Ministério da Saúde reforça compromisso global no combate à meningite

Durante o mês de outubro, a Organização Mundial da Saúde (OMS) está reforçando a urgência do compromisso global para combater a meningite. Entre as diversas ações realizadas, destaca-se o lançamento das “Diretrizes para o Enfrentamento das Meningites até 2030” no Brasil, considerada uma iniciativa exemplar pela OMS. A construção dessas diretrizes começou em 2023 e foi concluída em 2024, sendo oficialmente apresentadas pelo Ministério da Saúde no dia 4 de outubro, um dia antes do Dia Mundial da Meningite.

Meningitis after COVID-19 vaccination, a systematic review of case reports and case series.

INTRODUCTION: Vaccination is considered as one of the most promising strategies to overcome the COVID-19 pandemic. However, it could be associated with rare but serious complications. In the present study, we aimed to review the clinical course and etiology of post COVID-19 vaccination meningitis. METHODS: After a systematic search in PubMed, Scopus, and Web of Sciences online databases as well as Google Scholar, documents were screened and qualified. Then data extraction was performed and the most frequent underlying agent of meningitis was found based on the reported cases. RESULTS: Overall, 35 cases of post COVID-19 vaccination meningitis from 33 articles were included in the review. Among them, 12 cases had proven viral diagnosis and 23 of them were reported to be vaccine-induced. The most frequent viral pathogen among the cases was VZV. The most prevalent symptom was headache, and the most common time of appearance symptoms was one week after vaccination. CONCLUSION: Overall, our study suggested meningitis as a critical but not devastating complication of COVID-19 vaccination. Almost all patients responded well to common agents used to manage viral or vaccine-induced meningitis. It is recommended to monitor patients with a history of chickenpox after COVID-19 vaccination regarding the development of meningitis.

Utility of cell index in the diagnosis of healthcare-associated ventriculitis and meningitis: an analytical cross-sectional study.

BACKGROUND: The diagnosis of healthcare-associated ventriculitis and meningitis (HCAVM) can be complex because multiple factors confound the interpretation of cerebrospinal fluid (CSF) tests. The cell index (CI) may help in the diagnosis of HCAVM. It does not incur additional medical cost and it avoids delays from the turnaround time of CSF cultures. It is derived by calculating the ratio of CSF white blood cell (WBC) and red blood cell (RBC) divided by the ratio of peripheral WBC and RBC. This study aimed to evaluate the diagnostic utility of this parameter. METHODS: An analytic, observational, cross-sectional study was conducted at the University of the Philippines - Philippine General Hospital. All admitted pediatric and adult patients from 2015 to 2022 who underwent external ventricular drain (EVD) insertion for hydrocephalus secondary to intracranial hemorrhage (ICH), acute ischemic stroke, intracranial neoplasms, traumatic brain injury, or congenital hydrocephalus were screened. Records of patients fulfilling the inclusion criteria were then reviewed. RESULTS: A total of 363 patients underwent EVD insertion from 2015 to 2022. Of these, 161 were included in the study. Two-thirds (66.5%) were adults ≥ 19 years old whereas the remaining were pediatric patients 1 to < 19 years old. There were no patients < 12 months old as they fulfilled at least one exclusion criteria. Forty-nine of them were later confirmed to have HCAVM based on the CDC/NHSN criteria. A CI cut-off of ≥ 1.21 gave a maximum sensitivity of 30.6% and specificity of 86.4%. Receiver operating characteristic area under the curve (AUC-ROC) analysis was 0.585. Subgroup analysis by age showed sensitivity of 52.9% in the pediatric age group and 3.13% in adults. Subgroup analysis by neurologic indication showed sensitivity of 27.6% for ICH and 35.0% for neoplasms. Subsequent AUC-ROC analyses, however, showed that CI failed to adequately diagnose HCAVM in these subgroups. CONCLUSIONS: In our population of neurologic patients who underwent EVD insertion, the cell index is not a reliable parameter in the diagnosis of HCAVM.

The challenge of etiologic diagnosis of subacute and chronic meningitis: an analysis of 183 patients.

Subacute and chronic meningitis (SCM) presents significant diagnostic challenges, with numerous infectious and non-infectious inflammatory causes. This study examined patients aged 16 and older with SCM admitted to referral centers for neuroinfections and neuroinflammations in Mashhad, Iran, between March 2015 and October 2022. Among 183 episodes, tuberculous meningitis was the most common infectious cause (46.5%), followed by Brucella meningitis (24.6%). The cause of SCM was definitively proven in 40.4%, presumptive in 35.0%, and unknown in 24.6% of cases. In-hospital mortality was 14.4%, and 30.5% of survivors experienced unfavorable outcomes (Glasgow Outcome Scale 2-4). Patients with unknown causes had a significantly higher risk of death compared to those with presumptive or proven diagnoses (risk ratio 4.18). This study emphasizes the diagnostic difficulties of SCM, with one-quarter of cases remaining undiagnosed and over one-third having only a presumptive diagnosis. Improving diagnostic methods could potentially enhance prognosis and reduce mortality.

Etiological Profile of First Episode Seizures in Paediatric Patients at a Tertiary Care Centre: A Descriptive Cross-sectional Study.

INTRODUCTION: Seizures are the most common neurological emergency and one of the most common reasons for paediatrics hospital admissions. This study aimed to identify the etiology, clinical profile, and immediate outcome of children with the first episode of seizure in Eastern Nepal. METHODS: This was a prospective descriptive study carried out in the Tertiary Care Centre from September 2022 to August 2023. Ethical clearance was taken from the Institutional Review Committee (Ref no:654/2022). Convenience sampling was done to include 170 children presenting with the first episode of seizure at age 6 months to 15 years. Variables collected were demographics, clinical presentations, family history, trauma history, laboratory tests, neuroimaging, EEG, final diagnosis, and immediate outcome. RESULTS: A total of 170 patients were admitted with the first episode of seizure with 123 (72.36%) males and 47 (27.64%) females. The mean age of the patients was 5.13±2.95 years with 104 (61.18%) patients under 5 years of age. The most common seizure was generalized tonic-clonic type in 132 (77.64%) patients. The most common associated symptom was fever in 150 (88.23%) children. Neuroimaging was abnormal in 52 (30.59%) patients, with neurocysticercosis seen in 27 (15.88%). The most common etiology was febrile seizure in 92 (54.17%) patients, neurocysticercosis in 27 (15.88%), and meningitis in 12 (7.05%). CONCLUSIONS: Febrile seizures, neurocysticercosis, infection, and trauma were the major causes of seizures in children. When simple febrile seizures were unlikely, lumbar puncture, neuroimaging, and laboratory tests were useful tools for diagnosing etiologies of seizures.

[A case of hypertrophic pachymeningitis as a systemic autoimmune/inflammatory disorder (SAID) associated with chronic myelomonocytic leukemia].

A 67-year-old woman with past medical history of chronic myelomonocytic leukemia (CMML) presented with a chief complaint of headache, diplopia, and hearing impairment in the right ear. Examination revealed impaired ocular movement in the left eye and sensorineural hearing loss in the right ear. Cerebrospinal fluid analysis showed increased cell count and protein, and MRI showed contrast enhancement of hypertrophic dura mater. Since there were no other abnormalities which would have been a cause of hypertrophic pachymeningitis, it was considered as systemic autoimmune/inflammatory disorder (SAID) associated with CMML. Treatment with steroid, cyclophosphamide, and methotrexate led to improvement of the symptoms. SAIDs develop in up to 25% of patients with myelodysplastic syndromes (MDS) or CMML, which may be the only symptoms of MDS/CMML. As a phenotype of SAIDs, systemic vasculitis, connective tissue diseases, and neutrophilic diseases are frequently reported; however, isolated involvement of central nerve system is rarely reported. To our knowledge, this is the first report of hypertrophic pachymeningitis as SAID associated with CMML. To clarify the pathogenesis of neurologic involvement of SAIDs, accumulation of cases is necessary.

Cochlear Implant Infections.

Cochlear implants (CIs) are associated with a range of infections. These infections present unique considerations because of their position relative to the respiratory tract and the central nervous system, as well as the propensity for biofilms to form on CIs. This article reviews infections related to CIs, including otitis media, mastoiditis, meningitis, and deep CI infection. High-quality evidence on the prevention and management of CI infections is lacking; however, best practices regarding prevention and management are provided.

Spinal cord compression by cystic IgG4-related spinal pachymeningitis mimicking neurocysticercosis: a case report.

BACKGROUND: To report a case of IgG4-related pachymeningitis presenting with cystic lesions mimicking neurocysticercosis. CASE PRESENTATION: A 40-year-old female patient with tetraparesis, dysphagia and dysphonia was evaluated with clinical examination, magnetic resonance imaging, and meningeal biopsy. Magnetic resonance imaging (MRI) revealed diffuse pachymeningeal enhancement involving the cranial, cervical, thoracic, and lumbar segments with spinal cord compression and cystic lesions. CSF immunology was initially positive for cysticercus cellulosae. After disease progression a meningeal biopsy was compatible with IgG4 related disease. The patient had partial response to rituximab and needed multiple surgical procedures for spinal cord decompression and CSF shunting. CONCLUSIONS: This case highlights the possibility of IgG4-related disease in patients with diffuse pachymeningitis causing spinal cord compression, even with cystic lesions on MRI. Diagnosis of IgG4-related pachymeningitis is paramount due to the possibility of treatment response to immunotherapy, particularly to anti-CD20 agents.

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Cochlear Implantation in Post-Meningitis Deafness: Audiological, Imaging, and Postoperative Outcomes: A Systematic Review With Qualitative Synthesis.

INTRODUCTION: Post-meningitis deafness (PMD) is a potentially devastating cause of hearing loss among pediatric and adult patients, for which hearing rehabilitation with cochlear implants (CIs) remains the standard of care. To date, there have been limited systematic studies on the impact of cochlear ossification (CO) and time-to-implantation (TTI) on audiological outcomes. METHODS: An online database search was performed on the PubMed, Embase, and Scopus databases for articles within the past 20 years pertaining to audiological outcomes among pediatric and adult patients with PMD. Information on study characteristics, patient demographics, clinical outcomes, and postoperative complications was collected and analyzed. RESULTS: From 8,325 articles generated in the original search, 11 were included in the final analysis, representing 376 patients in total. Of the articles discussing TTI, the majority (3 of 4) found that a shorter TTI of 6 months on average led to improved audiological outcomes compared with control groups with a longer TTI. Of the articles that discussed the impact of preoperative CO, the majority (4 of 6) found that the presence of CO had a detrimental effect on postoperative audiological outcomes after CI. Finally, of the articles that discussed long-term audiological outcomes for PMD compared with the non-PMD control group after CI, the majority (4 of 7) found that PMD patients had inferior long-term outcomes. CONCLUSION: CI is a safe and effective treatment modality for PMD, with the majority of literature demonstrating improved long-term outcomes for patients without CO and a reduced TTI.

Two cases of MPO-ANCA-positive hypertrophic pachymeningitis mimicking as intracranial infection.

Hypertrophic pachymeningitis (HP) is a rare disorder marked by thickening of the dura mater due to diverse etiologies. MPO-ANCA-positive HP represents a variant of AAV confined to the central nervous system, distinguished by the presence of serum MPO antibodies. Distinguishing HP triggered by MPO-ANCA from other causes can be challenging.In this study, we present two cases of MPO-ANCA-positive HP initially misdiagnosed as intracranial infections. Case 1 underwent surgery for chronic suppurative otitis media, with histopathological findings revealing inflammatory changes without definitive suppuration. He was presumed to have a secondary intracranial infection resulting from the surgery. However, his condition deteriorated despite two weeks of antibiotic and antiviral treatment. Case 2 presented with headache and was initially suspected of having intracranial Brucellosis given his serum Brucella positivity. Despite treatment for brucellosis, his symptoms persisted, and he developed visual and hearing impairments. Both patients were ultimately diagnosed with MPO-ANCA-positive HP, exhibiting serum MPO antibody positivity. Their symptoms showed improvement with glucocorticoid and immunosuppressive therapy.Based on these observations, we propose that MPO-ANCA-positive HP may initially present as intracranial infection. For HP patients presenting with headache, mastoiditis, otitis media, and visual loss, it is imperative to conduct ANCA antibody-related tests to enhance diagnostic precision.

High-Resolution Ultrasound Platform for Infant Meningitis Detection: An In Vitro Demonstration.

Infant meningitis remains a severe burden on global health, particularly for young infants. Traditional ultrasound imaging techniques are limited in spatial resolution to visualize white blood cells (WBCs) in the cerebrospinal fluid (CSF), which is considered a well-established marker for meningitis detection. This work presents a novel platform that uses high-resolution ultrasound to detect the backscatter signals from microscopic CSF WBCs through the anterior fontanelle of neonates and young infants. The whole system was built around a custom probe that allows for a 20 MHz focused transducer to be mechanically controlled to map the area of interest in the CSF. Data processing can be performed internally in the device without the need to extract the images for further analysis. The in vitro feasibility of the proposed solution was evaluated in imaging 7 µm particle suspensions at different concentrations relevant to meningitis diagnosis ranging from 7- to 646-particles (pp)/µL. The experimental tests were conducted from a simple setup using a sample container to a more realistic setup based on an anatomical phantom of the neonatal head. The results show high-quality images, where 7 µm particles can be resolved for the different concentrations.

Central nervous system nocardiosis in a 54-year-old man with lateral ventricular choroid plexitis and diffused meningitis: A case report.

INTRODUCTION: Nocardiosis is an unusual infection caused by aerobic gram-positive bacteria in the genus Nocardia. Infections resulting from Nocardia species are frequent in immunosuppressive patients. Weakened immune systems caused by human immunodeficiency virus infection, diabetes, cancer, and other conditions such as chronic lung disease, renal failure, etc, are the main risk factors for nocardiosis. Central nervous system (CNS) nocardiosis has been reported to represent ~2% of all and to be present in 15% to 50% of patients with systemic infection. The patient in our case had an isolated CNS nocardiosis caused by Nocardia terpenica infection, a rare reclassified Nocardia pathogen of CNS nocardiosis. CASE: We here present a 54-year-old Chinese male with a fever and headache for 15 days who showed positive meningeal irritation signs. Magnetic resonance imaging showed the right trigone of the lateral ventricular choroid plexitis and diffused leptomeningeal meningitis involving the bilateral cerebral hemisphere, cerebellar hemisphere, and brain stem. The patient was quickly diagnosed with CNS Nocardia infection by next-generation sequencing within 48 hours after admission. Meanwhile, the diagnosis was validated by Nocardia-positive staining in cerebral spinal fluid culturing. The patient was given trimethoprim-sulfamethoxazole, and his symptoms recovered after 3 days. CONCLUSIONS: In this case, the clinical, radiological, and microbiological findings highlight the importance of suspecting Nocardia as the potential pathogen in patients with central nervous system inflammation of doubted immune incompetence. In addition, next-generation sequencing as an effective test is also highly recommended for suspicious CNS infection patients to perform a rapid diagnosis and treatment.

A 79-Year-Old Woman With Worsening Headaches and Pachymeningeal Enhancement: A Case Report From the National Multiple Sclerosis Society Case Conference Proceedings.

A 79-year-old woman presented with subacutely worsening headaches and right arm weakness. MRI showed diffuse pachymeningeal enhancement. Serologic workup revealed elevated erythrocyte sedimentation rate and C-reactive protein. CSF demonstrated elevated opening pressure, a lymphocytic pleocytosis, and elevated protein. We discuss our differential diagnosis and distinguish between 2 overlapping clinical entities.

Rheumatoid meningitis in the absence of rheumatoid arthritis: 2 cases.

Rheumatoid meningitis (RM) is a rare extra-articular manifestation of rheumatoid arthritis (RA) that has been increasingly recognized by neurologists. However, the diversity of its clinical manifestations makes its diagnosis difficult. RM does not have a unified diagnostic standard, and its link with RA needs to be studied further. Here we report two cases of RM without a history of RA. The first patient, an 80-year-old woman, presented with sudden unilateral limb weakness, with brain MR showing abnormal signals in the leptomeningeal of the right frontal parietal. Subarachnoid hemorrhage was excluded after imaging examination, and infectious meningitis was ruled out after cerebrospinal fluid (CSF) examination. The patient was diagnosed as having RM, she had increased levels of CCP and AKA, the markers of RA, but no history of the disease or other clinical manifestations of it. Another case, a 65-year-old man, was hospitalized with Bell's palsy. We found that he had intracranial imaging changes highly consistent with those characteristic of RM during his routine examination. Except for the left peripheral facial palsy, the patient had no other neurological signs or symptoms and no RA history. After a careful physical examination, we found no joint or other manifestations or serological abnormalities consistent with RA (RF, CCP, AKA, etc.). However, after excluding infection meningitis and considering the patient's unique imaging results, we diagnosed him as having RM. We report these two cases as references for clinical diagnosis and treatment of RM, providing a discussion of our rationale.

Glioma grade and post-neurosurgical meningitis risk.

BACKGROUND: Post-neurosurgical meningitis (PNM) constitutes a grave complication associated with substantial morbidity and mortality. This study aimed to determine the risk factors predisposing patients to PNM following surgery for low- and high-grade gliomas. METHODS: We conducted a retrospective analysis encompassing all patients who underwent glioma surgery involving craniotomy at Turku University Hospital, Turku, Finland, between 2011 and 2018. Inclusion criteria for PNM were defined as follows: (1) Positive cerebrospinal fluid (CSF) culture, (2) CSF leukocyte count ≥ 250 × 106/L with granulocyte percentage ≥ 50%, or (3) CSF lactate concentration ≥ 4 mmol/L, detected after glioma surgery. Glioma grades 3-4 were classified as high-grade (n = 261), while grades 1-2 were designated as low-grade (n = 84). RESULTS: Among the 345 patients included in this study, PNM developed in 7% (n = 25) of cases. The median time interval between glioma surgery and diagnosis of PNM was 12 days. Positive CSF cultures were observed in 7 (28%) PNM cases, with identified pathogens encompassing Staphylococcus epidermidis (3), Staphylococcus aureus (2), Enterobacter cloacae (1), and Pseudomonas aeruginosa (1). The PNM group exhibited a higher incidence of reoperations (52% vs. 18%, p < 0.001) and revision surgery (40% vs. 6%, p < 0.001) in comparison to patients without PNM. Multivariable analysis revealed that reoperation (OR 2.63, 95% CI 1.04-6.67) and revision surgery (OR 7.08, 95% CI 2.55-19.70) were significantly associated with PNM, while glioma grade (high-grade vs. low-grade glioma, OR 0.81, 95% CI 0.30-2.22) showed no significant association. CONCLUSIONS: The PNM rate following glioma surgery was 7%. Patients requiring reoperation and revision surgery were at elevated risk for PNM. Glioma grade did not exhibit a direct link with PNM; however, the presence of low-grade gliomas may indirectly heighten the PNM risk through an increased likelihood of future reoperations. These findings underscore the importance of meticulous post-operative care and infection prevention measures in glioma surgeries.