Tuberculous meningitis: a clinical and laboratory study of 20 patients in Qatar

Twenty cases of tuberculous meningitis were diagnosed at the Hamad Medical Corporation between 1990 and 1995. Most of the patients (90%) were expatriates. The most common presenting features were fever, headache, neck stiffness and altered mental status. Five patients were in stage 1 disease at the time of presentation, 11 in stage 2, and four in stage 3. Examination of cerebrospinal fluid showed at least one abnormal finding in all patients, and culture grew Mycobacterium tuberculosis in 50%. A positive tuberculin skin test in 50% of patients, abnormal chest X-ray in 35%, abnormal CT scan or MRI showing tuberculoma or hydrocephalus in 55%, and positive sputum culture for M. tuberculosis in 15% helped establish the diagnosis. All the patients were treated with antituberculous drugs and steroids. Seventeen (85%) survived, three with severe neurological sequelae; three (15%) died. Poor outcome was associated with advanced stage of disease at presentation and high CSF protein. Tuberculous meningitis continues to be an important disease in Qatar, especially in expatriates, and should be considered in the differential diagnosis in any patient presenting with fever and change in sensorium.     

Pitfalls of hyperfractionation: theoretical considerations of effect of repair time on late radiation damage]

We conducted a 3-year Taiwan-wide hospital-based survey of invasive Haemophilus influenzae infections in children less than 15 years of age. From January 1992 to December 1994, 105 cases (57 boys, 48 girls) were reported. Seventy-three patients (69.5%) had meningitis and 32 patients had other diseases (12 pneumonia, 10 sepsis, 7 cellulitis, 3 arthritis). Fourteen patients (13%) died, all of whom had meningitis or sepsis. Among the 63 patients who survived meningitis, 17 (27%) had neurologic sequelae and eight (47%) had hearing impairment. The number of cases of H. influenzae meningitis (30%) and other H. influenzae diseases (29%) peaked in children between 6 and 12 months of age. Patients with invasive infections (82%) and meningitis (73%) were younger than 24 months of age. Only 12 patients (11%) were older than 5 years of age and four had underlying diseases. The annual incidence of invasive H. influenzae infections in children less than 5 years old was 1.9 per 100,000 per year. During the same period a survey of purulent meningitis in children younger than 15 years of age was also conducted in 20 hospitals. A total of 198 patients, in whom the causative organisms were identified, were included; 94 patients were 2 months of age or under and the most frequent pathogen was group B streptococci (35 cases, 37%). Among the 104 patients who were older than 2 months of age, H. influenzae was the leading cause (38 cases, 37%). In conclusion, invasive H. influenzae type b (Hib) diseases exist in Taiwan but have an incidence lower than in Western countries. Hib meningitis is still the most common cause of purulent meningitis in children in Taiwan and is an important cause of mortality and morbidity. Continuous active surveillance of invasive H. influenzae infections is suggested to determine the best time to introduce an Hib conjugate vaccine in Taiwan.     

Bacterial meningitis in Swaziland: an 18 month prospective study of its impact

STUDY OBJECTIVE: To describe the epidemiology, clinical features, and outcome of bacterial meningitis in Swaziland. DESIGN: Prospective study of patients diagnosed as having meningitis of nonviral aetiology during an 18 month period from February 1991 to July 1992. SETTING: Four regional hospitals covering the population of the four districts in Swaziland. SUBJECTS: All patients with non-viral meningitis admitted to hospital within the study period. MAIN RESULTS: Altogether 85 patients were reported to have bacterial meningitis: 48.3% were aged under 1 year. Causative organisms were identified in 60% of cases, and Streptococcus pneumoniae was found to be the commonest (49% of cases). Overall, case fatality was 38.8% for all age groups, and 62.5% (15 of 25) for adults. Neurological sequelae occurred in 22.4%. Three of the adult cases were HIV seropositive. Seizures, but not duration of symptoms before admission, were associated with a poor prognosis. There was a significant rise in incidence related to a period of drought. Fifteen patients were reported with tuberculous meningitis, of whom five were known to be HIV seropositive; the case fatality was 73.3%. CONCLUSIONS: The aetiology and age distribution of cases of meningitis differs greatly from that in developed countries. Rising HIV infection may have an important impact on the future incidence of meningitis. The high case mortality found should encourage efforts towards earlier diagnosis and treatment, and strengthens the need to develop appropriate vaccines.     

Candidal meningitis in HIV-infected patients: analysis of 14 cases

Five cases of candidal meningitis in human immunodeficiency virus (HIV)-infected patients have been diagnosed in our hospital. This article describes these cases and reviews another nine previously reported in the literature. Most patients (71%) had at least one well-known predisposing factor for candidiasis. Median CD4 cell count was 135/mm3. Headache and fever, in the absence of focal neurologic signs, were the predominant clinical features. The CSF analysis revealed mild pleocytosis and hypoglycorrachia, indistinguishable from those seen in tuberculous or cryptococcal meningitis. Twelve patients (92%) received amphotericin B for a median of 51 days, in combination with flucytosine in five cases. The overall mortality among treated patients was 31%. Although the risk of relapse of candidal meningitis is unknown, maintenance antifungal therapy was given to seven patients (63%), usually with fluconazole. Candida species must be kept in mind as a cause of chronic meningitis in HIV-infected patients who have a known predisposing factor.     

Community-acquired bacterial meningitis: risk stratification for adverse clinical outcome and effect of antibiotic timing

BACKGROUND: Community-acquired bacterial meningitis causes substantial morbidity and mortality in adults. OBJECTIVE: To create and test a prognostic model for persons with community-acquired bacterial meningitis and to determine whether antibiotic timing influences clinical outcome. DESIGN: Retrospective cohort study; patients were divided into derivation and validation samples. SETTING: Four hospitals in Connecticut. PATIENTS: 269 persons who, between 1970 and 1995, had community-acquired bacterial meningitis microbiologically proven by a lumbar puncture done within 24 hours of presentation in the emergency department. MEASUREMENTS: Baseline clinical and laboratory features and times of arrival in the emergency department, performance of lumbar puncture, and administration of antibiotics. The target end point was the development of an adverse clinical outcome (death or neurologic deficit at discharge). RESULTS: For the total group, the hospital mortality rate was 27%. Fifty-six of 269 patients (21 %) developed a neurologic deficit, and in 9% the neurologic deficit persisted at discharge. Three baseline clinical features (hypotension, altered mental status, and seizures) were independently associated with adverse clinical outcome and were used to create a prognostic model from the derivation sample. The prediction accuracy of the model was determined by using the concordance index (c-index). For both the derivation sample (c-index, 0.73 [95% CI, 0.65 to 0.81]) and the validation sample (c-index, 0.81 [CI, 0.71 to 0.92]), the model predicted adverse clinical outcome significantly better than chance. For the total group, the model stratified patients into three prognostic stages: low risk for adverse clinical outcome (9%; stage I), intermediate risk (33%; stage II), and high risk (56%; stage III) (P=0.001). Adverse clinical outcome was more common for patients in whom the prognostic stage advanced from low risk (P=0.008) or intermediate risk (P=0.003) at arrival in the emergency department to high risk before administration of antibiotics. CONCLUSIONS: In persons with community-acquired bacterial meningitis, three baseline clinical features of disease severity predicted adverse clinical outcome and stratified patients into three stages of prognostic severity. Delay in therapy after arrival in the emergency department was associated with adverse clinical outcome when the patient's condition advanced to the highest stage of prognostic severity before the initial antibiotic dose was given.     

Pattern and antibiotic susceptibility of bacteria in pyogenic meningitis in a children's emergency room population in Maiduguri, Nigeria, 1988-1992

From January 1988 to November 1992, 107 (3.5%) of 3074 postneonatal children admitted to the Children's Emergency Room, University of Maiduguri Teaching Hospital, Nigeria, had sporadic pyogenic meningitis; 66 (61.7%) were aged < or = 12 months. Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae together were responsible for 77.3% (58) of 75 culture-proven cases, 13.4% (10) had Enterobacteriaceae, 5.3% (4) had Staphylococcus aureus and 4% (3) untyped alpha-haemolytic streptococci. Fifty percent of 62 bacteria were resistant to ampicillin, 47.2% of 36 to penicillin and 10.7% of 56 to chloramphenicol; none of 21 bacteria was simultaneously resistant to all three antibiotics. Up until 1992, we have encountered treatment failure with a regimen containing chloramphenicol in only 2 of 53 patients; the 2 patients had coliform meningitis. Non-meningococcal bacteria are an important cause of sporadic pyogenic meningitis in sub-Saharan Nigeria and chloramphenicol is the most appropriate initial drug of choice at the present time for the management of sporadic meningitis.     

Use of cerebrospinal fluid shunts in patients having acquired immunodeficiency syndrome with cryptococcal meningitis and uncontrollable intracranial hypertension

OBJECTIVE: To evaluate the treatment of serious and uncontrollable intracranial hypertension in patients with acquired immunodeficiency syndrome who developed cryptococcal meningitis. METHODS: All cases of cryptococcal meningitis with elevated pressure and acquired immunodeficiency syndrome were reviewed in detail and described. RESULTS: Cerebrospinal fluid shunting dramatically improved these critically ill patients and was much more successful than serial lumbar punctures or the use of high-dose dexamethasone. CONCLUSION: Patients with acquired immunodeficiency syndrome who develop cryptococcal meningitis and who suffer serious visual loss or ocular palsies with elevated pressures should be considered for cerebrospinal fluid shunting at an early stage.     

Acute encephalitis and bacterial meningitis in children in Aichi Prefecture (1984-1993)

A survey was performed of acute encephalitis and bacterial meningitis in infancy and childhood from 1984 to 1993 using a questionnaire directed to departments of pediatrics in large hospitals in Aichi prefecture. The case records for 391 patients with acute encephalitis including related diseases and 328 patients with bacterial meningitis were obtained from 63 hospitals. Of 391 patients with acute encephalitis, 224 were male and 167 were female. Of 328 patients with bacterial meningitis, 200 were male and 128 were female. Sex ratio were 1.3, 1.6 respectively. Of the patients, 52.4% of encephalitis and 84.8% of meningitis were under 4 years of age and 0 year olds made up 53.7% of the latter. The causes of these diseases were confirmed in 38.7% and 82.9% of the encephalitis and meningitis patients, respectively, etiologically. In encephalitis, rubella virus was the most frequent with 29 cases, followed by measles virus (27 cases), herpes simplex virus (24) and varicella-zostervirus (19). In meningitis H. influenzae (95 cases), S. pneumoniae (56), Group B streptococcus (41) and E. coli (27) were frequently diagnosed. These diseases showed respective patterns of age distribution and clinical course, and moreover, the increases in their onset were clearly related to the prevalence of causal infections. Therefore, the results of this study should be utilized in the development of administrative measures for prevention of these diseases.     

Bacterial meningitis in southwestern Alaska

Between July 1, 1971, and June 30, 1974, thirty-nine cases of bacterial meningitis were diagnosed at the Alaska Native Health Service Hospital at Bethel, Alaska. Thirty-two (82%) occurred in infants less than one year of age. Haemophilus influenzae (H. influenzae) was the predominant causative agent, and was isolated from 23 (72%) of the 32 patients under one year of age. The annual incidence of H. influenzae meningitis in the Bethel area was 63/100,000, and the annual incidence of H. influenzae meningitis in children less than five years of age was 474/100,000 cases.     

Bacterial meningitis in a rural Kenyan hospital

In a prospective study to investigate mortality and antibiotic resistance in meningitis patients, thirty two meningitis cases were seen over a three month period. Mean age was 11.3 years (range one month-60 years). Cerebrospinal fluid cultures were positive in 26 patients (81.3%). S.pneumoniae was responsible for 15 cases (46.9%), followed by H.influenzae in seven (21.9%). Salmonella infection was seen in two patients, and E.coli and N.meningitidis in one each. Twelve patients (37.5%) died during hospitalisation with most of the deaths occurring within 48 hours after admission. No patients presented with atypical signs of meningitis. No significant differences were found between delay and outcome. Malaria parasites were found in blood of thirteen patients (41%), but did not contribute to higher mortality. Three of H.influenzae isolates (42.9%) were resistant to ampicillin and penicillin. Reduced sensitivity to penicillin was found in two (13.3%) of S.pneumoniae isolates.     

Salmonella meningitis: clinical experience of third-generation cephalosporins

Fifteen paediatric patients with Salmonella meningitis were retrospectively reviewed. Presenting symptoms and signs included fever, vomiting, seizures, poor activity, diarrhoea and bulging anterior fontanelle in most patients. Seven out of eight patients with prolonged fever for > 10 days had neurologic sequelae; therefore, prolonged fever is a significant prognostic factor of a poor outcome (p < 0.005). All 15 patients had a brain ultrasound or computed tomography in the acute stage and 11 patients had abnormal findings. The 14 surviving patients were treated with a third-generation cephalosporin for at least 3 weeks. Seven patients (47%) made complete recoveries; two of them were treated solely with a third-generation cephalosporin. Only one mortality (6%) occurred and there were no relapses. In conclusion, high frequencies of prolonged fever, neuroimaging abnormalities and neurologic sequelae were seen in patients with Salmonella meningitis treated with third-generation cephalosporins.     

Color doppler ultrasonography in peripheral artery occlusive disease: continuous application of a signal enhancer

OBJECTIVE: The purpose of this study was to evaluate the clinical and epidemiological characteristics of meningitis in our environment. PATIENTS AND METHODS: A retrospective study of 166 cases of meningitis diagnosed in our hospital during a 10 year period (1986-1995) was performed. The patients were between 1 month and 14 years of age. RESULTS: Sixty-six percent of the patients were male and 34% female. Eleven cases were younger than 2 months (6.6%), 122 cases (73.5%) were between 3 months and 5 years of age and 33 cases (19.9%) were older than 5 years. The most frequent symptoms and signs were fever (96%), vomiting (60%), impairment of consciousness (24%) and meningeal signs (49%). CSF cultures were positive in 52% and blood cultures in 32%. The pathogen isolated was N. meningitidis in 53 cases (32%), H. influenzae in 38 (23%), S. pneumoniae in 9 patients (5%) and others in 3 children (2%). Meningitis due to H. influenzae increased each year. No microorganism was isolated in blood and CSF in 63 cases (38%). Meningitis in children between 3 months and 5 years of age was due to N. meningitidis in 40 children (33%) and H. influenzae in 36 (29%). The mortality rate was 3%. The most frequent complications were sepsis (36%) and seizures (16%). CONCLUSIONS: The most frequently isolated agent in our study was N. meningitis. Meningitis due to H. influenzae is increasing such that H. influenzae and N. meningitis currently show similar frequency in children between 3 months and 5 years of age.     

Cerebrospinal fluid leukocyte aggregation in meningitis

OBJECTIVE: To evaluate whether the difference in aggregation of cerebrospinal fluid cells from patients with bacterial, viral, aseptic and partially treated meningitis can be used for diagnostic purposes. METHODS: Cerebrospinal fluid samples of 100 patients with meningitis (15 bacterial, 13 partially treated, 10 viral and 62 aseptic) were compared on the basis of the predefined leukocyte aggregation score (LAS). RESULTS: Mean LAS was 56% in the bacterial meningitis group (range, 15 to 90%), 5.8% in the partially treated meningitis group (range, 0 to 27%), 2% in the proven viral meningitis group (range, 0 to 5%) and 2% in the aseptic meningitis group (range, 0 to 15%). All patients with bacterial meningitis had a LAS of > 15%, whereas all those with viral or aseptic meningitis had a score of < 15%. Although most patients with partially treated meningitis had a low LAS, several had higher scores, which may indicate bacterial infection. There was no statistical correlation between number of cells, type of cells (mononuclear or polymorphonuclear) or cerebrospinal fluid protein and glucose concentration and degree of leukocyte aggregation for the different groups. CONCLUSION: Measurement of the LAS may contribute to the immediate differential diagnosis of bacterial or viral meningitis, especially in patients with very high pleocytosis, as sometimes seen in enteroviral meningitis. It may also serve as a guide for the likelihood of bacterial infection in cases of partially treated meningitis. Additional studies are needed to confirm these observations.     

Central venous access: low internal jugular vein approach using imaging guidance

We reviewed the results of microscopic Gram stain examination and routine culture for 2,635 cerebrospinal fluid (CSF) samples processed in an adult hospital microbiology laboratory during 55 months. There were 56 instances of bacterial or fungal meningitis (16 associated with central nervous system [CNS] shunt infection), four infections adjacent to the subarachnoid space, four cases of sepsis without meningitis, and an additional 220 CSF specimens with positive cultures in which the organism isolated was judged to be a contaminant. Because 121 of these contaminants were isolated in broth only, elimination of the broth culture would decrease unnecessary work. However, 25% of the meningitis associated with CNS shunts would have been missed by this practice. The most common cause of meningitis was Cryptococcus neoformans, followed by Streptococcus pneumoniae and Neisseria meningitidis. In 48 of 56 (88%) of cases, examination of the Gram-stained specimen revealed the causative organism. If patients who had received effective antimicrobial therapy prior to lumbar puncture are excluded, the CSF Gram stain is 92% sensitive. Microscopic examination incorrectly suggested the presence of organisms in only 3 of 2,635 (0.1%) CSF examinations. Thus, microscopic examination of Gram-stained, concentrated CSF is highly sensitive and specific in early diagnosis of bacterial or fungal meningitis.     

Systemic Haemophilus influenzae infection in childhood

Forty-nine children who had systemic Haemophilus infection and were treated at the Westmead Centre, Sydney, over a two-year period are described. The majority (29 of 49 children) were aged two years or less. Epiglottis and meningitis accounted for 77% of these infections. All H. influenzae isolates associated with clinical disease were of the capsular type b. Eight per cent (four of 50) of H. influenzae infections were caused by beta-lactamase producing strains. There was no geographic clustering or seasonal variation. There was no mortality. Major morbidity included two patients who had epiglottis and required tracheostomy, and two patients who had meningitis developed bilateral profound sensorineural deafness. No secondary cases were detected in household contacts of 21 patients with H. influenzae meningitis during the study period. Epiglottis frequently occurs in very young children. The rapid response to antibiotic treatment suggests that early cases of epiglottis may be undiagnosed, but treated with antibiotic agents in the community.     

Group B streptococcal meningitis in adults: report of twelve cases and review

Group B streptococcus (GBS) is the leading etiologic agent of bacterial meningitis and sepsis during the neonatal period, but it is an infrequent cause of meningitis in adults. We report 12 episodes of group B streptococcal meningitis in adults and review 52 cases reported in the literature. A total of 24 men and 40 women were included in the study; the mean age (+/- SD) was 49.2 +/- 20.5 years (range, 17-89 years). All the patients had cerebrospinal fluid cultures positive for GBS. Eighty-six percent of the patients had comorbid conditions, 50% had a distant focus of infection, and blood cultures yielded GBS for 78.7%. The overall case-fatality rate was 34.4% (22 patients). Factors associated with a poor outcome were advanced mean age (+/- SD) (61.5 +/- 17.4 years vs. 42.8 +/- 19.2 years; P = .0003) and the presence of complications on admission (P = .0001). Seven percent of survivors had neurological sequelae. Group B streptococcal meningitis in adults has become increasingly frequent in recent years; it tends to occur in patients with severe underlying conditions and is associated with a high case-fatality rate. Factors associated with a poor prognosis are advanced age and the occurrence of neurological and extraneurological complications.     

Long-term sequelae of pneumococcal meningitis in children

The purpose of this study was to assess the long-term effects of pneumococcal meningitis in children. From 1967 to 1988, a total of 90 children were admitted to the Hospital for Infectious Diseases, Thessaloniki, Greece, with the diagnosis of pneumococcal meningitis. Sixteen patients died in the hospital as a direct result of meningitis. Eleven others were excluded from the study (neurologic deficits prior to onset of meningitis, two; death subsequent to hospitalization, two; recurrent meningitis, seven). Of the remaining 63 survivors, we were able to evaluate 47 patients (75%). Evaluation was performed 4 to 23 years (mean 12.3 +/- 5.8 years) after discharge. Forty patients returned to hospital for evaluation, and seven were evaluated by their primary physicians, who sent information by a standardized questionnaire. The following examinations were carried out: history, physical and neurologic examination, ophthalmologic and hearing evaluation, and psychometric testing. Fourteen patients (30%) had at least one neurologic handicap; nine (19%) had mental retardation, eight (17%) hearing loss, seven (15%) seizure disorder, five (11%) motor defects, and one each (2%) behavioral problems and visual impairment. The presence of coma was the strongest predictor of increased morbidity. The high frequency of long-term sequelae observed in our study supports the need of an effective vaccine.     

Where''s the cash?

This study was done to analyze the epidemiology of invasive Haemophilus influenzae disease in Bochum city area. Forty-eight children with invasive Haemophilus influenzae infections were treated at the University Children's Hospital in Bochum during the study period from January 1971 to June 1992. Clinical manifestations included meningitis (n = 34), epiglottitis (n = 8), pneumonia (n = 2), bacteremia (n = 2), cellulitis (n = 1) and osteomyelitis (n = 1). The overall yearly incidence rate for all invasive Haemophilus influenzae infections was 13 per 100,000 children younger than five years of age, with a marked increase in the last six years. Haemophilus influenzae meningitis showed no significant change during the study period with an overall yearly incidence of 9 per 100,000 children younger than five years. Twenty-eight cases (58%) of all invasive Haemophilus influenzae infections occurred in patients under two years of age and five cases (10%) were younger than six months. Invasive Haemophilus influenzae disease showed no seasonal prevalence. All isolates were susceptible to ampicillin. No deaths occurred, but severe bilateral deafness resulted in one patient with meningitis. Prospective epidemiologic studies are needed to estimate clinical efficacy of the Haemophilus influenzae type b immunization program in Germany.     

The value of C-reactive protein for the differentiation of bacterial meningitis from viral meningitis

In order to differentiate bacterial meningitis versus viral meningitis, we have comparatively tested the efficacy of the following tests: C-reactive protein (CRP), erythrocytes sedimentation rate (ESR), fever, level of glucose in cerebro-spinal fluid (CSF), glucose in CSF/glycemia ratio, number of white blood cells in peripheric blood, percentage of neutrophils in peripheric blood, level of proteins in CSF and number of nucleated cells in CSF for a group of 49 patients, both children and adults with central nervous system infection (37 patients with bacterial meningitis and 12 with viral meningitis) hospitalised between May 1993 and July 1994 in Clinical Hospital for Infectious Diseases in Ia?i. The mean value of CRP in bacterial meningitis patients was 8.78 mg%, contrasting with the mean value of CRP = 1.92 mg% recorded in patients with viral meningitis. Ten out of 37 bacterial meningitis patients presented a CRP concentration < 1.85 mg%. All these 10 patients have already had an antibiotic treatment at the moment of the assay. One out of 12 cases of viral meningitis had a value of CRP = 3.3 mg%, all the remainder cases having values under 1.85 mg%. We recorded highly significant differences between the two patient groups for CRP (p < 0.001), ESR (p < 0.01), protein concentration in CSF (p < 0.001) and number of nucleated cells in CSF (p < 0.001). Differences recorded for fever, concentration of glucose in CSF, glucose in CSF/glycemia ratio, number of leucocytes in peripheric blood and percentage of neutrophils in peripheric blood, were not significant (p > 0.5). Data were analysed also by box-plot method which facilitates the visual appraisal of the differences recorded between the two aetiological groups. In conclusion, assays of CRP and ESR may be used as differentiation tests for bacterial meningitis versus viral meningitis, when assay is done before the antibiotic treatment, being sufficient sensitive, and easy to perform.