Meningitis after combined spinal-extradural anaesthesia in obstetrics

We report two cases of meningitis which developed after combined spinal-extradural procedures for obstetric analgesia. The first case was thought to be caused by aseptic or chemical meningitis and the second was a case of bacterial meningitis in a patient who also received an extradural blood patch. It is important that meningitis is considered as a differential diagnosis in patients who present with headache after spinal anaesthesia and that antibiotic therapy is selected to cover unusual organisms.     

Patients with malignant meningitis presenting with neuropsychiatric manifestations

BACKGROUND: Malignant meningitis is often thought of as a late event in the course of cancer. At one time, it was thought to be rare, but it has been recognized more frequently in recent times. Clinical suspicion of malignant meningitis is prompted by neurologic symptoms and signs in patients at risk for this oncologic complication. Neuropsychiatric symptoms previously were not considered as presenting symptoms of malignant meningitis. METHODS: Three patients with cancer with no neurologic symptoms were examined for malignant meningitis based on neuropsychiatric symptoms. Cerebrospinal fluid was examined for malignant cells to confirm the diagnosis of malignant meningitis. RESULTS: The clinical presentation of malignant meningitis for three patients was neuropsychiatric. None of the patients had delirium during their initial presentation. CONCLUSIONS: It is important that clinicians recognize that psychiatric symptoms without neurologic findings may indicate malignant meningitis and that malignant meningitis needs to be included in the differential diagnosis of neuropsychiatric disorders in patients with cancer.     

Recurrent Mollaret's meningitis of herpetic origin

BACKGROUND: Benign recurrent meningitis, or Mollaret's meningitis, is an uncommon disease whose viral origin was long unidentified. Since 1991, about twenty cases have been reported in patients with herpes infection. CASE REPORT: A female patient had experienced repeated episodes of spontaneous meningitis since 1983. The episodes resolved spontaneously and no etiology had been identified. A spinal tap was performed when the patient was again hospitalized a new episode of meningitis and PCR amplification of the herpes simplex virus type 2 (HSV 2) was positive. The patient was given long term acyclovir per os. A new spinal tap after resolution of the meningitis episode was PCR HSV2 negative. DISCUSSION: HSV2 infection is one of the known causes of Mollaret's meningitis. Long-term antiviral therapy appears to prevent recurrence as was observed in our patient.     

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.     

Data sampling under the interface of windows in the EEG signal processing system & analysis

Staphylococcus aureus meningitis is a rare but well recognized condition which had a high mortality and incidence of neurological sequelae. It is usually associated with chronic underlying conditions. A case is reported of S. aureus meningitis in a previously healthy young man. The epidemiology, microbiological findings and treatment of this condition are discussed.     

Enterococcus faecalis endocarditis presenting as meningitis

Although Enterococcus faecalis is a relatively common cause of infective endocarditis, it rarely causes meningitis. A case of Enterococcus faecalis endocarditis presenting as meningitis in a 74-year-old diabetic man on chronic hemodialysis is reported. A review of the literature showed that the association of enterococcal meningitis and endocarditis has rarely been reported. This clinical association may be more common than previously recognized and it is suggested that echocardiography be considered for all patients with enterococcal hematogenous meningitis in order to rule out endocarditis.     

Bacterial meningitis in the health sector of Virgen del Rocio, Spain

BACKGROUND: The aim of this study was review the epidemiology of the bacterial meningitis in our area. MATERIAL AND METHODS: A retrospective study was carried out of all the cases of bacterial meningitis in children with ages between two months and fourteen years, admitted in our hospital between 1986 and 1997. The following variables we analyzed: Sex, age of the patient, yearly and monthly incidence, previous antibiotic therapy, length of hospital stay, and analytical data of blood and cerebrospinal fluid. RESULTS: In the 755 cases analyzed, the 50% correspond to bacterial meningitis, the 47.6% to viral or aseptic and 2.3% to tuberculous. In of the bacterial meningitis Neisseria meningitidis was isolated in 55.7% of cases, Haemophilus influenzae in 20.4%, Streptococcus pneumoniae in 5.5%, other bacterias in 3.4%, and in 14.5% was not isolated any bacteria. We are assisting to an increase of Neisseria meningitidis serotype C during the last years. Haemophilus influenzae represents a more percentage of bacterial meningitis that in prior years. In meningitis by Streptococcus pneumoniae we observe a clear association with risk factors in children older than 2 years. CONCLUSION: Neisseria meningitidis is the main etiologic agent in children. The vaccination against Haemophilus influenzae serotype b and Neisseria meningitidis A and C can change the epidemiology in next years.     

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.     

Use of radioresistance as a method for evaluating species independence of closely-related forms using the example of hamsters of the genus Phodopus (Rodentia, Cricetinae)

A case of chronic chemical meningitis occurring after a radical mastoidectomy is reported. Imaging and surgical findings were suggestive of a dissemination of cholesteatoma debris within the subarachnoid spaces. Chemical meningitis has been described in epidermoid and dermoid cyst rupture. This report illustrates that clinicians should be aware of this possible complication. Skull base imaging is mandatory before considering the diagnosis of idiopathic meningitis. Only treatment of the abnormal communication between cerebrospinal fluid and middle ear may eradicate the origin of this rare meningitis.     

Hypouricemia in patients with meningitis

Serum urate and sodium concentrations were measured in 23 patients with acute viral and bacterial meningitis. Serum urate level was 3.0 +/- 0.2 mg/dl (mean +/- S.D.) (3.6 +/- 1.2 mg/dl in male and 2.5 +/- 0.9 mg /dl in female) on admission, but gradually elevated with improvements of meningitis. It turned to 4.8 +/- 0.2 mg/dl after recovery, and the value on admission was significantly lower than that after recovery (p < 0.0001). Serum sodium level was 137.6 +/- 2.9 mEq/l on admission and 139.7 +/- 2.7 mEq/l after recovery; also lower in the former (p < 0.01). These results show that patients develop transient hypouricemia, which may be explained by SIADH (syndrome of inappropriate secretion of ADH), although SIADH is subclinical in most cases of meningitis.     

The outcome of patients with upper airway obstruction transported to a regional paediatric intensive care unit

Two cases of nodular hidradenoma of the breast with possibly different origins are reported. Case 1 is of a 58-year-old female with a breast mass in the left, outer lower-quadrant. A histogenetical origin in the skin adnexal glands was suspected due to its superficial location and immunohistochemical findings. Case 2 is of a 44-year-old male with a subareolar nodule and nipple discharge. Histological examination demonstrated that the tumor was located deep in the breast tissue, was surrounded by dilated mammary ducts and exhibited intraductal extensions, which are all features mimicking those of breast cancer. Immunohistochemical positivity against gross cystic disease fluid protein-15 was weakly identified and negativity for endoplasmic reticulum was observed. This case can be interpreted as arising in the mammary ducts. It is well known that various kinds of skin adnexal tumors arise in the breast tissue; however, nodular hidradenoma of the breast is still a rare benign neoplasm. Clinically, nodular hidradenoma of the breast tends to occur in the nipple or subareolar region of the female breast. It should be kept in mind that nodular hidradenoma may occur in mammary ducts and it should be included when differential diagnoses are made of subareolar breast tumors.     

Mollaret meningitis. A report of three cases

Three cases of benign, recurrent meningitis of Mollaret demonstrated unusual aspects of this disease. Postpartum pituitary necrosis was an antecedent event in one case. A second case occurred in an otherwise healthy 82-year-old woman, and a third patient was thought to have Histoplasma meningitis. The pathophysiology of Mollaret meningitis remains an enigma, and the therapy consists of supportive care.     

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.     

Bacteroides fragilis meningitis revealing a meningorectal fistula

Cases of meningitis due to Bacteroides fragilis are rare; we report a case revealing a meningorectal fistula. CASE REPORT: A 2-month-old infant developed a severe sepsis syndrome following a rectosigmoidoscopy for rectal bleeding. Lumbar puncture diagnosed bacterial meningitis. Cerebrospinal fluid (CSF) culture evidenced B fragilis with betalactamase. The initial antibiotherapy was changed for imipenem-metronidazole, which is at present the recommended antibiotherapy. Malformation including pre-spinal tumor and meningorectal fistula was evoked on magnetic resonance imaging (MRI) and confirmed by surgery. The outcome was favorable after surgery and antibiotherapy. CONCLUSION: B fragilis meningitis are usually associated with sepsis, whose origin is obvious. In our case, meningitis was isolated, revealing a meningorectal fistula.     

Tuberculous meningitis with hydrocephalus. Contribution of PCR assay of CSF before VP shunting

A 10-month-old infant with tuberculous (Tb) meningitis accompanying hydrocephalus was successfully treated with a VP shunt operation soon after a PCR assay of CSF was found to be negative for Mycobacterium tuberculosis. PCR assay of CSF is helpful for determination of the timing for VP shunting in Tb meningitis.     

Recurrent purulent meningitis in traumatic lesions of the ethmoid (author's transl)

A report is presented of two cases of recurrent meningitis (mainly pneumococcal meningitis with different serotypes). The different possible causes of recurrent meningitis are discussed. The key to diagnosis in recurrent meningitis caused by forgotten traumatic fracture of the ethmoid bone is X-ray investigation including tomography of this region. The prognosis is poor in infancy, but improves with increasing age of the child and is dependent on early diagnosis of the underlying causative process.     

Trimethoprim-sulphamethoxazole-induced meningitis

Drug-induced meningitis is rarely included in the differential diagnosis of aseptic (usually recurrent) meningitis. A 74-year-old man who suffered from recurrent aseptic meningitis following re-exposures to trimethoprim-sulphamethoxazole (Resprim) is presented. The clinical and laboratory findings resembled those found in bacterial meningitis, excluding normal glycorrachia. Extensive microbiological, serologic and imaging studies did not disclose any relevant findings. All symptoms and signs resolved rapidly following drug withdrawal, and findings on follow-up lumbar puncture were normal.     

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.     

Rapid and sensitive detection of enteroviruses in specimens from patients with aseptic meningitis

A 5-h PCR assay (Amplicor enterovirus test) was compared with viral culture for the detection of enteroviruses in cerebrospinal fluid. Of the cerebrospinal fluid specimens collected during a summer outbreak of aseptic meningitis, 34% were positive by viral culture whereas 66% were positive by the Amplicor PCR, suggesting that this technique improves the diagnosis of enteroviral meningitis.     

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.