[Pneumococcal meningitis in children in Iceland - case report and summary].

An eleven month old girl was referred to the pediatric emergency department at Landspitali Hospital due to fever and lethargy. On examination she was acutely ill with fluctuating level of conciousness. She deteriorated quickly after arrival at the emergency department and was diagnosed with pneumococcal meningitis. In the past year several cases of bacterial meningitis have been diagnosed with Streptococcus pneumoniae as the most common pathogen. The disease causing serotypes have been serotypes that were not in the vaccine that was used in iceland and the Icelandic health authorities have decided to change the vaccination programme accordingly.

A Retrospective Study of Recurrent Bacterial Meningitis in Children: Etiology, Clinical Course, and Treatment.

Objectives: Recurrent bacterial meningitis (RBM) is a rare but life-threatening disease. This study aims to analyze the clinical features, potential causes, and therapeutic outcomes of RBM in children. Methods: This article retrospectively reviews the clinical characteristics, etiologies, and treatments in children with RBM hospitalized in Hebei children's hospital from 2012 to 2020. Results: A total of 10 children with RBM, five males and five females, were included in this study. The age of RBM in children spans from the neonatal stage to the childhood stage. The underlying illnesses were identified and classified as cerebrospinal fluid rhinorrhea (1 case), humoral immunodeficiency with Mondini dysplasia (1 case), common cavity deformity with cerebrospinal fluid ear leakage (1 case), Mondini malformations (2 cases), incomplete cochlear separation type I with a vestibular enlargement (2 cases), local inflammation of the sphenoid bone caused by cellulitis (1 case), congenital skull base defects (1 case), and congenital dermal sinus with intraspinal abscess (1 case). 6 patients chose targeted therapy for potential reasons. Conclusions: Congenital abnormalities or acquired injuries lead to intracranial communication with the outside world, which can quickly become a portal for bacterial invasion of the central nervous system, resulting in repeated infections.

Oval window perilymph fistula in child with recurrent meningitis and unilateral hearing loss.

A 2-year-old boy presented to Ears, Nose and Throat (ENT) surgeons with unilateral hearing loss. Following a prodrome of upper respiratory tract infection (URTI), he developed two episodes of pneumococcal meningitis in quick succession. This case demonstrates an unusual cause of perilymph fistula diagnosed on imaging and confirmed surgically. He had failed the Newborn Hearing Screening Programme and was therefore referred to audiology, who confirmed profound sensorineural hearing loss in the right ear. MRI showed incomplete partitioning (type 1) of the right cochlea, suggesting cerebrospinal fluid (CSF) leak from the region of the stapes. Exploratory tympanotomy confirmed this, and proceeded to CSF leak repair, obliteration of the Eustachian tube, subtotal petrosectomy, abdominal fat grafting and blind sac closure. Although middle ear effusions are common; particularly in children with recent URTI, the possibility of otogenic CSF leak needs to be considered, especially in cases of recurrent meningitis.

Recurrent Pneumococcal Meningitis Secondary to Nasoethmoidal Meningocele.

Since the widespread introduction of the conjugate pneumococcal vaccine and subsequent decline of invasive pneumococcal disease in children, a significant proportion of children with pneumococcal meningitis are identified as having an underlying immunodeficiency or predisposing anatomic abnormality. We present 3 cases of recurrent pneumococcal meningitis where detailed neuro-imaging revealed subtle anterior base of skull defects not detected on initial investigations.

[Meningitis Due to Streptococcus pneumoniae Serotype 24B in a Patient with Cochlear Implant Previously Vaccinated with the Pneumococcal Vaccine]. / Pnömokok Asili Koklear Implantli Hastada Streptococcus pneumoniae Serotip 24B'ye Bagli Menenjit.

Streptococcus pneumoniae is a major cause of bacterial meningitis in children. It can progress and carries a serious risk of mortality and morbidity despite effective treatment. Cochlear implantation is a fairly successful procedure for restoring hearing in cases of sensorineural hearing loss. Moreover, patients with cochlear implants are at increased risk of contracting pneumococcal meningitis compared to the general population. The development of meningitis is associated with pathogens in the middle ear that contaminate the cerebrospinal fluid (CSF), as a result of congenital anomalies in the cochlea, and the cochlear implant. A 4-year-old girl presented to our clinic with fever, vomiting, and weakness. A physical examination showed an axillary temperature of 38.3°C, heart rate of 134/min, respiration rate of 50 breaths/minute, and arterial blood pressure of 120/88 mmHg. The patient also had a neck stiffness and her Kernig and Brudzinski signs were positive. It was discovered that the patient had undergone cochlear implantation approximately five months prior due to bilateral congenital sensorineural hearing loss. She had also received the Haemophilus influenzae type b and PCV-13 vaccines in line with the national immunization calendar. Her laboratory findings showed a leukocyte count of 21.900/mm3 (neutrophils 90% and lymphocytes 10%) and her procalcitonin level was 1.22 ng/ml. An uncountable number of neutrophils was identified in her cerebrospinal fluid, which led to the initial diagnosis of meningitis. There was also 1 mg/dl of glucose (blood glucose, 102 mg/dl) and 706 mg/dl of protein in her cerebrospinal fluid. Empirically, vancomycin (60 mg/kg/day) and ceftriaxone (100 mg/kg/day) were started. Following 5 days of antibiotic treatment, penicillin-susceptible S.pneumoniae was yielded in her CSF culture and identified as serotype 24B. S.pneumoniae with the same antibiotic sensitivity was also identified in her blood culture. Since rhinorrhea was observed on day 16 of hospitalization, she underwent an operation to repair the fistula tract. A computerized tomography cranial scan was performed after the development of acute mental fog at postoperative day 3 and showed brain edema and a thrombus in the right middle cerebral artery. The patient died on day 42 of hospitalization due to multiple organ failure. To our knowledge, this is the first case of meningitis reported in our country associated with S.pneumoniae serotype 24B in a patient with a cochlear implant. While there has been a decrease in the prevalence of invasive pneumococcal disease with routine administration of the pneumococcal conjugate vaccine, a relative increase has been observed in its non-vaccine serotypes. This is relevant not only to patients with more risk factors, such as a cochlear implant, but also those who are at lower risk for pneumococcal infection.

Recurrent meningitis by Streptococcus pneumoniae in a girl with cochlear implant and head trauma despite 13-valent conjugated pneumococcal vaccine. / Meningitis recurrente por Streptococcus pneumoniae en una niña con un implante coclear y traumatismo craneoencefálico a pesar de haber recibido la vacuna neumocócica conjugada de 13 serotipos.

Recurrent bacterial meningitis is a very rare phenomenon in children. Skull base fractures and cochlear implant are the important predisposing factors and, Streptococcus pneumoniae is the most frequently isolated agent. Implementation of 13-valent conjugated pneumococcal vaccine (PCV13) has reduced the occurence of invasive pneumococcal diseases. Vaccination breakthrough is typically related to underlying predisposing conditions. Herein, we reported recurrent pneumococcal meningitis in a patient with a cochlear implant who experienced a head trauma after being fully vaccinated with PCV13. The patient experienced three meningitis episodes within one year. S.pneumoniae was determined on CSF culture in the first and third episodes and detected by PCR at the second episode. Neurosurgical intervention was performed after the third meningitis episode, and the patient had no recurrence problems for the following two years. To our knowledge, breakthrough S.pneumoniae serotype 1 meningitis after full PCV13 immunization has not been reported elsewhere in the literature.

La meningitis bacteriana recurrente es un fenómeno muy poco frecuente en los niños. Las fracturas de la base del cráneo y los implantes cocleares son factores predisponentes importantes, y el agente aislado con mayor frecuencia es el Streptococcus pneumoniae. La implementación de la vacuna neumocócica conjugada de 13 serotipos (VNC13) redujo la incidencia de enfermedades neumocócicas invasivas. La incidencia de enfermedades neumocócicas intercurrentes en pacientes vacunados suele estar relacionada con afecciones predisponentes preexistentes. En este artículo, presentamos un caso de meningitis neumocócica recurrente en una paciente con un implante coclear que sufrió un traumatismo craneoencefálico luego de haber recibido la vacunación completa con la VNC13. La paciente tuvo tres episodios de meningitis en el transcurso de un año. Se detectó la presencia de S. pneumoniae en el cultivo de líquido cefalorraquídeo (LCR) en el primer y tercer episodios, y mediante la prueba de reacción en cadena de la polimerasa (PCR, por su sigla en inglés) en el segundo episodio. Se realizó una intervención neuroquirúrgica luego del tercer episodio de meningitis, y la paciente no tuvo problemas de recurrencias durante los siguientes dos años. Hasta donde sabemos, en la bibliografía no se han descrito casos de meningitis de serotipo 1 por S. pneumoniae luego de la inmunización completa con PCV13.

Increased Risk of Late-onset Streptococcus pneumoniae Meningitis in Adults With Prior Head or Spine Surgeries.

In a case-control study within the Kaiser Permanente Northern California adult population, prior head or spine surgery was associated with increased Streptococcus pneumoniae meningitis outside of the postoperative period (no prior head or spine surgery; odds ratio, 6.0 [95% confidence interval, 1.9-18.6]). Among the cases, only 33.3% had received any prior pneumococcal vaccinations.

Bacterial meningitis: a rare complication of an unrecognised nasal foreign body in a child.

We present an interesting case of a 7-year-old child who developed severe bacterial meningitis requiring admission to paediatric ICU. Initial investigations failed to identify the reason for this otherwise healthy child to develop this life-threatening condition. The child recovered fully with no long-term sequelae. Further on-going unilateral purulent rhinorrhoea lead to ENT referral. CT head from a previous admission showed mucosal thickening and fluid within paranasal sinuses. Reluctance to expose the child to further radiation meant that no formal scan of sinuses was organised and the child was diagnosed with chronic rhinosinusitis. Symptoms failed to improve despite the treatment. A subsequent CT scan of sinuses revealed a radiopaque foreign body in the nasal cavity. This is a rare presentation of a nasal foreign body causing bacterial meningitis. This case highlights the importance of comprehensive investigations to avoid delays in establishing a correct diagnosis and initiating the appropriate treatment.

Transalar transsphenoidal meningoencephalocele presenting in the form of recurrent meningitis: Report of two cases and discussion of the diagnosis and treatment.

INTRODUCTION: Skull base meningoencephaloceles are rare congenital malformations. The two cases of transalar transsphenoidal malformation reported here differ from the classical transsphenoidal meningoencephalocele. CASE REPORTS: Case 1 was a three-and-a-half-year-old boy and case 2 was a 36-year-old man. Both cases presented with clinical features of recurrent meningitis. Surgical management of case 1 was performed via an intradural infratemporal fossa craniotomy with reoperation 2years later. In the second case, surgery was initially performed via an endonasal approach and then via pterional craniotomy. Reoperation via Sekhar's transpetrosal approach was also a failure. Only closure of the trigeminal-pontine angle via a suboccipital retrosigmoid approach allowed repair of the defect. DISCUSSION: Surgical access to the pterygopalatine fossa is complex due to its anatomical position and its anatomical relations with nerves and vessels. An endoscopic approach appears to be a valuable alternative to classical craniotomy. CONCLUSION: In the two cases reported here, neurosurgery allowed lasting closure of the defect.

Autosplenectomy Causing Catastrophic Pneumococcal Meningitis in a Patient with Lupus/Antiphospholipid Antibody Syndrome.

We present the case ofa26-year-old female who presented to the hospital with pneumococcal meningitis. A review of her records showed atrophic spleen, and a hypercoagulable workup was positive for Systemic Lupus Erythematous (SLE)/Antiphospholipid Antibody Syndrome (APS). An autosplenectomy from thrombotic occlusion of the splenic artery made her susceptible to pneumococcal meningitis. Autoimmune conditions, particularly SLE and APS, are important causes of hypercoagulable states in a young population, and earlier detection of these conditions and appropriate treatment helps to decrease morbidity and mortality among these patients.

Invasive Bacterial Infection in Patients with Interleukin-1 Receptor-associated Kinase 4 Deficiency: Case Report.

Interleukin-1 receptor-associated kinase 4 (IRAK4) deficiency (OMIM #607676) is a rare primary immunodeficiency of innate immune defect. We identified 10 patients from 6 families with IRAK4 deficiency in Japan, and analyzed the clinical characteristics of this disease. Nine patients had homozygous c.123_124insA mutation, and 1 patient had c.123_124insA and another nonsense mutation (547C>T). Umbilical cord separation occurred on the 14th day after birth or thereafter. Two patients had no severe infections owing to the prophylactic antibiotic treatment. Severe invasive bacterial infections occurred before the age of 3 in the other 8 patients. Among them, 7 patients had pneumococcal meningitis. Five patients died of invasive bacterial infection during infancy, although intravenous antibiotic treatment was started within 24 hours after onset in 4 patients among them. Analysis of cerebrospinal fluid of the patients who had fatal meningitis revealed very low glucose levels with only mild pleocytosis. The clinical courses of invasive bacterial infections were often rapidly progressive despite the early, appropriate antibiotic treatment in IRAK4 deficiency patients. The early diagnosis and appropriate prophylaxis of invasive bacterial infections are necessary for the patients.

IRAK-4 deficiency as a cause for familial fatal invasive infection by Streptococcus pneumoniae.

In this Letter to the Editor we report the case of two siblings with fatal pneumococcal meningitis as the initial manifestation of IRAK-4 deficiency caused by previously undescribed mutations in IRAK4. The letter also highlights the importance of invasive pneumococcal infection as a critical 'red flag' warning of the potential for an underlying primary immunodeficiency and identifies some of the challenges in making the clinical diagnosis of IRAK-4 deficiency.

Post-operative Streptococcus pneumoniae meningoencephalitis complicating surgery for acromegaly in an identical twin.

This case report provides provocative and useful data regarding two aspects of acromegaly and its management. The patient, who is one of a pair of identical twins, has no known hereditary, genetic or otherwise potentially etiologic factors as compared to her unaffected sister. Secondly, transsphenoidal surgery, which was ultimately successful, was complicated by pneumococcal meningitis, an unusual event with only four previously reported patients, three of whom ended in death or major neurologic deficits. In this case, a 57-year-old woman gradually developed classical signs and symptoms of acromegaly while her identical twin sister remained normal with no evidence of endocrine disease. Endoscopic transsphenoidal surgery was complicated by the development of meningitis 25 days after surgery. This was controlled following a difficult hospital course. Streptococcus pneumoniae meningoencephalitis is a rare but life-threatening complication of transsphenoidal surgery. A high index of suspicion for incipient meningitis should be maintained when patients present with severe headache and increased intracranial pressure, even if they initially lack the typical symptoms and signs. Immediate and aggressive treatment is necessary to avoid significant neurologic deficit.

Unilateral common cavity deformity: Recurrent meningitis due to insufficient newborn hearing screening.

Insufficient newborn hearing screening may leave the other ear with undetected hearing loss. Subsequently, the missed pathology behind the impairment may have potential risk for severe infections. We describe a case of recurrent Streptococcus pneumoniae meningitis in an infant with unilateral common cavity deformity. The diagnosis of the deaf left ear was delayed due to insufficient newborn hearing screening and not until the second meningitis the pathology behind the deafness was confirmed. Subtotal petrosectomy was performed unsuccessfully and resulted in another meningitis. We highlight the importance of proper newborn hearing screening and surgical technique to treat cochlear malformations.