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.     

Aluminum neurotoxicity in preterm infants receiving intravenous-feeding solutions

BACKGROUND: Aluminum, a contaminant of commercial intravenous-feeding solutions, is potentially neurotoxic. We investigated the effect of perinatal exposure to intravenous aluminum on the neurologic development of infants born prematurely. METHODS: We randomly assigned 227 premature infants with gestational ages of less than 34 weeks and birth weights of less than 1850 g who required intravenous feeding before they could begin enteral feeding to receive either standard or specially constituted, aluminum-depleted intravenous-feeding solutions. The neurologic development of the 182 surviving infants who could be tested was assessed by using the Bayley Scales of Infant Development at 18 months of age. RESULTS: The 90 infants who received the standard feeding solutions had a mean (+/-SD) Bayley Mental Development Index of 95+/-22, as compared with 98+/-20 for the 92 infants who received the aluminum-depleted solutions (P=0.39). In a planned subgroup analysis of infants in whom the duration of intravenous feeding exceeded the median and who did not have neuromotor impairment, the mean values for the Bayley Mental Development Index for the 39 infants who received the standard solutions and the 41 infants who received the aluminum-depleted solutions were 92+/-20 and 102+/-17, respectively (P=0.02). The former were significantly more likely (39 percent, vs. 17 percent of the latter group; P=0.03) to have a Mental Development Index of less than 85, increasing their risk of subsequent educational problems. For all 157 infants without neuromotor impairment, increasing aluminum exposure was associated with a reduction in the Mental Development Index (P=0.03), with an adjusted loss of one point per day of intravenous feeding for infants receiving the standard solutions. CONCLUSIONS: In preterm infants, prolonged intravenous feeding with solutions containing aluminum is associated with impaired neurologic development.     

Beneficial effects of dexamethasone in children with pneumococcal meningitis

Fifty-six children older than 2 years with meningitis caused by Streptococcus pneumoniae were enrolled in a prospective, double blind, placebo-controlled trial to evaluate the efficacy of dexamethasone therapy in addition to antimicrobial therapy. Twenty-nine of 56 received dexamethasone (0.6 mg/kg/day iv, divided into 4 daily doses for 4 days) and the remaining 27 received placebo. At the beginning of therapy the clinical and laboratory characteristics of the patients in the treatment groups were comparable, except for the Glasgow coma score (P = 0.004), which was lower in the dexamethasone group. Patients were examined daily during hospitalization and 6 weeks after discharge from the hospital. Hearing was assessed 6 weeks after discharge by means of pure tone audiometry. Two patients in the dexamethasone group and one patient in the placebo group died. There were no differences between the two groups with regard to the duration of fever, the incidence of secondary fever and electrolyte imbalance, seizure activities occurring during hospitalization and rash. Although the differences were statistically insignificant, moderate or severe unilateral or bilateral sensorineural hearing loss at 6 weeks and the overall neurologic sequelae, including hearing loss, at 1 year were higher in the placebo group, at 23% vs. 7.4% (P = 0.11) and 26.9% vs. 7.4% (P = 0.062), respectively. At 3 months after discharge, because of the improvement in hearing loss in one dexamethasone-treated patient the incidence of hearing impairment was significantly less than that in the placebo group, at 3.7% vs. 23%, respectively (P = 0.044). No improvement in hearing loss was observed after 3 months.(ABSTRACT TRUNCATED AT 250 WORDS)     

D2 receptor imaging with iodine-123-iodobenzamide brain SPECT in infants with hypoxic-ischemic brain injury

The purpose of this study was to evaluate the striatal dopamine D2 receptor density in infants with perinatal hypoxic-ischemic brain injury (HIBI) using 123I-iodobenzamide (IBZM) brain SPECT and to correlate the findings with the severity of HIBI and neurologic outcome. METHODS: Twenty infants who were diagnosed to have perinatal HIBI were included in this study. They were classified as having mild (n = 6), moderate (n = 10) or severe (n = 4) HIBI according to their neurologic findings at birth using the criteria of Sarnat and Sarnat. Neurologic outcome of these infants was determined by serial neurologic examinations and the Denver developmental screening test; 10 infants recovered without any deficit and the remaining 10 were affected to a degree varying from motor impairment to cerebral palsy. All 20 infants were examined using 123I-IBZM brain SPECT at age 7.8 +/- 2.3 mo. Transaxial slices were obtained 2 hr after intravenous injection of 300 micro ci (11.1 MBq) 123I-IBZM and the activity ratios of striatal to occipital cortex (ST/OC) were calculated. RESULTS: The mean ST/OC ratios in patients with mild, moderate and severe HIBI (1.219 +/- 0.078, 1.097 +/- 0.069 and 0.813 +/- 0.140, respectively) were significantly different from each other (p = 0.001). The infants who recovered from HIBI without any neurologic sequelae had higher mean ST/OC ratios than the others (1.184 +/- 0.010 versus 0.969 +/- 0.160, p = 0.002). CONCLUSION: The results of this study show that in infants with HIBI, striatal D2 receptor density decreases as the severity of injury increases. The D2 receptor density is higher in infants who recover without neurologic deficits compared to those who are affected neurologically. Dopamine D2 receptor imaging can be used to assess the severity of HIBI in children.     

Prevention of hearing loss in experimental pneumococcal meningitis by administration of dexamethasone and ketorolac

Pneumococcal meningitis remains a significant cause of morbidity, particularly sensorineural hearing loss. Recent literature has suggested that a vigorous host immune response to Streptococcus [corrected] pneumoniae is responsible for much of the neurologic sequelae, including deafness, after bacterial meningitis. This study used a rabbit model of hearing loss in experimental pneumococcal meningitis to evaluate the therapeutic effect of two anti-inflammatory agents, dexamethasone and ketorolac, coadministered with ampicillin. Both adjunctive drugs minimized or prevented sensorineural hearing loss compared with placebo. Dexamethasone, administered 10 min before ampicillin, was particularly effective in minimizing mean hearing threshold change compared with placebo for both clicks (dexamethasone: 6.7-dB sound pressure level [SPL] vs. placebo: 33. 4-dB SPL, P=.0078) and 10-kHz tone bursts (dexamethasone: 8.4-dB SPL vs. placebo: 53.4-dB SPL, P=.0003). These findings support the beneficial role of anti-inflammatory agents in reducing the incidence of hearing loss from pneumococcal meningitis, especially if therapy is instituted early in the course of infection.     

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.     

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.     

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.     

Predictive significance of magnetic resonance imaging at 4 months of adjusted age in infants after a perinatal neurologic insult

The aim of this prospective study was to evaluate the predictive significance of magnetic resonance imaging (MRI) performed at 4 months of corrected age in 60 neonates after a perinatal neurologic insult. Follow-up ranged from 2 to 5 years of chronological age. MRI examination was normal in 10; isolated external hydrocephalus was found in 15 infants. Twenty-three of these infants developed normally. Focal or multifocal lesions were shown in 6 infants, of whom 2 developed normally. Diffuse brain involvement was present in 29 cases as atrophy (n = 18), leukomalacia (n = 5), basal ganglia lesions (n = 3), and delayed myelination (n = 3). All but 4 infants showed neurologic impairment. MRI performed at 4 months of adjusted age is of prognostic significance in neonates who suffer a moderate or mild neurologic insult.     

Proton MR spectroscopy after acute central nervous system injury: outcome prediction in neonates, infants, and children

PURPOSE: To evaluate the usefulness of proton magnetic resonance (MR) spectroscopy in predicting 6-12-month neurologic outcome in children after central nervous system injuries. MATERIALS AND METHODS: Localized single-voxel, 20-msec-echo-time MR spectra (including N-acetylaspartate [NAA], choline [Ch], creatine and phosphocreatine [Cr]) were obtained in the occipital gray matter in 82 patients and 24 control patients. Patient age groups were defined as neonates (< or = 1 month [n = 23]), infants (1-18 months [n = 31]), and children (> or = 18 months [n = 28]). Metabolite ratios and the presence of lactate were determined. Linear discriminant analysis-with admission clinical data, proton MR spectroscopy findings, and MR imaging score (three-point scale based on severity of structural neuroimaging changes)-was performed to help predict outcome in each patient. Findings were then compared with the actual 6-12-month outcome assigned by a pediatric neurologist. RESULTS: Outcome on the basis of proton MR spectroscopy findings combined with clinical data and MR imaging score was predicted correctly in 91% of neonates and in 100% of infants and children. Outcome on the basis of clinical data and MR imaging score alone was 83% in neonates, 84% in infants, and 93% in children. The presence of lactate was significantly higher in patients with poor outcome than in patients with good-moderate outcomes in all three age groups (neonates, 38% vs 5%; infants, 87% vs 5%; children, 64% vs 10% [chi 2 test, P < .02]). In children with poor outcomes, NAA/Cr ratios were significantly lower in infants (P = .006) and children (P < .001), and NAA/Ch ratios were significantly lower in infants (P = .001) and neonates (P = .05). CONCLUSION: Findings at proton MR spectroscopy helped predict long-term neurologic outcomes in children after central nervous system injury.     

Prognosis for survival and improvement in function in children with severe developmental disabilities

OBJECTIVE: To evaluate the feasibility and cost-effectiveness of using transient evoked otoacoustic emissions (TEOEs) to assess hearing in infants recovered from meningitis. METHODS: Recordings of TEOEs and visual reinforcement audiometry (VRA) were performed in a prospective study of 39 children aged 6 to 24 months recovering from a purulent meningitis. Patients with no TEOEs, or whose VRA findings were abnormal, were also tested by impedance audiometry and recording of auditory brain-stem responses (ABRs) after treatment of any secretory otitis media. Costs were compared with those of a previous protocol including VRA, impedance audiometry, and ABR for all children. RESULTS: A total of 29 children had TEOEs in both ears and normal VRA findings. Ten children lacked TEOEs in one or both ears; 9 of them had otitis media with effusion. Further examination by VRA and ABR led to the diagnosis of bilateral sensorineural hearing loss in 2.6% (1/39) of patients and unilateral sensorineural hearing loss in 7.7% (3/39) of patients. Cost analysis revealed that this protocol costs about half the previous one. CONCLUSION: Recording TEOEs appears to be a feasible and cost-effective hearing screening test for infants recovered from meningitis. If TEOEs are absent, impedance audiometry, ABR recordings, and audiometric evaluation techniques are needed to distinguish between conductive and sensorineural hearing loss and to assess hearing thresholds precisely.     

Placental lesions associated with neurologic impairment and cerebral palsy in very low-birth-weight infants

OBJECTIVE: Systematic placental examination has the potential to shed light on poorly understood antenatal processes that may increase the risk of neurologic impairment and cerebral palsy. DESIGN: Using data from a retrospective case-control study, we analyzed placentas from 60 inborn, singleton, very low-birth-weight (<1.5 kg) infants delivered between 1983 and 1991 who had subsequent neurologic impairment at 20 months corrected age (42 with cerebral palsy and 18 with other neurologic abnormalities) and 59 control infants of comparable gestational age, birth weight, sex, and race. Three a priori hypotheses based on previous studies were that neurologic impairment would be increased with fetal vascular lesions with or without coexisting chorioamnionitis, decreased with chronic maternal vascular underperfusion, and increased when multiple placental abnormalities were seen in the same case. RESULTS AND CONCLUSIONS: We found 2 types of fetal placental vascular lesions to be associated with neurologic impairment, namely, recent nonocclusive thrombi of chorionic plate vessels (P < .04) and severe villous edema (P < .01). Chorionic plate thrombi were seen only with chorioamnionitis and accounted for the increased risk of neurologic impairment seen with chorioamnionitis. Maternal vascular lesions showed a biphasic relation to neurologic impairment in the subgroup of patients without chorioamnionitis. Mild lesions were increased in controls (inadequate vascular remodeling, P=.03, and accelerated maturation, P=.004). A more severe lesion, multiple villous infarcts, although not reaching significance, was increased in the neurologically impaired cases. Finally, in a test of 9 selected placental lesions, cases with cerebral palsy were more likely to have 2 or more lesions (P < .0001) and were less likely to have no lesions (P < .04) than control infants.     

The genetics of ovarian cancer: concepts in testing and counseling

This article describes a screening program for hearing loss among infants. The program, designed according to ASHA recommendations, was implemented in a public health district of the province of Quebec. In the first stage of the program all infants born between April 1, 1990 and March 30, 1992 were assessed for risk factors for deafness. In the second stage, those infants considered at risk were given an audiological examination at six months of age. There were 3,944 births during the study period and of these, 8.4% of the infants had at least one risk factor for hearing impairment, the most frequent of which was a family history of hearing impairment at an early age, followed by: hyperbilirubinemia, admission to a high risk neonatal unit, consumption of ototoxic medications, anatomical malformations, perinatal infections and insufficient birthweight. Of the infants at risk, 54.2% were given the audiological examination at six months and one case of deafness was diagnosed.     

Neonatal hyperbilirubinemia and long-term outcome: another look at the Collaborative Perinatal Project

OBJECTIVE: To examine the association between neonatal bilirubin levels and subsequent neurodevelopmental outcome. DESIGN: Prospective cohort study. SETTING: 12 US medical centers from 1959 (first births) to 1974 (last follow-up). PARTICIPANTS: 41,324 singleton white or black infants with birth weight > or = 2500 g who had neonatal bilirubin measurements recorded and survived at least 1 year. MAIN OUTCOME MEASURES: Wechsler Intelligence Scale for Children Intelligence Quotient (IQ) at age 7 years, blinded neurologic examination at age 7 years, and sensorineural hearing loss at age 8 years. RESULTS: There was no association between IQ and bilirubin. For example, comparing children who had maximum bilirubin levels > or = 342 mumol/L (20 mg/dL) with those who had lower bilirubin levels, adjusted mean IQs were 105.0 and 103.4 in whites (difference + 1.6; 95% confidence interval [CI]: -0.4 to +3.5) and 91.0 and 93.3 in blacks (difference -2.3; 95% CI: -4.8 to +0.2). Abnormal neurologic examination results were reported in 12 of 268 children (4.5%) with bilirubin > or = 342 mumol/L (20 mg/dL) compared with 1249 of 33,004 children (3.8%) with lower levels (relative risk [RR] = 1.2; 95% CI: 0.7 to 2.1). The frequency of abnormal or suspicious neurologic examination results increased in a stepwise fashion with increasing bilirubin level (P < .001), from 4346/29,258 (14.9%) of those with bilirubin levels < 171 mumol/L (10 mg/dL) to 60/268 (22.4%) of those with bilirubin levels. > or = 342 mumol/L (20 mg/dL), apparently due to increasing minor motor abnormalities at higher bilirubin levels. Sensorineural hearing loss was not associated with high bilirubin levels (RR = 1.0; 95% CI: 0.3 to 3.0). CONCLUSIONS: Neonatal bilirubin levels seem to have little effect on IQ, definite neurologic abnormalities, or hearing loss. Higher bilirubin levels are associated with minor motor abnormalities, but the clinical importance of this finding is limited by the weakness of the association, the mild nature of the abnormalities, and the lack of evidence that they are prevented by treatment.     

A prospective, population-based study of the demographics, epidemiology, management, and outcome of out-of-hospital pediatric cardiopulmonary arrest

STUDY OBJECTIVEs: To perform a population-based study addressing the demography, epidemiology, management, and outcome of out-of-hospital pediatric cardiopulmonary arrest (PCPA). METHODS: Prospective, population-based study of all children (17 years of age or younger) in a large urban municipality who were treated by EMS personnel for apneic, pulseless conditions. Data were collected prospectively for 3(1/2) years using a comprehensive data collection tool and on-line computerized database. Each child received standard pediatric advanced cardiac life support. RESULTS: During the 3(1/2)-year period, 300 children presented with PCPA (annual incidence of 19. 7/100,000 at risk). Of these, 60% (n=181) were male (P =.0003), and 54% (n=161) were patients 12 months of age or younger (152,500 at risk). Compared with the population at risk (32% black patients, 36% Hispanic patients, 26% white patients), a disproportionate number of arrests occurred in black children (51.6% versus 26.6% in Hispanics, and 17% in white children; P <.0001). Over 60% of all cases (n=181) occurred in the home with family members present, and yet those family members initiated basic CPR in only 31 (17%) of such cases. Only 33 (11%) of the total 300 PCPA cases had a return of spontaneous circulation, and 5 of the 6 discharged survivors had significant neurologic sequelae. Only 1 factor, endotracheal intubation, was correlated positively with return of spontaneous circulation (P =.032). CONCLUSION: This population-based study underscores the need to investigate new therapeutic interventions for PCPA, as well as innovative strategies for improving the frequency of basic CPR for children.     

Inhibition of peripheral blood mononuclear cell proliferation by cardiac glycosides

We prospectively studied the epidemiologic, clinic signs and outcome of bacterial meningitis in 125 children who were admitted into a PICU (Pediatric Intensive Care Unit) of 11 hospitals of Spain and whose meningitis was diagnosed between May 1994 and April 1995. RESULTS: The median age of the children was 3.55 +/- 3.32 years (range 1 month to 16.5 yrs). Eighty-eight were bacterial meningitis, probably bacterial 30 and aseptic 7. The most frequently isolated organisms were N. meningitidis (52), H. influenza type b (17) and S. pneumoniae (8). Twenty-five percent of N. meningitidis had C serotype. Incidence rate of each germen was depending of age. All patients diagnosed of H. influenza type b meningitis were less than 3 years old. H. influenza type b and meningococcus had similar incidence rate during the first year of life (27% versus 31%). During the first three years of life H. influenza type b produced one third of bacterial meningitis. A mortality rate of 5.6% (seven patients: 3 S. pneumoniae, 1 N. meningitidis, 1 H. influenza type b and 2 unknown germen) was observed. Patients who die had lower Glasgow coma score (p = 0.034) and seizures (p = 0.001) at admission. At discharge of PICU, 9 survivors (7.2%) had sequelae: mental retardation in 7 patients and hearing loss in two. One third of patients needed hemodynamic support and a 15% of them ventilatory support. CONCLUSIONS: Age is an important epidemiological factor in the etiology of pediatric acute meningitis. H. influenza type b and N. meningitidis had similar incidence rate during the first year of life. S. pneumoniae had the highest mortality rate (37.5%). The presence of coma and seizures at admission were associated with mortality.     

Diagnostic value of atypical lymphocytes in cerebrospinal fluid from adults with enteroviral meningitis

We have noted two morphologically distinct types of atypical lymphocytes (AL) in the cerebrospinal fluid (CSF) of adult patients with meningitis: one, which we designate type-I AL, with multilobulated nuclei resembling those of the abnormal cells in adult T-cell leukaemia (ATL); and another, type-II AL, characterized by large lymphocytes with basophilic cytoplasm and nuclei containing coarse chromatin. Type-I AL were detected in 25 of 39 patients (64%) with enteroviral and in 11 of 109 (11%) with aseptic meningitis presumed to be caused by other viruses, but not in meningitis resulting from Cryptococcus neofirmans (n = 14), Mycobacterium tuberculosis (n = 19) or acute bacterial infection (n = 49). Type-I AL were not seen in herpes zoster (n = 15) aseptic meningeal reactions (n = 15), or in leptomeningeal carcinomatosis (n = 14). Type-II AL were often present in meningitis of various aetiologies and in aseptic meningeal reactions, but not in leptomeningeal carcinomatosis. The presence of type-I AL in the CSF was found to be indicative of enteroviral meningitis with the highest predictive value (69%), while type-II AL had a lower diagnostic positive predictive value in meningitis of the five aetiologies above. Type-I AL immunostained for CD4, while type-II AL were stained for CD8. The presence of type-I AL in CSF strongly suggests enteroviral meningitis, which warrants careful follow-up without antifungal, antituberculous or antibacterial agents. However, type-I AL, which are likely to be virally transformed lymphocytes, must be distinguished from ATL cells, which frequently involve the meninges.     

Hearing evaluation in children with bacterial meningitis

Twenty four children with bacterial meningitis were studied prospectively to ascertain the incidence, type and severity of hearing loss. The incidence of sensorineural hearing loss was 20.8%. Patients with hearing loss were followed-up audiologically for six months to find out the progress of hearing impairment. Of the five patients with sensorineural hearing loss only one showed partial recovery while the other three did not show any improvement. Of the five patients with sensorineural hearing loss only one showed partial recovery while the other three did not show any improvement. One patient was lost to follow-up, therefore, recovery was not known. The degree of hearing loss varied form mild to moderate. Antibiotic treatment and laboratory data were analysed to identify the high risk factors predisposing to hearing impairment. The presence of low CSF sugar level, high protein at the initial lumbar puncture and presence of neurological deficits was associated with a significantly higher risk of hearing loss. However, the nature of antibiotic therapy, duration of illness, age and sex of the patients were not significant risk factors in the development of hearing impairment.     

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.     

Subdural effusion in type B Haemophilus influenzae meningitis. A study of 38 cases

OBJECTIVE: Studying clinical, laboratory and radiologic findings, as well as outcome, observed in patients with meningitis caused by Hib, and its relationship with subdural effusion. MATERIAL AND METHODS: Retrospective study of 38 meningitis caused by Hib. Patients were aged between 3 months and 5 years. Imaging was performed in 26 cases (68%): CT in 21 children (55%) and cranial sonography in 11 cases (29%). EEG was made in 29 patients (76%) and auditory-evoked potentials in 13 (34%). The mean follow-up period after discharge was 24 months. RESULTS: Sixty-six per cent were male and 34% female. Eight cases had subdural effusion. These patients showed higher white cell counts in blood and CSF, higher levels of proteins in CSF, and lower levels of glucose in the same medium. They also had seizures before or during hospitalization, with higher frequency than those without subdural effusion (50% vs 26%) as well as more prolonged fever (127 vs 73 hours). No specific treatment was required in any case. CONCLUSIONS: Subdural effusion is one of the most frequent complications observed in meningitis. Patients frequently present more important clinical and laboratory alterations. This finding is not related with neurologic sequelae and they resolve spontaneously with time.