Seminar: Neuroinfections in children: enteroviruses, TBE, Lyme neuroborreliosis, bacterial meningitis.

Clinical classes: Clinical manifestations, diagnostic workup, treatment, lumbar puncture, and cerebrospinal fluid examination.

Time: 4 hours (8:00 AM – 12:00 PM)

Goal

To understand the clinical presentation, diagnosis, differential diagnosis, and management of central nervous system (CNS) infections in children, with particular emphasis on early recognition of meningitis and encephalitis, interpretation of cerebrospinal fluid findings, and the principles of urgent treatment.

Before the class

Students should revise:

• Anatomy and physiology of the central nervous system and meninges.
• Cerebrospinal fluid production, circulation, and normal composition.
• The blood-brain barrier.
• Neurological examination in infants and children.
• Basic microbiology of bacterial and viral CNS infections.
• Principles of antimicrobial and antiviral treatment.

Topics

1. Classification and clinical presentation of neuroinfections

1.1. Meningitis, encephalitis, and meningoencephalitis.

1.2. Differences between bacterial and viral meningitis.

1.3. Clinical manifestations in neonates, infants, and older children.

1.4. Signs of neurological deterioration and increased intracranial pressure.

2. Viral neuroinfections

2.1. Enteroviral meningitis and encephalitis.

2.2. Tick-borne encephalitis

2.3 Other selected viral causes of CNS infections.

2.4. Principles of antiviral treatment.

3. Bacterial neuroinfections

3.1. Common causes of bacterial meningitis in different pediatric age groups.

3.2. Pneumococcal and meningococcal meningitis.

3.3. Group B Streptococcus and Escherichia coli infections in neonates.

3.4. Listeria monocytogenes CNS infection.

3.5. Principles of empirical and targeted antimicrobial treatment.

4. Diagnostic workup

4.1. Lumbar puncture: indications and contraindications.

4.2. Basic principles of the lumbar puncture procedure.

4.3. Cerebrospinal fluid examination: cell count, differential, protein, glucose, and microbiological testing.

4.4. CSF bacterial culture, Gram stain, and molecular diagnostics.

4.5. Interpretation of CSF findings in different types of meningitis.

4.6. Indications for neuroimaging.

5. Management and complications

5.1. Initial management of suspected bacterial meningitis.

5.2. Selection and timing of empirical antimicrobial therapy.

5.3. Indications for antiviral therapy.

5.4. Supportive care and management of neurological complications.

5.5. Long-term complications of CNS infections.

Topics' details

Students should be able to explain or discuss:

• Pathogenesis of bacterial and viral CNS infections.
• Age-related differences in the clinical presentation of meningitis.
• Typical features of meningeal irritation and their limitations in infants.
• Clinical features suggesting encephalitis rather than isolated meningitis.
• Neurological warning signs requiring urgent investigation.
• Indications and contraindications for lumbar puncture.
• Why suspected bacterial meningitis requires urgent empirical therapy.
• Circumstances in which treatment must not be delayed by lumbar puncture or neuroimaging.
• Normal age-dependent values of CSF parameters.
• Characteristic CSF findings in bacterial, viral, and fungal meningitis.
• Interpretation of CSF pleocytosis, elevated protein, and decreased CSF glucose.
• Diagnostic use and limitations of PCR, culture, and other microbiological tests.
• Interpretation of CSF obtained after antimicrobial treatment.
• Indications for intravenous acyclovir in suspected HSV encephalitis.
• Complications including seizures, hydrocephalus, hearing loss, and neurological sequelae.
• Principles of prevention, including immunization against major bacterial causes of meningitis.

Clinical skills

During clinical classes, students should practice:

• Performing a focused neurological examination.
• Recognizing clinical signs suggestive of meningitis and encephalitis.
• Identifying indications and contraindications for lumbar puncture.
• Practicing lumbar puncture techniques on infant and adult simulation mannequins, with each student required to perform the procedure on both models.
• Interpreting CSF findings from clinical cases.
• Formulating an initial diagnostic and therapeutic approach to suspected CNS infection.