How are seizures and epilepsy due to Haemophilus influenzae type b (Hib) meningitis monitored and treated?

Updated: Jul 09, 2018
  • Author: Prateek Lohia, MD, MHA; Chief Editor: Niranjan N Singh, MBBS, MD, DM, FAHS, FAANEM  more...
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Answer

Seizures that occur on presentation and during the earliest acute phase of Hib meningitis do so because of transient focal derangements in cortex or because of metabolic disturbances such as hyponatremia or hypoglycemia. Treatment may require the administration of anticonvulsants, the choice of which involves consideration of type of seizures, age of patient, and route of drug administration.

During the acute phase of presentation, care must be taken to diagnose and appropriately treat seizures prior to sedating or paralyzing patients for such procedures as brain imaging. Failure to do so may permit seizures to persist unrecognized for intervals of 40 minutes or more, which may have a very deleterious effect on outcome.

Occasionally, children with meningitis manifest subtle change in mental status in the wake of prolonged generalized seizures. Signs of such a process include poor responsiveness and the presence of widespread irregularly repetitive minipolymyoclonic jerks or twitches. Electroencephalographic assessment may be necessary.

Initial administration of anticonvulsants may precede discernment of the cause of seizure in cases in which seizures are prolonged or may increase ICP or metabolic demand. In such instances, children are generally treated with IV benzodiazepines, phenytoin, or phenobarbital. The decision to continue providing maintenance anticonvulsant treatment during the course of hospitalization depends on the cause and severity of seizures as well as the likelihood of recurrence.

Epilepsy, which may be difficult to control despite multiple antiepileptic medications, is present in less than 10% of survivors. The first seizure after the acute phase usually occurs within the first 2 years, although it may occur much later. Seizures are generally focal or have a focal onset. Most patients with epilepsy had transient focal seizures during the acute phase. However, seizures during the acute phase do not independently predict the occurrence of late seizures.

The presence of a persistent neurologic deficit other than sensorineural hearing loss is a risk factor for late manifestation of seizures (ie, seizures appearing for the first time in the late stages of hospitalization or after a period of weeks to years after discharge). In one study, all patients with a persistent deficit other than sensorineural hearing loss went on to have recurrent seizures after Hib meningitis.

Provision of appropriately selected anticonvulsants with consideration of seizure type and age of patient is necessary in patients with persistent seizures. Generally, patients respond well to treatment and have no recurrence for the ensuing year. In such cases, medications may be discontinued at the end of a year of treatment with small risk for recurrence. A second group continues to have seizures despite the first appropriately chosen drug. Their seizures remain difficult to control despite multiple anticonvulsants.

Occasionally, persistent seizures manifest in children who have had Hib meningitis but who recover fully and without any evidence on examination of focal neurologic deficits. These children are usually found to have structural brain abnormalities on brain imaging. In some of these cases, if seizures are intractable, as well as in cases where persistent deficits are mild or moderate, epilepsy surgery can be considered at an appropriately remote time from acute hospitalization.


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