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.     

The relationship between fatty liver and hyperinsulinemia in obese Japanese children

During 1994, 603 cases of bacterial meningitis were reported in Italy. Seventy-five percent of cases with determined etiology was due to three agents: Neisseria meningitidis (33.4%), Streptococcus pneumoniae (23.4%) and Haemophilus influenzae (18.6%). The majority of cases due to N. meningitidis and H. influenzae occurred in subjects below five years of age (35.7% and 84.8%, respectively) while S. pneumoniae accounted for 52.8% of meningitis cases in subjects older than 44 year of age. The estimated incidence of N. meningitidis on the national population in 1994 was 0.27 per 100,000. Serogroup B accounted for 62.5% of the serotyped isolates, group C for 23.1%, group A for 7.2%, group W135 for 3.6%, group Y for 1.8%. All tested meningococcal strains were susceptible to penicillin as well as to rifampin. Incidence of meningococcal meningitis in 1994 has been low suggesting that its relative importance compared to other bacteria causing meningitis is likely to change in the future. Therefore, extended surveillance on bacterial meningitis by other etiological agents has to be maintained and implemented in order to undertake the appropriate control measures and evaluate their effect.     

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.     

Mixed effect modeling of sumatriptan pharmacokinetics during drug development. I: Interspecies allometric scaling

A sample of 22 subjects was studied from a population of adults who had suffered from bacterial meningitis in childhood. Audiovestibular, oculomotor and neuropsychological investigations were performed and quality of life was assessed. An age-matched control group of 20 subjects was recruited. In the meningitis group, nine subjects had abnormal pure tone audiograms. One was previously undiagnosed and a progression was found in four. There was an overrepresentation of subclinical vestibular pathology (6 out of 9 (67%)) in this group. Audiovestibular test results showed a peripheral pattern and oculomotor tests were normal. The quality of life scores of those with hearing loss were significantly higher than those in the control group. Neuropsychological tests of brain dysfunction were abnormal in six out of 22 (27%) who had recovered from meningitis. The prevalence of such dysfunctions was not related to audiovestibular disorder. The quality of life scores of those with brain dysfunctions were similar to those of the control group. The findings of reduced auditory memory and tone level perception in four out of 22 (18%), suggest that lesions of central auditory pathways may follow from bacterial meningitis. The results support the idea that inner ear damage is the major cause of hearing loss after bacterial meningitis. Despite the absence of brainstem involvement, central nervous system lesions with disturbed auditory processing and language functions can be of significance. The high frequency of discrete brain dysfunctions indicate that a thorough neuropsychological investigation is required after bacterial meningitis.     

Dexamethasone therapy for bacterial meningitis in children: 2- versus 4-day regimen

Four-day dexamethasone therapy has been used to treat bacterial meningitis. This prospective, randomized study compared the effect of a 2-day versus a 4-day regimen. Children (n = 118, ages 2.5 months to 15 years) were evaluated; 50% of the cases were due to Neisseria meningitidis and 40% to Haemophilus influenzae type b. Patients were treated intravenously (iv) mainly with conventional antimicrobial therapy and were randomly assigned to receive dexamethasone, 0.15 mg/kg iv every 6 h for 2 or 4 days. The clinical response was similar for both dexamethasone regimens. The meningococcal meningitis patients survived without neurologic or audiologic sequelae. On long-term follow-up, neurologic sequelae or moderate or more severe unilateral or bilateral hearing impairment (or both) were found in 1.8% and 3.8% of patients treated with dexamethasone for 2 and 4 days, respectively. The 2-day regimen appears appropriate for the treatment of H. influenzae and meningococcal meningitis.     

Etiologic structure and clinical characteristics of acute viral infections of the central nervous system with hyperproteinorachia

Clinical syndrome of acute viral meningitis and meningoencephalitis may be induced by different viruses. Etiologic diagnosis may be set by the isolation of the virus from the liquor and by the detection of specific antibodies in the blood and liquor. Our aim was to determine viral etiology of AVI with special reference to hyperproteinorachia. The study was conducted in 55 patients treated at the Clinic of Infectious Diseases in Novi Sad, with clinical picture of acute meningitis or meningoencephalitis, with pleocytosis above 50 ml in the cerebrospinal fluid. Depending on the levels of proteinorachia the patients were divided into the group with proteinorachia levels below 1g/l (34 patients) and above 1 g/l (21 patients). In the first group the most common was herpes simplex- and adenoviral etiology while in the second group most frequently found were choriolymphocytic meningitis virus (LCM) and herpes simplex virus. The protein level was in correlation with the severity of the clinical features and the duration of the treatment.     

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.     

Antibiotic therapy for enterobacter meningitis: a retrospective review of 13 episodes and review of the literature

Enterobacter meningitis is an uncommon form of meningitis whose treatment poses a therapeutic dilemma because of the development of resistance to the third-generation cephalosporins while the patient receives therapy. In recent years, we have been using trimethoprim-sulfamethoxazole (TMP-SMZ) as treatment for this infection. In this report, we reviewed 13 episodes of enterobacter meningitis that were treated with various antibiotic regimens and 33 episodes from the literature. We found that the development of resistance to beta-lactam agents may be much higher than that seen in bacteremias (approximately 30%), that the case-fatality rate is lower among our patients than among those described previously, and that all patients who received TMP-SMZ were cured, compared with about 70% of those receiving beta-lactam agents. TMP-SMZ appears to be an acceptable alternative to the cephalosporins for the treatment of enterobacter meningitis.     

The aseptic meningitis syndrome: a complication of posterior fossa surgery

The syndrome of aseptic meningitis is characterized by spiking fever and meningismus. CSF analysis generally shows increased pleocytosis, hypoglycorrhachia, elevated protein and negative cultures. In an earlier series, 70% of children with posterior fossa operations developed the syndrome. In a new review the incidence was slightly more than 30%. The incidence of aseptic meningitis following operation for structural lesions was 44%, which was higher than the tumor group, where the meningitic syndrome was seen in 25% of the children. It is the purpose of this paper to reexamine the impact that steroids have made on the prevalence of the aseptic meningitis syndrome, and to review recent studies that have attempted to distinguish between aseptic and bacterial meningitis.     

Electroencephalographic derivatives as a tool for predicting the depth of sedation and anesthesia induced by sevoflurane

Phylogenetic relationships of 69 neonatal meningitis Escherichia coli strains isolated worldwide were studied. Restriction fragment length polymorphism of rrn operons (rrn RFLP) in these isolates was compared with that of the 72 strains of the ECOR reference collection. Distributions of K1 antigen, of polymerase chain reaction-detected ibe10 gene, pap, afa, sfa/foc, hly, and aer operons, and of a 14.9-kb rrn-containing HindIII fragment previously associated with neonatal meningitis were compared. Oligoclonality was observed for the meningitis strains. Factorial analysis of correspondence on the rrn RFLP data showed a frequency gradient of meningitis strains from the phylogenetic B2 group (68%) to the A group (6%), via the D and B1 groups (26%). The distribution of the virulence determinants argues for their horizontal transfer during the evolution of E. coli. Analysis of the status of some neonates further suggests that neonatal meningitis results from a balance between bacterial genes of virulence and host factors.     

Effectiveness of bacillus of Calmette-Guerin (BCG) vaccination against tuberculous meningitis: a case-control study

A hospital-based pair-matched case-control study was carried out at Government Medical College Hospital, Nagpur to estimate the effectiveness of bacillus of Calmette-Guerin (BCG) vaccination against tuberculous meningitis. The study included 92 cases of tuberculous meningitis in the age group of 0-12 years and equal number of controls, matched for age, sex and socio-economic status. The protective effectiveness and prevented fraction were higher for the subjects in the age group of 0-6 years, males and subjects from upper strata of socio-economic class. The overall vaccine effectiveness and prevented fraction were estimated to be 86.54% (70.38-93.88%) and 65.54% (39.22-80.64%) respectively. Results of this study thus indicated that BCG vaccination was highly effective against tuberculous meningitis and played significant role in its prevention, in this population.     

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.     

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.     

Liver histology in a ''normal'' population--examinations of 503 consecutive fatal traffic casualties

Sensori-neural hearing loss after H. influenzae meningitis in children has been reported to occur more frequently after treatment with ampicillin than with chloramphenicol. In the present survey, hearing was assessed clinically and, in most cases, audiometrically in 47 children seen after H. influenzae meningitis. Three children were found to have some sensori-neural hearing loss. In no case was this severe or suspected prior to examination. One was among 27 children treated with ampicillin; one was among eight treated with ampicillin and chloramphenicol; and one was treated with chloramphenicol and streptomycin. Most of the children received ampicillin in a dose of 250mg/kg/day or less, but the two who were treated with ampicillin and developed hearing loss were among five children who received higher doses, suggesting that ampicillin may be ototoxic when given in very high doses.     

Kleinschmidt''s syndrome (author''s transl)

This is a case-report about a 4 year old boy with "cherry red" epiglottis, purulent meningitis and pleuropneumonia. Purulent meningitis and pleuropneumonia are not complications of treatment of "cherry red" epiglottis but an entity caused by Hemophilus influenzae-infection and is called Kleinschmidt's syndrome (Hemophilus influenzae type B-infection-syndrome). This severe illness is successfully treated if recognized early enough. At present, chloramphenicol is the therapy of choice. Intubation or tracheotomy are important but supportive measures.     

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.     

Tuberculous meningitis: a 30-year review

Tuberculous meningitis remains an important illness that can be difficult to diagnose in a timely fashion and carries significant morbidity. We present a retrospective review of the cases of tuberculous meningitis diagnosed and treated at a single institution. Fifty-eight cases were identified and stratified according to stage of disease at presentation. Four patients (7%) died; three (5%) developed severe neurological sequelae. Poor outcomes were largely confined to cases presenting in an advanced stage and at the extremes of age. Corticosteroids were administered to 56 patients and may have contributed to the comparatively good outcome in these cases.     

Conservative operation for infective endocarditis of the mitral valve

BACKGROUND: Subvalvular preservation is necessary to maintain left ventricular function, but accidental retention of infected tissue could cause postoperative endocarditis. METHODS: We examined 71 consecutive patients who underwent operation for mitral endocarditis. Endocarditis was uncontrolled and active in 24 patients, partially treated (unfinished antibiotic course) in 17, and healed in 30. RESULTS: Valves were repaired in 17% versus 59% versus 63% and replaced with subvalvular preservation in 25% versus 6% versus 3% of the uncontrolled active, partially treated, and healed groups, respectively. Thirty-day mortality was 29% versus 0% versus 3.3% (p=0.003), total mortality was 46% versus 18% versus 17% (p=0.035), and complications-related mortality was 38% versus 11% versus 13% (p=0.054), respectively. There was a trend toward lower complications-related mortality with subvalvular preservation than without. Postoperative endocarditis occurred in 3 of 30 patients without and 1 of 41 patients with subvalvular preservation. CONCLUSIONS: Postoperative mortality in uncontrolled active mitral endocarditis remains high, but results are good with partially treated or healed endocarditis. Subvalvular preservation improves outcome, does not increase postoperative endocarditis rates, and should be performed whenever feasible.     

Clinical and laboratory profile of sixty patients with AIDS: a South Indian study

Sixty patients who fulfilled the WHO case definition of acquired immunodeficiency syndrome (AIDS) were admitted and treated between January 1993 and June 1995 in JIPMER Hospital, Pondicherry, South India. Their mean age was 30.3 +/- 6.4 years. Male: female ratio was 5 : 1. The heterosexual route was the major mode of transmission (96.7%). Fever was the commonest presentation (98.3%), followed by weight loss (85%) and cough (36.7%). The commonest opportunistic infection seen was tuberculosis (pulmonary, extrapulmonary - single or in combination) followed by esophageal candidiasis. Cryptococcal meningitis, intestinal crytosporidiosis, CNS toxoplasmosis, Pneumocystis pneumonia and group B Salmonella septicemia were the other infections encountered. Ten out of the 38 patients with tuberculosis were followed up on antituberculous treatment for 6 months. Seven out of 18 patients with esophageal candidiasis were treated with ketoconazole.     

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.