Meningitis in Children

Neurology

Clinicals - History

Fact Explanation
Fever Bacterial pathogens reach the CNS either by hematogenous spread or by direct extension from a contiguous site.After bacteremia, pathogens penetrate the blood-brain barrier to enter the
subarachnoid space.An intense inflammation is elicited by bacterial products which gives rise to fever.(invading bacteria cause the body to reset it's thermostat to a higher level)
Fever
Bacterial pathogens reach the CNS either by hematogenous spread or by direct extension from a contiguous site.After bacteremia, pathogens penetrate the blood-brain barrier to enter the
subarachnoid space.An intense inflammation is elicited by bacterial products which gives rise to fever.(invading bacteria cause the body to reset it's thermostat to a higher level)
Vomiting Intense inflammation is elicited by bacterial products gives rise to oedema.This causes increased intracranial pressure which causes vomiting Vomiting
Intense inflammation is elicited by bacterial products gives rise to oedema.This causes increased intracranial pressure which causes vomiting
Lethargy Cerebral edema in the nonexpendable cranial vault increases intracranial pressure (>300cm
of H2O)
Lethargy
Cerebral edema in the nonexpendable cranial vault increases intracranial pressure (>300cm
of H2O)
Irritable Cerebral edema in the nonexpendable cranial vault increases intracranial pressure (>300cm
of H2O)
Irritable
Cerebral edema in the nonexpendable cranial vault increases intracranial pressure (>300cm
of H2O)
Refusing food or drink Cerebral edema in the nonexpendable cranial vault increases intracranial pressure Refusing food or drink
Cerebral edema in the nonexpendable cranial vault increases intracranial pressure
Headache Cerebral edema in the nonexpendable cranial vault increases intracranial pressure (>300cm
of H2O)
Headache
Cerebral edema in the nonexpendable cranial vault increases intracranial pressure (>300cm
of H2O)
Chills or shivering Invading bacteria cause the body to reset it's thermostat to a higher level Chills or shivering
Invading bacteria cause the body to reset it's thermostat to a higher level
Skin rash Non blanching petechiae and purpura in meningococcal meningitis Skin rash
Non blanching petechiae and purpura in meningococcal meningitis
Altered mental state Intense inflammation is elicited by bacterial products gives rise to oedema.Mental state will be altered due to edema and increased intra cranial pressure Altered mental state
Intense inflammation is elicited by bacterial products gives rise to oedema.Mental state will be altered due to edema and increased intra cranial pressure
Paresis Weakness of the muscles secondary to irritation of the nerve cells that control them Paresis
Weakness of the muscles secondary to irritation of the nerve cells that control them
Seizures Intense inflammation is elicited by bacterial products gives rise to oedema.It irritates the nerve cells of the brain which produces the seizure Seizures
Intense inflammation is elicited by bacterial products gives rise to oedema.It irritates the nerve cells of the brain which produces the seizure
Focal neurological deficit Cerebral edema irritates the nerve cells of the spinal cord which results in the palsies.Cranial nerves (CN) may also be affected by compressible
pressure of brain in general. Abducent (VI) nerves with its longest intra cranial route
adjacent to brain stem are more prone to raised intra cranial pressure and exudates (perineuritis) related
compression. Other CNs like III, IV, and VII may also be affected.
Focal neurological deficit
Cerebral edema irritates the nerve cells of the spinal cord which results in the palsies.Cranial nerves (CN) may also be affected by compressible
pressure of brain in general. Abducent (VI) nerves with its longest intra cranial route
adjacent to brain stem are more prone to raised intra cranial pressure and exudates (perineuritis) related
compression. Other CNs like III, IV, and VII may also be affected.
Photophobia Intense inflammation is elicited by bacterial products gives rise to oedema.Oedema irritates the nerve cells of the optic nerve which produces the visual changes Photophobia
Intense inflammation is elicited by bacterial products gives rise to oedema.Oedema irritates the nerve cells of the optic nerve which produces the visual changes
Age Most cases of viral meningitis occur in children younger than age 5. Bacterial meningitis commonly affects people under 20, especially those living in community settings Age
Most cases of viral meningitis occur in children younger than age 5. Bacterial meningitis commonly affects people under 20, especially those living in community settings
Living in a community setting Children in boarding schools and childcare facilities are at increased risk of meningococcal meningitis. This increased risk likely occurs because the bacterium is spread by the respiratory route and tends to spread quickly wherever large groups congregate Living in a community setting
Children in boarding schools and childcare facilities are at increased risk of meningococcal meningitis. This increased risk likely occurs because the bacterium is spread by the respiratory route and tends to spread quickly wherever large groups congregate
Compromised immune system Factors that may compromise the immune system, including AIDS, childhood diabetes and use of immunosuppressant drugs,also make the child more susceptible to meningitis. Removal of the spleen, which is an important part of the immune system, also increase the risk Compromised immune system
Factors that may compromise the immune system, including AIDS, childhood diabetes and use of immunosuppressant drugs,also make the child more susceptible to meningitis. Removal of the spleen, which is an important part of the immune system, also increase the risk
Skipping vaccinations The routine use of conjugated Hib vaccines in children has been associated with a reduction of more than 99% of invasive disease, including meningitis.If a child has not receive the vaccine, the risk of meningitis is high Skipping vaccinations
The routine use of conjugated Hib vaccines in children has been associated with a reduction of more than 99% of invasive disease, including meningitis.If a child has not receive the vaccine, the risk of meningitis is high

Clinicals - Examination

Fact Explanation
Febrile Bacteria reach the CNS either by hematogenous spread or by direct extension from a contiguous site.After bacteremia, pathogens penetrate the blood-brain barrier to enter the
subarachnoid space.An intense inflammation is elicited by bacterial products which gives rise to fever.(invading bacteria cause the body to reset it's thermostat to a higher level)
Febrile
Bacteria reach the CNS either by hematogenous spread or by direct extension from a contiguous site.After bacteremia, pathogens penetrate the blood-brain barrier to enter the
subarachnoid space.An intense inflammation is elicited by bacterial products which gives rise to fever.(invading bacteria cause the body to reset it's thermostat to a higher level)
Non blanching rash Non blanching petechiae and purpura in meningococcal meningitis Non blanching rash
Non blanching petechiae and purpura in meningococcal meningitis
Irritable Cerebral edema in the nonexpendable cranial vault increases intracranial pressure (>300cm
of H2O)
Irritable
Cerebral edema in the nonexpendable cranial vault increases intracranial pressure (>300cm
of H2O)
Altered mental state (includes confusion, drowsiness, and impaired consciousness) Intense inflammation is elicited by bacterial products gives rise to oedema.Mental state will be altered due to edema and increased intra cranial pressure Altered mental state (includes confusion, drowsiness, and impaired consciousness)
Intense inflammation is elicited by bacterial products gives rise to oedema.Mental state will be altered due to edema and increased intra cranial pressure
Bulging fontanelle (only relevant in children under 2 years) Cerebral edema in the nonexpendable cranial vault increases intracranial pressure (>300cm
of H2O)
Bulging fontanelle (only relevant in children under 2 years)
Cerebral edema in the nonexpendable cranial vault increases intracranial pressure (>300cm
of H2O)
Kernig’s sign Positive when the thigh is bent at the hip and knee at 90 degree angles, and subsequent extension in the knee is painful.Occurs due to irritation of the meninges
Sensitivity of 5% and specificity of 95%
Kernig’s sign
Positive when the thigh is bent at the hip and knee at 90 degree angles, and subsequent extension in the knee is painful.Occurs due to irritation of the meninges
Sensitivity of 5% and specificity of 95%
Brudzinski’s sign Forced flexion of the neck elicits a reflex flexion of the hips.Occurs due to irritation of the meninges
Sensitivity of 5% and specificity of 95%
Brudzinski’s sign
Forced flexion of the neck elicits a reflex flexion of the hips.Occurs due to irritation of the meninges
Sensitivity of 5% and specificity of 95%
Focal neurological deficit including cranial nerve involvement and abnormal pupils Cerebral edema irritates the nerve cells of the spinal cord which results in the palsies.Cranial nerves (CN) may also be affected by compressible
pressure of brain in general. Abducent (VI) nerves with its longest intra cranial route
adjacent to brain stem are more prone to raised intra cranial pressure and exudates (perineuritis) related
compression. Other CNs like III, IV, and VII may also be affected.
Focal neurological deficit including cranial nerve involvement and abnormal pupils
Cerebral edema irritates the nerve cells of the spinal cord which results in the palsies.Cranial nerves (CN) may also be affected by compressible
pressure of brain in general. Abducent (VI) nerves with its longest intra cranial route
adjacent to brain stem are more prone to raised intra cranial pressure and exudates (perineuritis) related
compression. Other CNs like III, IV, and VII may also be affected.
Seizures Intense inflammation is elicited by bacterial products gives rise to oedema.It irritates the nerve cells of the brain which produces the seizure Seizures
Intense inflammation is elicited by bacterial products gives rise to oedema.It irritates the nerve cells of the brain which produces the seizure
Capillary refill time more than 2 seconds,Hypotension,Cold hands or feet In severe condition, child can go into septicemia and shock Capillary refill time more than 2 seconds,Hypotension,Cold hands or feet
In severe condition, child can go into septicemia and shock
Paresis Weakness of the muscles secondary to irritation of the nerve cells that control them Paresis
Weakness of the muscles secondary to irritation of the nerve cells that control them
Papilledema Intense inflammation is elicited by bacterial products gives rise to oedema.Mental state will be altered due to edema and increased intra cranial pressure Papilledema
Intense inflammation is elicited by bacterial products gives rise to oedema.Mental state will be altered due to edema and increased intra cranial pressure

Investigations - Diagnosis

Fact Explanation
Lumbar puncture - bacterial meningitis A lumbar puncture is necessary for the definitive diagnosis of bacterial meningitis.Analysis of CSF should include Gram stain and cultures, white blood cell
(WBC) count and differential, and glucose and protein concentrations.

Bacterial meningitis
Neutrophils:
(x 1 000 000/L)
100-10,000
(but may be normal)
Lymphocytes:
(x 1 000 000/L)
Usually < 100
Protein:
(g/L)
> 1.0
(but may be normal)
Glucose:
(CSF:blood ratio)
< 0.4
(but may be normal)
Lumbar puncture - bacterial meningitis
A lumbar puncture is necessary for the definitive diagnosis of bacterial meningitis.Analysis of CSF should include Gram stain and cultures, white blood cell
(WBC) count and differential, and glucose and protein concentrations.

Bacterial meningitis
Neutrophils:
(x 1 000 000/L)
100-10,000
(but may be normal)
Lymphocytes:
(x 1 000 000/L)
Usually < 100
Protein:
(g/L)
> 1.0
(but may be normal)
Glucose:
(CSF:blood ratio)
< 0.4
(but may be normal)
Lumbar puncture - viral meningitis Neutrophils:
(x 1 000 000/L)
Usually <100
Lymphocytes:
(x 1 000 000/L)
10-1000
(but may be normal)
Protein:
(g/L)
0.4-1
(but may be normal)
Glucose:
(CSF:blood ratio)
Usually normal
Lumbar puncture - viral meningitis
Neutrophils:
(x 1 000 000/L)
Usually <100
Lymphocytes:
(x 1 000 000/L)
10-1000
(but may be normal)
Protein:
(g/L)
0.4-1
(but may be normal)
Glucose:
(CSF:blood ratio)
Usually normal
Lumbar puncture - TB meningitis Neutrophils:
(x 1 000 000/L)
Usually <100
Lymphocytes:
(x 1 000 000/L)
50-1000
(but may be normal)
Protein:
(g/L)
1-5
(but may be normal)
Glucose:
(CSF:blood ratio)
< 0.3
(but may be normal)
Lumbar puncture - TB meningitis
Neutrophils:
(x 1 000 000/L)
Usually <100
Lymphocytes:
(x 1 000 000/L)
50-1000
(but may be normal)
Protein:
(g/L)
1-5
(but may be normal)
Glucose:
(CSF:blood ratio)
< 0.3
(but may be normal)
Gram stain Commonest organisms causing bacterial meningitis in children over 2 months of age are:
Streptococcus pneumoniae
Neisseria meningitidis
Haemophilus influenzae type B (in unimmunised children)

Streptococcus pneumoniae: gram-positive
diplococci or gram positive cocci in short
chains

Neisseria meningitidis :
gram-negative diplococci singly and in pairs

Haemophilus influenzae type B: gram-negative coccobacilli
Gram stain
Commonest organisms causing bacterial meningitis in children over 2 months of age are:
Streptococcus pneumoniae
Neisseria meningitidis
Haemophilus influenzae type B (in unimmunised children)

Streptococcus pneumoniae: gram-positive
diplococci or gram positive cocci in short
chains

Neisseria meningitidis :
gram-negative diplococci singly and in pairs

Haemophilus influenzae type B: gram-negative coccobacilli
PCR PCR is routinely available for Neisseria meningitidis and Enterovirus.
As results are not immediately available, they will only help with decisions concerning discontinuing treatment.
Also useful to diagnose TB meningitis
PCR
PCR is routinely available for Neisseria meningitidis and Enterovirus.
As results are not immediately available, they will only help with decisions concerning discontinuing treatment.
Also useful to diagnose TB meningitis
Bacterial antigen CSF bacterial antigen tests have low sensitivity and specificity Bacterial antigen
CSF bacterial antigen tests have low sensitivity and specificity
Blood glucose levels The CSF glucose levels are compared with the blood glucose levels in order to interpret the results of CSF full report Blood glucose levels
The CSF glucose levels are compared with the blood glucose levels in order to interpret the results of CSF full report
Full blood count Will show high neutrophil counts in bacterial septicemia Full blood count
Will show high neutrophil counts in bacterial septicemia

Investigations - Management

Fact Explanation
CT brain Identify hydrocephalus which is a complication of acute meningitis.It is commonly associated with untreated or partially treated pyogenic
meningitis and tuberculous meningitis

Identify brain abscess which is a complication of meningitis
CT brain
Identify hydrocephalus which is a complication of acute meningitis.It is commonly associated with untreated or partially treated pyogenic
meningitis and tuberculous meningitis

Identify brain abscess which is a complication of meningitis
Audiology assessment Sensorineural hearing loss or vestibular dysfunction are the most frequent complications. They are most frequent with H. influenzae and S. pneumoniae Audiology assessment
Sensorineural hearing loss or vestibular dysfunction are the most frequent complications. They are most frequent with H. influenzae and S. pneumoniae
Development assessment Should assess the growth and development of the child as neurological damage due to meningitis can give rise to growth and development defects Development assessment
Should assess the growth and development of the child as neurological damage due to meningitis can give rise to growth and development defects
Full blood count Will show high neutrophil counts in patients with septicemia Full blood count
Will show high neutrophil counts in patients with septicemia
Blood culture Can isolate the organisms giving rise to septicemia and to check the antibiotic sensitivity Blood culture
Can isolate the organisms giving rise to septicemia and to check the antibiotic sensitivity
Lumbar puncture - bacterial meningitis Bacterial meningitis
Neutrophils:
(x 1 000 000/L)
100-10,000
(but may be normal)
Lymphocytes:
(x 1 000 000/L)
Usually < 100
Protein:
(g/L)
> 1.0
(but may be normal)
Glucose:
(CSF:blood ratio)
< 0.4
(but may be normal)
Lumbar puncture - bacterial meningitis
Bacterial meningitis
Neutrophils:
(x 1 000 000/L)
100-10,000
(but may be normal)
Lymphocytes:
(x 1 000 000/L)
Usually < 100
Protein:
(g/L)
> 1.0
(but may be normal)
Glucose:
(CSF:blood ratio)
< 0.4
(but may be normal)
Lumbar puncture - viral meningitis Neutrophils:
(x 1 000 000/L)
Usually <100
Lymphocytes:
(x 1 000 000/L)
10-1000
(but may be normal)
Protein:
(g/L)
0.4-1
(but may be normal)
Glucose:
(CSF:blood ratio)
Usually normal
Lumbar puncture - viral meningitis
Neutrophils:
(x 1 000 000/L)
Usually <100
Lymphocytes:
(x 1 000 000/L)
10-1000
(but may be normal)
Protein:
(g/L)
0.4-1
(but may be normal)
Glucose:
(CSF:blood ratio)
Usually normal
Lumbar puncture - TB meningitis Neutrophils:
(x 1 000 000/L)
Usually <100
Lymphocytes:
(x 1 000 000/L)
50-1000
(but may be normal)
Protein:
(g/L)
1-5
(but may be normal)
Glucose:
(CSF:blood ratio)
< 0.3
(but may be normal)
Lumbar puncture - TB meningitis
Neutrophils:
(x 1 000 000/L)
Usually <100
Lymphocytes:
(x 1 000 000/L)
50-1000
(but may be normal)
Protein:
(g/L)
1-5
(but may be normal)
Glucose:
(CSF:blood ratio)
< 0.3
(but may be normal)

Management - Supportive

Fact Explanation
Anti pyretic agents To control fever and those will also help in management of headache Anti pyretic agents
To control fever and those will also help in management of headache
Patient education Proper follow up for complications (eg: audiology assessment ) and assessment of growth and development Patient education
Proper follow up for complications (eg: audiology assessment ) and assessment of growth and development
Prevention (vaccination) Antibodies directed against the bacterial capsular components of H. influenzae,
N. meningitides, and S. pneumoniae play a major role in development of immunity against these organisms.
The routine use of conjugated Hib vaccines in children has been associated
with a reduction of more than 99% of invasive disease, including meningitis.
Heptavalent conjugate pneumococcal vaccine, PCV7, is routinely used for infants in some countries.
A quadrivalent meningococcal polysaccharide vaccine against serogroups A,
C, Y, and W-135 strains is recommended in some countries for high-risk
children older than 2 years
Prevention (vaccination)
Antibodies directed against the bacterial capsular components of H. influenzae,
N. meningitides, and S. pneumoniae play a major role in development of immunity against these organisms.
The routine use of conjugated Hib vaccines in children has been associated
with a reduction of more than 99% of invasive disease, including meningitis.
Heptavalent conjugate pneumococcal vaccine, PCV7, is routinely used for infants in some countries.
A quadrivalent meningococcal polysaccharide vaccine against serogroups A,
C, Y, and W-135 strains is recommended in some countries for high-risk
children older than 2 years

Management - Specific

Fact Explanation
Antibiotic Factors to consider when selecting the appropriate antibiotic for treating bacterial meningitis include its activity against the causative pathogen and its ability
to penetrate and attain effective bactericidal concentrations in the CSF.
N. meningitidis:
Benzylpenicillin 60mg/kg/dose (max 3g), iv 4 hourly for 7 days

S. pneumoniae (Penicillin sensitive) :
Benzylpenicillin 60mg/kg/dose (max 3g), iv 4 hourly for minimum of 10 days

Haemophilus influenzae type b:
Ceftriaxone 50 mg/kg/dose (2g) iv

Empirical regimens are selected to cover the most likely etiologic agents.In neonates, during the first 2 to 3 weeks of life,ampicillin with either an aminoglycoside or cefotaxime is commonly used as
initial empirical therapy
Antibiotic
Factors to consider when selecting the appropriate antibiotic for treating bacterial meningitis include its activity against the causative pathogen and its ability
to penetrate and attain effective bactericidal concentrations in the CSF.
N. meningitidis:
Benzylpenicillin 60mg/kg/dose (max 3g), iv 4 hourly for 7 days

S. pneumoniae (Penicillin sensitive) :
Benzylpenicillin 60mg/kg/dose (max 3g), iv 4 hourly for minimum of 10 days

Haemophilus influenzae type b:
Ceftriaxone 50 mg/kg/dose (2g) iv

Empirical regimens are selected to cover the most likely etiologic agents.In neonates, during the first 2 to 3 weeks of life,ampicillin with either an aminoglycoside or cefotaxime is commonly used as
initial empirical therapy
Dexamethasone Decreasing inflammation, reducing cerebral
edema and increased intracranial pressure, and lessening brain damage.Recommended dexamethasone dosing regimens range from 0.6 to 0.8 mg/kg
daily in two or three divided doses for 2 days to 1 mg/kg in four divided doses for
2 to 4 days
Dexamethasone
Decreasing inflammation, reducing cerebral
edema and increased intracranial pressure, and lessening brain damage.Recommended dexamethasone dosing regimens range from 0.6 to 0.8 mg/kg
daily in two or three divided doses for 2 days to 1 mg/kg in four divided doses for
2 to 4 days
Anti pyretic agents To control fever and those will also help in management of headache Anti pyretic agents
To control fever and those will also help in management of headache
Chemo prophylaxis - Haemophilus influenzae type b Chemoprophylaxis of Haemophilus influenzae type b and meningococcal meningitis (Neisseria
meningitidis)

H. influenzae:
Individuals for whom
chemoprophylaxis
is recommended -
All household contacts if household includes other children < 4 years of age who are not fully immunised.
All household contacts in households with any infants <12 months of age, regardless of immunisation status
All household contacts in households with a child 1 to 5 years of age who is inadequately immunised
All room contacts including staff in a child care group if Index Case attends > 18 hours / week and any contacts < 2 years of age who are inadequately immunised. (NB. Inadequately immunised children should be immunised.)

Rifampicin 20 mg/kg po as a single daily dose (600 mg) for 4 days
Infants < 1 month of age:
Rifampicin 10 mg/kg po daily for 4 days
Pregnancy / contraindication to Rifampicin:
Ceftriaxone 125 mg (<12 y) / 250 mg (>12 y) mg im as a single dose
Chemo prophylaxis - Haemophilus influenzae type b
Chemoprophylaxis of Haemophilus influenzae type b and meningococcal meningitis (Neisseria
meningitidis)

H. influenzae:
Individuals for whom
chemoprophylaxis
is recommended -
All household contacts if household includes other children < 4 years of age who are not fully immunised.
All household contacts in households with any infants <12 months of age, regardless of immunisation status
All household contacts in households with a child 1 to 5 years of age who is inadequately immunised
All room contacts including staff in a child care group if Index Case attends > 18 hours / week and any contacts < 2 years of age who are inadequately immunised. (NB. Inadequately immunised children should be immunised.)

Rifampicin 20 mg/kg po as a single daily dose (600 mg) for 4 days
Infants < 1 month of age:
Rifampicin 10 mg/kg po daily for 4 days
Pregnancy / contraindication to Rifampicin:
Ceftriaxone 125 mg (<12 y) / 250 mg (>12 y) mg im as a single dose
Chemo prophylaxis - meningococcal meningitis (Neisseria meningitidis) Index Case (if treated only with penicillin) and all intimate, household or daycare contacts who have been exposed to Index Case within 10 days of onset.
Any person who gave mouth-to-mouth resuscitation to the Index Case.

Rifampicin 10 mg/kg po 12 hourly (600 mg) for 2 days
Infants < 1 month of age:
Rifampicin 5 mg/kg po 12 hourly for 2 days
Pregnancy / contraindication to Rifampicin:
Ceftriaxone 125 mg (<12 y) / 250 mg (>12 y) mg im as a single dose or Ciprofloxacin 500 mg po as a single dose
Chemo prophylaxis - meningococcal meningitis (Neisseria meningitidis)
Index Case (if treated only with penicillin) and all intimate, household or daycare contacts who have been exposed to Index Case within 10 days of onset.
Any person who gave mouth-to-mouth resuscitation to the Index Case.

Rifampicin 10 mg/kg po 12 hourly (600 mg) for 2 days
Infants < 1 month of age:
Rifampicin 5 mg/kg po 12 hourly for 2 days
Pregnancy / contraindication to Rifampicin:
Ceftriaxone 125 mg (<12 y) / 250 mg (>12 y) mg im as a single dose or Ciprofloxacin 500 mg po as a single dose
Notification Bacterial meningitis is a notifiable disease Notification
Bacterial meningitis is a notifiable disease
Manegement of viral meningitis Admission is required if bacterial meningitis cannot be excluded or intravenous hydration is required.
Ensure adequate analgesia
Manegement of viral meningitis
Admission is required if bacterial meningitis cannot be excluded or intravenous hydration is required.
Ensure adequate analgesia
Manegement of TB meningitis Initial treatment is a combination of isoniazid (5 mg per kg per day in adults, 10 mg per kg per day in children, up to 300 mg); rifampin (10 mg per kg per day in adults, 10 to 20 mg per kg per day in children, up to 600 mg); pyrazinamide (15 to 30 mg per kg per day, up to 2 g); and ethambutol (15 to 25 mg per kg per day). Streptomycin (20 to 40 mg per kg per day, up to 1 g) should be used in lieu of ethambutol in young children. Adding dexamethasone to the treatment regimen improves mortality in patients older than 14 years with tuberculous meningitis Manegement of TB meningitis
Initial treatment is a combination of isoniazid (5 mg per kg per day in adults, 10 mg per kg per day in children, up to 300 mg); rifampin (10 mg per kg per day in adults, 10 to 20 mg per kg per day in children, up to 600 mg); pyrazinamide (15 to 30 mg per kg per day, up to 2 g); and ethambutol (15 to 25 mg per kg per day). Streptomycin (20 to 40 mg per kg per day, up to 1 g) should be used in lieu of ethambutol in young children. Adding dexamethasone to the treatment regimen improves mortality in patients older than 14 years with tuberculous meningitis

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