoms, abdominal symptoms, or “irritable child” syndrome Diagnostic Testing and Imaging Laboratory values (CBC, ESR, CRP) and blood cultures should be obtained, but are often normal or only mildly elevated Blood cultures will often be positive early in the course of the illness but given the delay in diagnosis, often only 50% are diagnostic Very early in the course, plain radiographs may be negative as it typically takes weeks to a month before disc space narrowing becomes apparent Initial evaluation should include an MRI of the entire spine with contrast Technetium-99, bone scans will identify the problem to 12 days after onset of symptoms, but are nonspecific and require distinction between inflammatory and neoplastic etiology Management Treatment is controversial as most spondylodiscitis infections have a relatively benign course If a pathogen is not identified, a CT-guided biopsy should be considered prior to initiation of antibiotic treatment unless clinically contraindicated in the unstable or critically ill patient More routinely however, a course of intravenous broad-spectrum antibiotics followed by oral antibiotics for to weeks is prescribed Antibiotic choice should be tailored to the pathogen identified by culture Surgery should be considered for refractory and progressive infections not responding to antibiotics Epidural extension with neurologic compromise should be treated with emergent decompression and evacuation of the infection Clinical Pitfall An entity known as chronic recurrent multifocal osteomyelitis (CRMO), or nonbacterial osteomyelitis (NBO), should be distinguished from spondylodiscitis or osteomyelitis It is often associated with additional inflammatory syndromes, including peripheral arthritis, sacroiliitis, psoriasis, inflammatory bowel disease or SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis) The etiology is poorly understood Young girls are more often affected (5:1) between the ages of to 14 years Patients are often asymptomatic between episodes, but symptoms may extend beyond months Patients may have minor diagnostic criteria of normal or mildly elevated labs (CRP, ESR), hyperostosis, other autoimmune diseases, and an associated family history Radiographic imaging can mimic osteomyelitis, but other long bones are typically involved Bone biopsies are often necessary for diagnosis and result as sterile but demonstrate evidence of inflammation and/or sclerosis or fibrosis Standard therapy involves NSAID use, but alternate medications such as oral steroids, methotrexate, and bisphosphonates, most commonly pamidronate, have been reported with positive early results Spinal Epidural Abscess The most common anatomical site for thecal sac encroachment by epidural abscess is in the cervical spine, followed by the thoracic and lumbar spine However, neurologic complications, paraparesis or paraplegia, as a result of thecal sac compression occurred more frequently in the thoracic and cervical regions The most feared complication of primary or secondary spinal epidural abscess is paralysis When paraplegia or tetraplegia is present, the prognosis is very poor POSTOPERATIVE COMPLICATIONS CLINICAL PEARLS AND PITFALLS ...TABLE 122.2 PEDIATRIC MENINGITIS CAUSATIVE ORGANISMS Age Common pathogens Birth to 90 days Group B streptococcus