Meningitis in newborns - causes, symptoms and consequences. What can cause childhood meningitis and how to treat it

CNS infections in newborns and children of the first year of life are among the most severe and unfavorable diseases. Among all infections of the central nervous system of young children, meningitis occupies the first place.

SYNONYMS

Acute bacterial meningitis.

CLASSIFICATION

Meningitis is called serous when the inflammatory process manifests itself in the form of lymphocytic pleocytosis and lymphocytic infiltration of the meninges.

The serous nature of inflammation of the meninges occurs most often in viral meningitis.

In cases where modern available clinical and laboratory diagnostic methods fail to identify the causative agent of the disease, the term "aseptic meningitis" is used.

EPIDEMIOLOGY

The incidence of purulent meningitis in newborns, according to various sources, is 0.1-0.5 per 1000 children. At the same time, up to 80% of all cases of the disease occur in preterm infants.

The mortality rate of newborns from purulent meningitis ranges from 6.5 to 37.5%.

Severe consequences of purulent meningitis are noted in 21-50% of patients. These include hydrocephalus, blindness, deafness, spastic paresis and paralysis, epilepsy, psychomotor retardation.

ETIOLOGY

The etiology of purulent meningitis in newborns differs significantly from the etiology of this infection in older children and adults.

Infection of a child leading to the development of meningitis can occur in utero, intranatally or postnatally.

Intrauterine meningitis, as a rule, is clinically manifested in the first 48-72 hours after birth (early); postnatal meningitis can occur at any age, but more often after 3-4 days of life (late).

The causative agents of early meningitis may contain maternal microflora. In contrast, most late meningitis is essentially a nosocomial infection (Table 27-9).

Table 27-9. Risk factors for meningitis and likely sources of infection

In addition to the time of development of meningitis, an important guide to its etiology may be the presence or absence of other foci of infection. Meningitis, which developed in the absence of obvious foci of infection, is considered as primary (isolated), and developed against the background of infectious processes of a different localization, as secondary (one of the septic foci).

LEADING ETIOLOGICAL AGENTS IN EARLY MENINGITIS

Streptococcus agalactiae

Streptococcus agalactiae ((3-hemolytic group B streptococcus). Str. agalactiae is divided into five serotypes: la, lb, Ic, II and III. Early bacterial meningitis is caused by all serotypes with almost the same frequency.

Antibiotic sensitivity Str. agalactiae

Str. agalactiae is characterized by high natural sensitivity to most antibiotics. Benzylpenicillin, ampicillin, cephalosporins, carbapenems are active. Acquired resistance to penicillins is quite rare (no data for the Russian Federation). The level of their natural resistance to aminoglycosides is low, and therefore antibiotics of this group can be used in combination to increase the effectiveness of beta-lactams.

Escherichia coli

The role of E. coli in the etiology of early meningitis is comparable to the value of Str. agalactiae. Virulence of E. coli

E. coli strains that cause early meningitis often have a capsular polysaccharide - Ar K-1, which is quite invasive in its chemical structure and immunochemical characteristics, dangerous for a child. Bacterial meningitis caused by E. coli with K-1 antigen is much more severe and has more serious consequences than meningitis caused by E. coli without this antigen.

E. coli antibiotic sensitivity

E. coli has a high natural sensitivity to semi-synthetic penicillins (amoxicillin, piperacillin, etc.), cephalosporins, aminoglycosides, less to ampicillin.

Listeria monocytogenes

The significance of L. monocytogenes in the etiology of meningitis in the Russian Federation has not been finally established, however, in other geographical regions, for example, in North America, this microorganism occupies the 3rd place in frequency in the etiology of neonatal meningitis.

Virulence of L.monocytogenes

L. monocytogenes (gram-positive coccobacillus) is a naturally occurring microorganism that causes infectious diseases in humans and animals. Due to the relatively low virulence in immunocompetent individuals, the infection is most often asymptomatic.

However, L. monocytogenes can be transmitted from mother to fetus, often resulting in either miscarriage or neonatal sepsis. In addition, cases of listeriosis endometritis during pregnancy are known, which can also serve as a source of fetal infection. The number of women infected with this microorganism in the Russian Federation is insignificant.

Antibiotic susceptibility of L. monocytogenes

Listeria is characterized by a high level of sensitivity to natural and semi-synthetic penicillins (primarily to ampicillin) and carbapenems (imipenem is not recommended for the treatment of meningitis, meropenem is not allowed in children under 3 months). An important feature of this microorganism is resistance to all existing generations of cephalosporins. Listeria is moderately sensitive to aminoglycosides.

ETIOLOGY OF LATE MENINGITIS

Late meningitis in most cases is a manifestation of nosocomial infection. Their etiology is diverse and depends on the epidemiological situation in specific institutions.

Most often, late neonatal meningitis develops in children in the NICU. And also in the departments of nursing premature babies.

The main pathogens are representatives of the Enterobacteriaceae family (E. coli, Klebsiellaspp., Serratia marcescens, Proteusspp., Citrobacter diversus, etc.), less often Pseudomonas aeruginosa, Flavobacterium meningosepticum and other "non-fermenting" microorganisms, III serotype Str. agalactiae.

Almost all pathogens of late meningitis are opportunistic pathogens. Therefore, the development of meningitis during this period is facilitated not only by severe immunosuppression in a particular newborn, but also by iatrogenic factors (invasive interventions, violations of the sanitary and epidemiological regime, etc.).

PATHOGENESIS AND PATHOLOGICAL ANATOMY

Possible routes of infection:

Hematogenous (the most common route of infection), as a result of bacteremia. Approximately 3/4 of cases of neonatal purulent meningitis are associated with the presence of bacteremia. The most common entry gate for microorganisms can be the mucous membranes of the respiratory tract. In these cases, bronchitis, tracheitis, pneumonia primarily develop. In some cases, the primary focus of inflammation is not clinically manifested, in such situations they speak of primary or isolated meningitis. In cases of a verified general septic process and confirmed bacteremia, they speak of secondary purulent meningitis as one of the septic foci;

Infection by contact along the length: with infectious processes in the scalp (for example, with suppurated cephalohematoma), inflammation of the paranasal sinuses, inflammation of the middle ear. osteomyelitis of the bones of the skull, with inflammation of the orbit and the eyeball, defects in the skin and soft tissues, after spinal punctures, with congenital malformations of the central nervous system and skeleton (cerebral and spinal hernias), dermal fistulas and sinuses. However, this path is quite rare; The rarest way for a bacterial infection to spread to the membranes of the brain in newborns is the penetration of microorganisms from the perineural spaces and lymphatic vessels that drain the nasal cavity.

In most cases, bacterial meningitis goes through several main stages of development.

Stage 1. In the process of childbirth, the primary meeting of the fetus with microorganisms occurs, the process of colonization in the upper respiratory tract and gastrointestinal tract is initiated. Colonization - the presence of bacteria in the body in the absence of a distinct immune response and clinical manifestations.

2. stage. The pathogen enters the blood, usually through the respiratory tract. Bacteremia occurs. Moreover, conditions are created under which microorganisms, bypassing the liver, enter the central nervous system in the shortest way.

3. stage. Hematogenous seeding of the soft meninges of the brain and spinal cord.

4. stage. Inflammation of the meninges with the development (or without) inflammatory changes in the brain parenchyma.

Despite the variety of pathogens of purulent neonatal meningitis, their morphological changes are similar. The inflammatory process is localized mainly in the soft and arachnoid membranes (leptomeningitis). Involvement in the process of the dura mater occurs only sometimes in the form of small purulent deposits and hemorrhages (pachymeningitis). To varying degrees, the inflammatory process also extends to the roots of the spinal and cranial nerves, to the superficial parts of the brain along the perivascular spaces, and sometimes to the ependyma and choroid plexuses of the ventricles.

In some cases, the cerebral vessels of the perivascular cerebral parenchyma may be involved in the inflammatory process, which can be regarded as meningoencephalitis.

If there is little exudate, it forms thin strips in the furrows of the brain along the veins. With a large amount of exudate, it impregnates the membranes completely, accumulating mainly at the base of the brain (in tanks). The volume and mass of the brain increase due to edema of its parenchyma. In some cases, the brain may be wedged into natural cracks and holes, especially in the large occipital. In the first 2 days of the disease, serous or serous-purulent inflammation predominates, in the next day - purulent.

Removal of exudate occurs by phagocytosis of fibrin and necrotic cells by macrophages. Sometimes it undergoes organization, which is accompanied by the development of adhesions in the cerebrospinal subarachnoid spaces. Violation of the CSF patency often leads to the development of occlusive hydrocephalus. Reparation can be delayed for 2-4 weeks or more.

CLINICAL MANIFESTATIONS

The clinical picture of purulent meningitis consists of general infectious symptoms and neurological disorders. Features of clinical manifestations in each specific case of the disease are determined by factors such as gestational age (degree of maturity), the presence of concomitant pathological or borderline conditions, various diseases, as well as the time and routes of penetration of the pathogen into the meninges.

Among general somatic disorders, the syndrome of "infectious toxicosis" often comes first, manifested by a grayish tint against the background of pallor or "marbling" of the skin, jaundice, impaired thermoregulation (often hyperthermia), tachycardia, respiratory rhythm disturbances, intestinal paresis, regurgitation or vomiting , hepato- and splenomegaly.

In the neurological status, there may be a large variability of signs. In some newborns, in the early stages of the disease, signs of CNS depression are noted: lethargy, drowsiness, disturbances in the level of wakefulness, adynamia, hyporeflexia, and muscle hypotension. In another part of the children, neurological disorders prevail in the form of agitation, motor restlessness, a painful or piercing cry, hyperesthesia, tremor of the chin and limbs.

Cranial nerve disorders may present with high-amplitude nystagmus, floating eyeball movements, convergent or divergent strabismus, or "setting sun" symptoms.

Bulging and tension of the large fontanel, stiffness of the muscles of the back of the neck are signs of meningitis that are not always early and clearly detected in newborns, especially premature ones. In some cases, one can observe a rapidly progressive increase in head circumference, divergence of cranial sutures.

Distinct disturbances in the level of wakefulness, up to the development of coma, extended convulsions, as a rule, appear against the background of current general infectious manifestations, but in some cases they may be one of the earliest neurological symptoms.

EARLY COMPLICATIONS OF NEONATAL PURULENT MENINGITIS

Like any infectious disease, meningitis has a certain phase of the course. The initial phase is distinguished: a violation of cerebral circulation and liquor dynamics. The most common complications in this period may be cerebral edema and convulsions.

Clinically, cerebral edema is manifested by increasing intracranial hypertension with progressive impairment of consciousness.

In the early stages of cerebral edema, a sharply animated (spontaneous) Babinsky reflex is recorded on both sides, which is of a long tonic nature. Due to severe muscular extensor hypertension, it is often impossible to study tendon reflexes and passive flexion of the lower extremities. Systemic blood pressure increases (especially its systolic component and mean blood pressure) as cerebral edema progresses, shortness of breath and tachycardia increase.

Newborns take a posture with a head thrown back, leg extension, semi-flexion or pronounced flexion of the arms. The cry is monotonous with episodes of piercing, sometimes turning into a groan. In most cases, a bulging of the large fontanel, its pulsation, and sometimes a rapid divergence of the cranial sutures are observed.

With severe cerebral edema, dislocation of its stem sections is possible, followed by their wedging into the foramen magnum, the development of secondary stem symptoms: coma, disturbance of the rhythm and depth of breathing, apnea attacks, a drop in systemic blood pressure, heart rhythm disturbance (more often bradycardia or bradyarrhythmia).

Coma is clinically manifested by increasing inhibition of all types of cerebral activity: adynamia, areflexia and diffuse muscle hypotension. However, due to severe disorders of peripheral hemodynamics in the muscles, a child often develops sclerema, and the identification of motor, reflex, tonic disorders can be difficult. With the deepening of the coma, convulsive paroxysms disappear, if they were before. The reaction of the pupils to light disappears, there is no pain and tactile sensitivity, apnea attacks become more frequent and deep, a drop in systemic blood pressure, and the development of bradyarrhythmia are possible.

Often the development of cerebral edema is accompanied or preceded by a convulsive syndrome.

Depending on the localization of the foci of cerebrovascular accident and the increase in cerebral edema, convulsions can be of a different nature: tonic (primary - characteristic of very premature babies); clonic (focal, multifocal, generalized - more often in full-term); fragmentary (motor, ophthalmic, absences, apnoetic); myoclonic (axial, limb myoclonus, mixed).

As a rule, in full-term convulsions, at first, convulsions are clonic in nature, and as brain edema progresses, they transform into tonic ones.

The appearance of isolated tonic seizures against the background of an intractable convulsive syndrome indicates decortication, a poor prognostic sign.

Cerebral edema can capture the nuclei and the cranial nerves themselves, which can be clinically manifested by dysfunction of the oculomotor nerves, facial nerve, trigeminal, hypoglossal nerves. In rare cases, the development of bulbar and pseudobulbar disorders is possible.

A very dangerous complication of meningitis caused by gram-negative flora is bacterial (septic) shock. Its development is associated with the penetration of a large number of bacterial endotoxins into the bloodstream (often at the time of prescribing antibiotics or changing the antibiotic regimen).

Clinically, septic shock is manifested by sudden cyanosis of the extremities, patchy pallor of the skin of the chest and abdomen, a catastrophic decrease in systemic blood pressure, tachycardia, severe shortness of breath, diffuse hypotension with bouts of short-term motor anxiety and a groaning weak cry, loss of consciousness, often in combination with DIC.

Late complications of neonatal purulent meningitis

Late complications of purulent meningitis include ventriculitis or ependymatitis, abscesses of the brain and spinal cord, various forms of hydrocephalus. Late complications develop, as a rule, with late diagnosis or inadequate treatment.

DIAGNOSTICS

The study of the clinical picture and course of bacterial meningitis in newborns indicates that they do not have unambiguous clinical criteria for early diagnosis, so additional laboratory research methods are of primary importance.

In all situations, the decisive role in the diagnosis belongs to the study of the CSF, so spinal puncture should be performed in all doubtful and unclear cases, at the slightest suspicion of meningitis.

Indications for lumbar puncture

Convulsive syndrome of unknown etiology.

Hyperthermia of unknown etiology.

Neck stiffness, hyperesthesia.

Coma of unknown etiology.

Progressive depression or excitement, the cause of which is not clear.

Rapidly increasing intracranial hypertension (bulging and tension of the large fontanel, divergence of cranial sutures, extensor hypertension in the legs).

The combination of any of the above syndromes with signs of "infectious toxicosis" without obvious clinical foci.

Contraindications for urgent lumbar puncture

DIC syndrome.

Cerebrospinal fluid examination for bacterial meningitis

Laboratory analysis of CSF includes the following studies (Tables 27-10).

Counting the number and determining the morphology of cells (determining their ratio in percent).

Determination of glucose and protein levels.

Bacterioscopy of a fixed drop of CSF stained by Gram.

CSF culture to determine the sensitivity of the pathogen to antibiotics.

Detection of bacterial antigens in CSF with standard antiserum kits (if possible).

Table 27-10. Summary data of laboratory parameters in the study of CSF in healthy newborns and in patients with purulent meningitis (McCracken G., 1992)

With purulent meningitis, the level of total protein in the CSF begins to rise much later than neutrophilic pleocytosis increases (on the 2nd-3rd day of the disease), this is an indicator of fibrinous exudation.

The higher the protein level in the CSF, the later the diagnosis of meningitis is made.

With concomitant hemorrhages, an increase in the concentration of total protein in the CSF, as a rule, is determined from the first days due to the penetration of plasma proteins into the CSF and lysis of erythrocytes.

In premature newborns, mainly in children with ELBW, water balance disorders are much more common, which indirectly affects the concentration of total CSF protein (on average, this figure is higher compared to full-term ones).

When examining the CSF, it is desirable to determine the level of sugar in it. With purulent meningitis, as a rule, it is reduced in relation to the level of sugar in the blood.

In all cases, a comparison of the dynamics of the clinical picture and changes in liquorological data makes it possible to make the correct diagnosis.

Of particular importance in differential diagnosis is ultrasound scanning of the brain, which, in the presence of spinal puncture data, can distinguish between intracranial hemorrhage, as well as the development of late complications of purulent meningitis in the form of ventriculitis, various forms of hydrocephalus, brain abscess.

Microbiological examination of cerebrospinal fluid

Microbiological examination of the CSF consists of smear microscopy, isolation of the pathogen, serological detection of antigen in the CSF.

Instrumental diagnostic methods

Neurosonography (NSG) is an ineffective method for the early diagnosis of meningitis itself, but it allows diagnosing concomitant complications: developing ventriculitis, expansion of the ventricular system, development of a brain abscess localized in the deep parts of the brain tissue or in the region of the basal subarachnoid spaces. In addition, this method allows you to confirm or exclude concomitant intracranial hemorrhages, ischemic infarcts, malformations, etc.

CT of the head is indicated to exclude brain abscess, subdural effusion, to identify areas of thrombosis, infarcts, or hemorrhages localized in the superficial (convexital) structures of the brain.

PRINCIPLES OF TREATMENT

Antibacterial therapy

The main place in the treatment of bacterial meningitis is occupied by antibiotic therapy, which must be carried out not only in case of confirmation of the diagnosis, but also in cases where meningitis cannot be completely excluded.

When choosing a treatment regimen for a child diagnosed with bacterial meningitis, it is necessary to focus on the following factors:

Time of onset of symptoms;

The nature of previous antibiotic therapy;

Data from microbiological monitoring (if any) in a specific neonatal unit.

The effectiveness of antibiotic therapy is assessed according to clinical data and the results of CSF microscopy, which is re-examined no later than 48-72 hours from the start of treatment. If after 48-72 hours from the start of empirical antibiotic therapy for neonatal bacterial meningitis there is no obvious clinical and laboratory improvement, then the antibiotic treatment regimen is changed.

When prescribing antibiotic therapy in connection with suspected purulent meningitis or when it is confirmed by laboratory data, the following general rules are followed:

In newborns for the first 7 days of life, antibiotics are administered, as a rule, intravenously, if not possible - intramuscularly, and the frequency of their administration depends on the effectiveness of diuresis;

One antibiotic or a combination of them is prescribed at the time of diagnosis in the maximum allowable for the newborn (the so-called meningeal) doses. An insufficient concentration of antibiotics in the blood serum can lead to a chronic process and reduce the penetration of the antibiotic through the blood-brain barrier. The dosage of antibiotics is not reduced within 3-5 days even after a clear clinical and laboratory improvement;

The effectiveness of antibiotic therapy is assessed by clinical data, microscopy results and CSF cultures over time. Repeated studies of CSF are carried out no later than 48-72 hours from the start of treatment;

In the treatment of ventriculitis or late diagnosed meningitis, it is advisable to administer one of the antibiotics intrathecally (intraventricularly or endolumbally), preferably intraventricularly. Not all antibiotics can be administered intrathecally due to their ability to provoke convulsions. Antibiotics that provoke the development of convulsive syndrome include all beta-lactams (penicillins, cephalosporins, carbapenems).

Treatment of early neonatal meningitis

The leading etiological agents of early meningitis and the means of choice for their treatment are given in Table. 27-11.

Table 27-11. Antibiotics of choice for early neonatal meningitis

Treatment of late neonatal meningitis

Often, late neonatal meningitis develops in children in the NICU.

The etiology of late neonatal meningitis in these conditions is characterized by significant variability, but their common property may be multiple resistance to antibiotics of the main groups. Under these conditions, the importance of timely microbiological diagnostics sharply increases, which makes it possible to carry out targeted etiotropic treatment. A rapid clinical effect can only be achieved through targeted antibiotic therapy.

None of the existing modern antibiotics or their combinations covers the entire spectrum of potential etiological agents (taking into account the spread among them of acquired resistance) of late neonatal meningitis. For this reason, it is not possible to recommend a universal regimen for empirical therapy of late meningitis. Targeted etiotropic therapy of meningitis can actually be carried out only after the isolation of the infectious agent and assessment of its sensitivity. However, a consistent analysis of data from the intermediate stages of microbiological diagnosis (smear microscopy, CSF culture, and pathogen isolation) makes it possible to substantiate treatment with increasing reliability.

A relatively informed choice can be made already at the level of obtaining the results of the CSF smear Gram stain. This diagnostic technique allows to differentiate three groups of etiological agents.

Gram-positive microorganisms;

Gram-negative microorganisms;

When gram-positive and gram-negative bacteria are detected in a CSF smear, it is advisable to start treatment with ceftriaxone or cefotaxime. However, it should be borne in mind that they cover a significant part of the spectrum of possible pathogens only if there is no high level of acquired resistance (multiresistance). If fungi are detected in a CSF smear (or if they are suspected), antifungal drugs should be prescribed.

After receiving the results of the species identification of the pathogen, a more accurate adjustment of etiotropic therapy is possible. For example, when P. aeruginosa is detected, a positive effect of treatment can be obtained using a combination of ceftazidime and amikacin. However, the most effective treatment of meningitis may be only after receiving the results of an assessment of the antibiotic sensitivity of the pathogen.

In the complex treatment of neonatal purulent meningitis, infusion, immunocorrective and anticonvulsant therapy, described in the relevant sections of the manual, is of great importance.

A neuroinfection that affects the membranes of the spinal cord and brain, accompanied by changes in the cerebrospinal fluid, is meningitis. There are 10 cases of illness in children under 14 per 100 thousand people, of which 80% are children under 5 years of age. Age affects the mortality rate - the lower it is, the more likely death is.

What is meningitis

The infectious process affects the membranes of the brain. Meningitis can be caused by bacteria, viruses, or fungi that enter the body through air or water. The reason for the high risk of meningitis is due to the development of infectious-toxic shock, which is caused by the mass reproduction and death of pathogens.

Endotoxins produced by meningococci disrupt microcirculation, promote intravascular coagulation, and disrupt metabolism. The result is cerebral edema, death from paralysis of the respiratory center.

Typical pathogens

The source of infection is a person. There are 100-20,000 bacteria carriers per 1 sick person. Depending on the age of the patient, pathogens are more often detected:

Up to a month of life - group B streptococci, Escherichia coli strain K1, lactobacillus monocytogenes.
1-3 months - group B streptococci, Escherichia coli, streptococcus pneumoniae, Neisseria, hemolytic infection.
3 months - 18 years - Neisseria (meningococcus), pneumostreptococcus, hemolytic infection.

Serous childhood meningitis is caused by ECHO, polio, herpes, Epstein-Barr viruses. Rickettsia, spirochetes, toxoplasma are isolated from other pathogens.

A potential source of infection is a person or a bacteriocarrier. The following factors contribute to the development of the disease in newborns:

adverse pregnancy, childbirth;
oxygen starvation (hypoxia);
tuberculosis;
infection.

In children, the causes are purulent otitis, tonsillitis. The predisposition to the disease is due to the immaturity of the immune system, the permeability of the brain barrier. Contributing factors are:

hypotrophy;
insufficient care;
hypothermia, hyperthermia.

Disease classification

Meningitis is divided into primary (in the meninges) and secondary (spread of infection from other foci). The course of infection is divided into:

fulminant (fatal outcome within a day.);
acute (develops up to a week);
subacute (from several days to several weeks);
chronic (more than 4 weeks).

By the nature of the cerebrospinal fluid, meningitis is serous (there are no impurities in the liquid), purulent (with bacteria and leukocytes), hemorrhagic (with hemorrhages).

Complications after meningitis in children

Severe consequences of meningitis in children:

dropsy;
stunning, coma;
epilepsy;
ataxia, hemiparesis (muscle weakness, paralysis));
cardiac arrest, breathing;
ventriculitis syndrome - inflammation of the ventricles of the brain.

Signs of a meningitis infection in a child

Symptoms of meningitis in children depend on the affected pathogen:

The bacterial form has a rapid onset, rapid development. The child becomes excitable during sleep, cries, screams with soothing movements. Infants experience repeated vomiting, dehydration. Older children complain of headaches.
Viral form - symptoms increase gradually. Sometimes meningitis manifests itself suddenly - nausea, inflammation of the conjunctiva, nasopharynx, muscles. Complications are encephalitis, coma.

The first manifestations of the disease

Signs of serous meningitis in a child:

Headache - due to intoxication, increased pressure, felt throughout the volume.
Dizziness, vomiting, light and sound fear - appear on 2-3 days of illness. Vomiting is independent of food intake. Any touch can increase pain and dizziness.

Babies in the first days of the development of the disease are very excited, worried. They suffer from diarrhea, drowsiness, regurgitation, convulsions. From the first days, brain symptoms appear:

muscle rigidity - the child cannot tilt his head or does it with difficulty;
Kernig's symptom - bending of the legs when the head is tilted to the chest;
pose of a pointing dog - turns away to the wall, bends its legs to the stomach, throws back its head;
diplopia (double vision);
tachypnea;
visual impairment;
decreased hearing acuity;
hallucinations;
pink rash - gradually spreads from the feet to the face (this is the most dangerous sign of incipient sepsis).

Clinical syndromes of meningitis

The course of the disease is accompanied by general infectious, cerebral, meningeal symptoms. One of the syndromes is more pronounced, the other may be completely absent. Most often, signs of all three are observed.

General infectious syndrome

In children, a group of signs is characterized by chills, tachypnea. Other signs:

pallor or redness of the mucous membranes;
loss of appetite;
insufficiency of the adrenal glands, respiratory organs;
diarrhea.

cerebral

With the development of meningitis in children, the following symptoms appear:

vomit;
disturbances of consciousness, coma;
fever;
convulsions;
strabismus;
hyperkinesis (excitation);
hemiparesis (muscle paralysis).

Manifestations of meningeal syndrome in children

The most typical manifestations of the disease are:

hyperesthesia (sensitivity to light, sounds);
tilted head;
neck stiffness;
blepharospasm (spasm of the eye muscles);
tension of the fontanel in infants.

Diagnostics

If a child is suspected of meningitis, an urgent need to show the pediatrician, he can send the patient to an infectious disease specialist. For the diagnosis, consultations of an otolaryngologist, a neurosurgeon are important. Important procedures for determining the disease:

lumbar puncture;
analysis of cerebrospinal fluid to determine the etiology;
the presence and increase in the number of antibodies in the blood serum by serological methods;
polymerase chain reaction to study the pathogen, blood cultures and nasopharyngeal secretions;
neurosonography;
electrocardiogram;
skull x-ray.

How to treat meningitis in a child

If you suspect a disease, the baby is hospitalized. Treatment of meningitis in children includes etiotropic or pathogenetic therapy. Additionally shown diet, bed rest.

Meningitis is a severe and life-threatening infection of the central nervous system in infants. The causes of meningitis in newborns are not much different from the development of the disease in children of other age groups. The main cause of meningitis in infants is the penetration of microorganisms into the child's body.

Inflammation of the membranes of the brain or spinal cord in children can be caused by various infectious agents:

meningococci;
hemophilic bacillus;
pneumococci;
group B streptococci;
staphylococci;
listeria;
klebsiella.

The most common cause of meningitis in infants is E. coli. The causative agents of infection in the Yusupov hospital are identified using modern laboratory methods. To determine the degree of brain damage, the presence of purulent foci in the brain, doctors perform magnetic resonance and computed tomography. For treatment, neurologists use the latest antimicrobial drugs that are highly effective and have minimal side effects.

A predisposing factor in the development of meningitis in newborns is perinatal lesions of the central nervous system. Meningitis can be an independent disease or a complication of another infectious disease. The primary focus of infection may be in carious teeth, ear, mastoid process, organ of vision. Only a timely diagnosis of meningitis and timely adequate treatment of the disease with modern antibacterial drugs can save the life of an infant and prevent serious complications.

Symptoms of meningitis in the baby

Signs of meningitis in newborns are usually non-specific. In babies, lethargy develops, periodically replaced by anxiety, appetite decreases, they refuse to breastfeed and spit up. Doctors determine the following signs of meningitis in infants:

pallor of the skin;
acrocyanosis (cyanotic shade of the tip of the nose, earlobes);
bloating;
signs of increased intracranial pressure (bulging or tense fontanel, "brain" cry, increased head circumference, vomiting).

Doctors identify such symptoms of meningitis in newborns as flinching, hyperesthesia, floating movements of the eyeballs, convulsions. At the first stages of the disease, you can notice a sign of Graefe, or a “symptom of the setting sun” - when the eyeball is lowered down, the eyelid of the baby remains raised, as a result of which the eye does not completely close.

Neck stiffness (pain or inability to bring the head to the chest) usually appears in the later stages of the disease. At the same time, neurologists find the following meningeal symptoms in infants with meningitis:

Babinsky reflex - with dashed irritation of the sole along the outer edge of the foot from the heel to the base of the big toe, involuntary dorsiflexion of the thumb and plantar flexion of other fingers occur (the reflex is physiological up to 2 years of life);
Kernig's symptom - the doctor fails to straighten the leg bent at the knee and hip joints at a right angle in the baby, who lies on his back (up to 4-6 months of age, the reflex is considered physiological);
Lasegue reflex - the inability to bend the baby's leg straightened at the hip joint by more than 60-70 degrees.

In newborns, for the diagnosis of meningitis, doctors use the Flatau syndrome (dilated pupils with a quick tilt of the head forward) and Lessage (pulling the baby's legs to the stomach in a suspended state) in combination with the clinical picture. Brudzinsky's reflexes up to 3-4 months of a child's life are also physiological. The upper symptom is passive flexion of the child's head with rapid flexion of the legs at the hip and knee joints. The average reflex is considered positive if, when pressing the edge of the palm on the area of \u200b\u200bthe pubic joint, the child has lower limbs. The lower symptom of Brudzinsky is positive, when, with passive flexion of one leg in the knee and hip joints, the other leg of the baby also flexes. Negative meningeal reflexes in infants are not grounds for excluding the diagnosis of meningitis in the presence of other symptoms of the disease.

The study of cerebrospinal fluid in meningitis in newborns

At the slightest suspicion of meningitis, newborns perform a lumbar puncture. The diagnosis can be confirmed or ruled out only on the basis of an examination of the cerebrospinal fluid. With purulent meningitis, cloudy or opalescent cerebrospinal fluid flows out under high pressure, a stream or frequent drops. In it, laboratory assistants find a large number of neutrophils. In addition to high neutrophilic cytosis, purulent meningitis is characterized by an increase in protein levels and a low concentration of glucose. To determine the type of pathogen, a bacterioscopic and bacteriological examination of the cerebrospinal fluid sediment is carried out. CSF analysis is repeated every 4-5 days until the newborn is fully recovered.

Tuberculous meningitis in newborns is extremely rare. Bacterioscopic examination of cerebrospinal fluid in tuberculous meningitis can give a negative result. For the tuberculous form of meningitis, a precipitation within 12-24 hours is typical in a taken sample of cerebrospinal fluid when it is standing. The sediment is a delicate fibrinous web-like mesh in the form of an overturned Christmas tree, sometimes coarse flakes. In 80% of cases, Mycobacterium tuberculosis is found in the precipitate.

Bacterioscopic examination of the cerebrospinal fluid in case of suspected meningococcal or pneumococcal nature of meningitis is a simple and accurate express diagnostic method. It gives a positive result at the first lumbar puncture 1.5 times more often than culture growth. Simultaneous bacterioscopic examination of cerebrospinal fluid and blood under a microscope gives 90% of positive results in meningococcal meningitis, if the examination of the newborn was carried out during the first day of hospitalization. By the third day of illness in infants, the percentage of positive results drops to 60.

With meningococcal meningitis, the disease proceeds in several stages:

first, the cerebrospinal fluid pressure rises;
then a small amount of neutrophils is found in the cerebrospinal fluid;
later, changes are noted that are characteristic of purulent meningitis.

Therefore, approximately in every fourth case, the cerebrospinal fluid, which is examined during the first hours of the disease, does not differ from the norm. In case of inadequate therapy, the cerebrospinal fluid becomes purulent, the concentration of neutrophils in it increases, and the protein level rises to 1-16 g / l. Its concentration in the cerebrospinal fluid reflects the severity of the disease. With adequate therapy, the number of neutrophils decreases, they are replaced by lymphocytes.

With serous meningitis of viral etiology, the cerebrospinal fluid is transparent, it contains a small amount of lymphocytes. In some cases, the initial stage of the disease is accompanied by an increase in the concentration of neutrophils, which indicates a severe course of the disease and has a less favorable prognosis. The protein content in serous meningitis does not go beyond the normal range or is moderately increased, up to 0.6-1.6 g/l. In some infants, the protein concentration is reduced due to increased production of cerebrospinal fluid.

Treatment of meningitis in newborns

Pediatricians, neurologists and infectious disease specialists make up individual treatment regimens for meningitis in newborns. The nature of the treatment depends on the type of meningitis (serous or purulent), the type of pathogen and the severity of the symptoms. Doctors individually select doses of drugs depending on the age and body weight of the newborn.

With viral meningitis, dehydration therapy with diuretics is carried out to reduce intracranial pressure. Prescribe anticonvulsants and antiallergic drugs that reduce the body's sensitivity to toxins and allergens. Antipyretic and analgesic drugs are used. Antiviral drugs and immunoglobulin are prescribed. In most cases, newborns recover in 1-2 weeks.

Bacterial meningitis is treated with antibiotics, to which various types of bacteria are sensitive. Since the analysis of cerebrospinal fluid taken during a puncture takes 3-4 days, empirical therapy with antibacterial drugs is started immediately after taking blood and cerebrospinal fluid for research. Express analysis results can be obtained within 2-3 hours. When identifying the causative agent of infection, antibiotics are prescribed, to which the identified microorganisms are most sensitive. If the condition of the infant does not improve 48 hours after the start of antimicrobial therapy, a second puncture is performed to clarify the diagnosis.

Meningitis in newborns caused by Haemophilus influenzae can be prevented by vaccination. The ACT-HIB vaccine, which is registered and approved for use in Russia, can be administered to babies from 2-3 months. Starting from the age of one and a half years, children are vaccinated against meningococcal infection with the domestic meningococcal A and A + C vaccine. The imported vaccine MENINGO A + C registered in the Russian Federation is administered to newborns if someone in the family has a meningococcal infection. Vaccination against pneumococcus with the PNEUMO 23 vaccine is done only at 2 years.

Meningitis in newborns is especially dangerous. Its consequences for infants can be unpredictable. Children after purulent meningitis suffered in infancy may lag behind in mental development. Toddlers develop deafness, visual impairment, and dysfunctional mental disorders.

At the first suspicion of the development of meningitis in infants, consult a doctor. Only the help of a qualified specialist will help save the life and health of a newborn.

Bibliography

ICD-10 (International Classification of Diseases)
Yusupov hospital
"Diagnostics". - Brief Medical Encyclopedia. - M.: Soviet Encyclopedia, 1989.
"Clinical evaluation of the results of laboratory studies" / / G. I. Nazarenko, A. A. Kishkun. Moscow, 2005
Clinical laboratory analytics. Fundamentals of clinical laboratory analysis V.V. Menshikov, 2002.

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Most meningitis is infectious and can be caused by various viruses or bacteria. Meningococcal infection is the most common form of all inflammatory infections of the meninges. This form of infection is recorded in 70-80% of cases in patients with this disease.

Meningitis in the bacterial form is serious and can turn into purulent forms. In most cases, streptococcal and meningococcal forms of meningitis are detected in infants and infants; these infections often lead to serious complications and are difficult.

Serous meningitis is overwhelmingly caused by viruses. These are mainly pathogens that cause rubella and chicken pox. Weakened babies are very susceptible to influenza infection. Problems in the work of the immune system are often fixed, immunodeficiency is observed. Children who have diabetes mellitus or who have been using glucocorticosteroids since birth may develop candidal meningitis.

This disease develops rapidly in a weak child's body. The harmful fungus Candida, which is the cause of candidal meningitis, enters the meninges along with the blood, after which it begins to multiply there, causing severe inflammation. This type of meningitis takes much longer to heal than bacterial meningitis.

The most rare type of meningococcal infection in newborns is the tuberculous variant, which is caused by protozoan microorganisms. This form of the disease occurs only in 2-3% of cases.

When a birth injury occurs, a traumatic form may occur, which is characterized by a severe form of leakage. Patients with this form of meningitis should be advised by a neurosurgeon and regularly monitored by a neurologist.

Examination methods

Extraction of cerebrospinal fluid (CSF) using a special needle for examination. Liquor constantly circulates in the ventricles of the brain. Taken into account:

general blood analysis;
c-reactive protein level;
blood glucose;
electrolytes;
the process of blood clotting;
the presence of bacteria.

The examination is based on the results of methods associated with the isolation of a culture of microorganisms from cultures of cerebrospinal fluid and blood. They may be positive in over 80% of patients who have not received antibiotic therapy. This type of therapy promotes negative cultures due to accumulation of pus in the brain, which can be caused by a specific bacteria, the herpes enterovirus.

Due to an infectious disease, which is meningitis in a newborn, there is an increase in protein in the cerebrospinal fluid and a decrease in glucose concentration. The increase in leukocytes is associated with the presence of white cells involved in maintaining human immunity over 90% in some cases.

To make a diagnosis of meningitis, it is necessary that leukocytes in the cellular composition of the cerebrospinal fluid exceed 21 cells per 1 mm3. Microscopic study of cells obtained from the focus of pathology and the diagnosis of diseases that lead to metabolic disorders may not give the proper result.

The concentration of glucose in the cerebrospinal fluid in a child who was born prematurely is from 55 to 105%, compared with the blood glucose level in a child born at the due date from 44 to 128%. The presence of protein is less than 0.3 g/l or more than 10 g/l.

positive blood culture;
the presence of a bacterial disease, which is manifested by foci of purulent inflammation, which is confirmed by data from clinical and laboratory studies;
the condition noticeably worsens when antimicrobials are used in therapy.

The procedure for inserting a needle into the space of the spinal cord in order to diagnose the composition of the cerebrospinal fluid at the level of the lumbar may be delayed until the patient's condition returns to normal, despite the delay in an accurate diagnosis, as well as the likelihood of incorrect medication.

If a newborn child who is suspected of having meningitis or sepsis has inadequate cerebrospinal fluid parameters, with a negative blood culture and CSF, it is worth re-diagnosing.

To exclude various infections and check for the presence of herpes, toxoplasmosis. With a late analysis of more than two hours, a significant decrease in the number of leukocytes and glucose saturation in the cerebrospinal fluid can be observed. It is best if the tests are with a specialist after half an hour.

Meningitis with CSF values within the normal range is observed in 30% of newborns. Even if the diagnosis is confirmed by microbiological examination, it is not always the cause of changes in the composition of the cells of the cerebrospinal fluid.

Indicators can be on the verge of normal and abnormal. In this case, it is necessary to conduct a survey of newborn patients for the presence of infections that could be transmitted directly from the mother. This applies to herpes, HIV, rubella, syphilis.

Microscopic examination of a native smear. Bacteria can be present in the cerebrospinal fluid in 83% of newborns, which is caused by group B streptococcus. At the same time, in 78% of patients in this group, meningitis appears due to gram-negative microorganisms.

The chance of detecting bacteria in this test is related to their presence in the cerebrospinal fluid. Important in making a diagnosis is the identification of a culture from the CSF, which does not depend on the data obtained from additional procedures.

The virus isolated from the blood is not always associated with a culture of cerebrospinal fluid, and therefore a detailed diagnosis of CSF is necessary. Extraction of cerebrospinal fluid using a special needle that constantly circulates in the ventricles of the brain is necessary if meningitis has not been detected during clinical and microbiological studies.

Treatment

The quality of getting rid of the disease directly depends on the cause of its occurrence, namely: on the pathogen. Purulent type meningitis occurs from a bacterial, fungal or viral infection. In the treatment, methods are used that are aimed at eliminating the pathogen.

This disease is quite dangerous with possible bad consequences, which is why a hospital stay is required. It is extremely important in case of meningitis in a premature baby, treat it only in the hospital, since the baby's body is very weak.

Treatment courses consist of injections of antibiotics, antiviral or antifungal medicines. Medicines are administered in significant volumes until the complete disappearance of the symptoms of the disease. To confirm complete recovery, a re-examination of the CSF is required.

Negative consequences of the disease

Including with timely diagnosis of the disease, the consequences are often negative. If the baby is premature, this only exacerbates the possibility of complications.

Meningitis in babies can lead to the following conditions:

brain abscess.
Lagging behind the age norms of development.
Dementia.
Hearing loss.
Loss of vision.
Dropsy of the brain.
epileptic seizures.
development of paralysis.
Damage to the nervous system.

In 30% of cases of the development of the disease in premature babies, therapeutic measures do not have the proper effect on the body and the situation ends in death.

In children under the age of 1 year, there is a risk of viral meningitis as a complication after ARVI, influenza, and various diseases. In weakened, often ill children, the development of a serous type of the disease is possible. Fungal meningitis caused by candidiasis is also common.

Dangerous symptoms that you should pay attention to and immediately visit a doctor:

intoxication of the body;
diarrhea;
nausea and vomiting;
increase in body temperature;
unexplained crying of a child.

Often, you can begin to suspect an inflammatory process in the meninges when the baby screams in bright light and loud sound. Thus gives the manifestation of soreness in the head during meningitis. In this condition, the lack of urgent medical attention can only aggravate the situation, for example, convulsive seizures.

In such a case, treatment is carried out in a hospital with the help of drugs that destroy the causative agent of the disease.

In children older than 2 years, the causes of meningitis can be:

viral microorganisms of other diseases such as rubella, chickenpox;
microbes;
fungal infections;
bacteria.

Often occurs after contact with stray animals that are carriers of viruses, or with a sick person. Most meningococcal infections occur due to the entry of harmful microorganisms into the human body. Often these are harmful bacteria or viral pathogens.

The undisputed leader among the causes that cause inflammation in the meninges is. This type of meningitis occurs in the vast majority of cases, while the bacterial forms of meningitis are acute and can turn into purulent forms.

Often, newly born babies and infants are susceptible to infection with streptococcal or meningococcal infection. Data diseases are difficult to cure and have a high risk of complications. Serous meningitis is always caused by the ingestion of viruses.

The causative agent of the disease can be the rubella virus, smallpox, etc. The influenza form is often observed in children with poor health. Often these children are found to have abnormalities in the functioning of the immune system. People who have been diagnosed with diabetes can get sick with candidal meningitis, which, along with the flow of blood, can enter the meninges, where it causes severe inflammation.

Such a disease is treated much longer than. Rarely, doctors detect a tuberculosis form. This type occurs in 2-3% of the total number of patients with this type of infection. Traumatic form can occur with birth trauma.

The disease begins to progress in the first days or months after birth. In most cases, the traumatic form causes various complications. During treatment, it is necessary to undergo regular examinations by a neurologist and a neurosurgeon.

Meningitis in newborns is manifested as a result of the ingress of pathogenic microflora into the membranes of the brain. This disease, in the absence of early diagnosis and complex treatment, can provoke the development of a mass of side effects on the body of a newborn, including death. The risk group includes children who have autoimmune diseases, as well as pathologically weakened immunity.

Meningitis is an infectious and inflammatory disease that is provoked by pathogenic microorganisms of a bacterial, viral and fungal nature. The disease is preceded by a weakened immune system, which does not allow timely fight against pathogenic microorganisms, which contributes to a rapid increase in their numbers. Together with the blood flow, they are carried to all tissues and organs, penetrating into the meninges.

The disease develops at lightning speed, in most cases causing a fatal outcome. The pathogenesis of meningitis is due to birth trauma, sepsis and the presence of pathogenic microflora in the mother's blood, which enters the body of the newborn during childbirth.

A feature of the disease in the neonatal period is:

Impossibility of early diagnosis.
Lightning flow.
The presence of complications in the gastrointestinal tract.
Severe dehydration, depressing the work of the kidneys.

Mortality occurs in 50% of cases, so the health of the newborn should be carefully monitored, avoiding contact with sick patients. Against the background of unformed immunity, the risks of infection remain high up to 1 year of life.

Causes

The inflammatory process of the meninges develops due to the ingress of pathogenic microorganisms into the children's body: streptococci, staphylococci, meningococci, E. coli. With the blood flow, these bacteria spread throughout the body, forming inflammatory foci in the brain and spinal cord.

The body of a newborn does not have its own immunity, so any bacteria, even conditionally pathogenic ones, can cause great harm. Most often, infection occurs during delivery or surgery, which is performed in the first weeks of life.

At-risk groups

Statistics show that the incidence of meningitis among newborns is due to factors such as:

The male sex - the body of girls is stronger.
Birth injuries - provoke a violation of normal blood flow, as well as the entry of pathogenic microflora into the body.
The presence of intrauterine pathologies - diseases of the kidneys and gastrointestinal tract, developing at the stage of fetal formation, do not allow the formation of immunity.
Immunodeficiency states in which immunity is completely absent.
The need for a long time to use glucocorticosteroids and other hormonal drugs.
The development of sepsis, which requires long-term antibiotic treatment.

Most often, meningitis is diagnosed in premature newborns. Children born before 35 weeks, in the presence of an infectious-bacterial lesion, die in almost 90% of cases.

Symptoms of the manifestation of pathology

Symptoms of meningitis in newborns are similar to those of a respiratory disease:

The body temperature rises to 39-40 °. The child becomes lethargic and lethargic. Sleeping most of the day.
Heavy and rare breathing, articulated with the appearance of yellowness of the skin.
No urination for 4-5 hours, indicating severe dehydration.
Refusal of food and the appearance of vomiting after eating it.
Spasms of the limbs, which are aggravated by the active crying of the child.

These symptoms should alert parents, as they are harbingers of a dangerous condition.

If they are ignored, the focus of the brain lesion increases, which provokes the development of symptoms specific to meningitis:

Stiffness of the muscles of the back of the head - when laying on the tummy, the child tries to throw his head back and roll over on his side.
Accumulation of cerebrospinal fluid - the fontanel begins to pathologically bulge and pulsate, and in its area the skin becomes hot.
The impossibility of stabilizing body temperature - no antipyretic drugs are able to normalize the temperature.
Soreness of the head and neck muscles - any touch, stroking the skin causes acute pain, which is accompanied by crying and irritability.
Tearfulness during motion sickness - the child begins to cry hysterically when he is motion sick, which is explained by an increase in intracranial pressure and increased headaches.
Spasms of the whole body, which cause paralysis of certain parts of the body, indicate damage to the nerve fibers and require immediate hospitalization.
Coma - the child does not respond to any mechanical stimuli. His breathing and pulse are irregular. Requires immediate resuscitation, the absence of which causes a fatal outcome.

The diagnosis is made on the basis of the results of the examination of the child and the evaluation of the complaints of the parents. The final stage involves the following research methods:

Analysis of the cerebrospinal fluid - a puncture helps to determine the quantitative and qualitative composition of the cerebrospinal fluid, which contains pathogenic microorganisms. By identifying the pathogen, you can choose the most optimal treatment.
MRI and CT - show foci of meningitis (there may be several), the degree of damage to the meninges, as well as the general condition of the baby's body.
Angiography - is prescribed for suspected development of large lesions with the involvement of blood vessels and nerve endings.

Drug therapy involves the use of antibiotics that can neutralize the activity of the causative agent of meningitis. It:

Ceftriaxone;
Cefazolin;
Amoxicillin;
Cefotaxime;
Cefix.

The choice of drug depends on which pathogen caused the inflammatory process. The child's body is supported with vitamins, hepatoprotectors, means to reduce irritation of the gastrointestinal tract.

Detoxification involves the introduction of lytic solutions that replenish the volume of freely circulating blood, as well as the appointment of diuretics that help remove fluid from the body. In the event that the kidneys are affected, hemodialysis may be prescribed. This procedure facilitates the work of the paired organ, enhancing the cleansing functions. It helps to eliminate toxins and toxins, normalizing the metabolic processes of the body.

In the presence of damage to the central and peripheral nervous system, antipsychotics and nootropics are prescribed. They strengthen and restore connections between neurons, which helps restore sensitivity. Seizures are stopped by anticonvulsants and muscle relaxants.

The advanced form of meningitis requires a surgical operation, as a result of which all foci of the inflammatory process are sanitized. After the procedure, the child's condition is rapidly improving, and the risk of developing negative consequences is reduced.

The duration of treatment directly depends on the degree of damage to the meninges, as well as the speed of diagnostic measures.

It is strictly forbidden to treat meningitis at home. The wrong medicine can be ineffective and life-threatening for the newborn. Only a doctor is able to correctly diagnose and choose the best treatment plan.

Complications

Unfortunately, in most cases, the child's body is not able to avoid the development of complications, which include:

epilepsy and other mental problems;
paralysis of various parts of the body;
hydrocephalus;
impaired vision;
deafness;
mental retardation.

In the absence of adequate treatment, disability develops in the shortest possible time. The child will not be able to become a full-fledged member of society and needs additional support.

Prevention

It is completely impossible to prevent the development of the disease. The body of a newborn is unpredictable. Only monitoring the condition and behavior of the child, as well as timely consultation with the doctor will help to avoid undesirable consequences.

You can reduce the risk of infection in an infant by following these rules:

limit the baby's contact with strangers;
avoid contact with sick family members;
in the presence of a respiratory disease, treat the child in a hospital under the close supervision of doctors;
properly dress the child, avoiding hypothermia and overheating;
Minimize visits to public places for up to 1 year.

A child under one year old should visit a pediatrician every month, who is required to perform a complete examination. If there are deviations, you need to consult with more highly specialized specialists.

Forecast

In 50% of all cases of detection of meningitis in newborns, a fatal outcome develops. The process of development of swelling of the brain occurs very quickly, so all vital functions are rapidly fading away.

With a favorable outcome, there is a high risk of complications, as well as negative consequences. 2-3 years after recovery, the child is periodically examined by an infectious disease specialist and a pediatrician, since the risks of re-infection remain.