Healthy adults with Streptococcus pneumoniae meningitis and Streptococcus pneumoniae subdural abscess: two case reports and a literature review.

We present the cases of two otherwise healthy adults, one with meningitis and another with a subdural abscess, with both conditions attributable to Streptococcus pneumoniae. A 31-year-old man was admitted with a 3-day history of fever, headache, and vomiting. Physical examination revealed intermittent confusion, irritability, and neck stiffness. Cerebrospinal fluid (CSF) culture was positive for S. pneumoniae. Contrast-enhanced magnetic resonance imaging (C-MRI) revealed multiple small lesions on the bilateral frontal lobes. Intravenous ceftriaxone and vancomycin were administered, followed by intravenous moxifloxacin. His symptoms resolved within 3 months. Additionally, a 66-year-old man was admitted for acute fever with confusion, abnormal behavior, and a recent history of acute respiratory infection. Physical examination revealed confusion, neck stiffness, and a positive right Babinski sign. CSF metagenomic analysis detected S. pneumoniae. C-MRI disclosed left occipitotemporal meningoencephalitis with subdural abscesses. Intravenous ceftriaxone was administered for 3 weeks. His condition gradually improved, with resorbed lesions detected on repeat MRI. This study expanded the clinical and imaging spectra of S. pneumoniae meningitis. In healthy adults, S. pneumoniae can invade the brain, but subdural abscess is a rare neuroimaging manifestation. Early diagnosis of S. pneumoniae meningitis by high-throughput sequencing and flexible treatment strategies are necessary for satisfactory outcomes.

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.

[Autoimmune chronic meningitis secondary to pneumococcal meningitis. Report of one case]. / Meningitis crónica autoinmune secundaria a meningitis aguda por neumococo. Caso clínico.

Pneumococcal meningitis produces several inflammatory disorders in susceptible subjects. A worsening of meningitis can occur on the fourth day of evolution in relation with the withdrawal of steroids. Other complications include the development of inflammatory signs in the post-acute stage of infection associated with disseminated vasculitis of the cerebral blood vessels and, even later, an autoimmune chronic meningitis. All these inflammatory complications are well controlled with the use of steroids. We report a 53-year-old woman with pneumococcal meningitis that had a good response to treatment with antibiotics and steroids. On the four day, after the steroids were discontinued, she complained of headache, became confused, and had an abnormal cerebrospinal fluid (CSF), report CT angiography showed signs of arteritis. She improved when the steroids were re-started. She was discharged in good condition but after slow tapering of the steroids over a four-month period she had a relapse of all her symptoms and had a gait disturbance. On readmission, she had an inflammatory CSF, there were no signs of infection and the cerebral MRI showed meningeal thickening with ventricular space enlargement. She improved again with steroids and she is now well on high-dose steroids but deteriorates each time the steroids are stopped. She experienced both acute and sub-acute inflammatory responses and finally developed a chronic meningitis responsive, and is dependent on steroids.

Meningitis crónica autoinmune secundaria a meningitis aguda por neumococo: caso clínico / Autoimmune chronic meningitis secondary to pneumococcal meningitis: report of one case

Pneumococcal meningitis produces several inflammatory disorders in susceptible subjects. A worsening of meningitis can occur on the fourth day of evolution in relation with the withdrawal of steroids. Other complications include the development of inflammatory signs in the post-acute stage of infection associated with disseminated vasculitis of the cerebral blood vessels and, even later, an autoimmune chronic meningitis. All these inflammatory complications are well controlled with the use of steroids. We report a 53-year-old woman with pneumococcal meningitis that had a good response to treatment with antibiotics and steroids. On the four day, after the steroids were discontinued, she complained of headache, became confused, and had an abnormal cerebrospinal fluid (CSF), report CT angiography showed signs of arteritis. She improved when the steroids were re-started. She was discharged in good condition but after slow tapering of the steroids over a four-month period she had a relapse of all her symptoms and had a gait disturbance. On readmission, she had an inflammatory CSF, there were no signs of infection and the cerebral MRI showed meningeal thickening with ventricular space enlargement. She improved again with steroids and she is now well on high-dose steroids but deteriorates each time the steroids are stopped. She experienced both acute and sub-acute inflammatory responses and finally developed a chronic meningitis responsive, and is dependent on steroids.

The attitudes, behaviors, and knowledge of healthcare professionals towards the diagnosis, treatment, and prevention of bacterial meningitis in Turkey.

INTRODUCTION: Bacterial meningitis is one of the leading causes of morbidity and mortality among children and adults. Better understanding of the seroepidemiology of meningitis is critical for both the selection and implementation of an effective meningitis vaccine for the national immunization program. Because physicians play a crucial role in the implementation of this vaccine, the aim of this study was to evaluate the attitudes, behaviors, and knowledge of healthcare professionals in Turkey regarding the diagnosis, treatment and prevention of bacterial meningitis, especially pneumococcal and meningococcal meningitis. METHODS: This study used a cross-sectional electronic survey with a national convenience sample of 339 physicians (171 pediatric age specialists [PAS] and 168 adult patient specialists [APS]) in Turkey. A web-based questionnaire which consisted 28 questions about the definition, diagnosis, and treatment of bacterial as well as knowledge and/or attitudes about meningococcal vaccines, was designed. RESULTS: Approximately 72.9% (n = 247) of the respondents followed a patient with meningitis in the last year. A 49.5% of participants preferred to perform computerized cranial tomography (CCT) for suspected meningitis cases before lumbar puncture (LP) at 75-100% frequency (27.5% PAS; 72% APS, p < .01). In addition 27.1% of the respondents reported using a routine steroid as an adjunctive treatment (19% PAS; 35% APS, p < .01). For meningococcal meningitis, 72.5% of the participants preferred to use third-generation cephalosporins (63.1% PAS; 82.1% APS, p < .05). For pneumococcal meningitis, approximately 50% of the participants preferred to use a third-generation cephalosporin plus glycopeptide (41.5% PAS; 58.9% APS, p < .05). While 32.7% of the sample preferred to administer a 7-day course of antibiotics for meningococcal meningitis, 40.9% preferred a course of 14 days or more. For pneumococcal meningitis, 88.4% of the sample preferred a 10-14 day course of antibiotics. In addition, 67% of the PAS group and 50% (p < .001) of the APS group thought that a conjugated meningococcal vaccine should be a part of the National Immunization Program. The top five groups recommended for routine immunization included all children, asplenia/splenectomy patients, immunodeficient patients, those who planned to travel to endemic areas, including Hajj, and military personnel. CONCLUSION: In this large convenient sample of physicians in Turkey, we showed that there are heterogenous approaches to the diagnosis and treatment of bacterial meningitis, also differences between pediatricians and non-pediatricians regarding their beliefs and attitudes, which may be due to differences in the epidemiology and clinical presentation between children and adults. We observed appropriate but unnecessary extended courses of antibiotics for meningitis. Most of the participants thought that children are a vulnerable risk group that should potentially be immunized and that meningococcal vaccines should be included in the National Immunization Program. Our results imply that more awareness is needed regarding diagnosis, treatment, and further recommendations for meningitis at the country level in Turkey.

Transcranial Doppler in pediatric emergency and intensive care unit: a case series and literature review.

PURPOSE: Transcranial Doppler (TCD) has been used for more than 30 years in clinical practice. Although adult intensive care is relatively well covered, pediatric cases are still underrepresented. We intend to review a series of pediatric cases where TCD was determinant in clinical decisions and a literature review on this topic. METHODS: We describe cases with different pathologies where TCD had an important role in clinical management of the patients. We discuss TCD utility and potential role both in the emergency department and the intensive care unit. RESULTS: Five patients with different neurologic insults are presented. TCD was useful in the identification of intracranial hypertension in traumatic brain injury, hydrocephalus and central nervous system infection; identification of decreased cerebral perfusion pressure in hypovolemic shock and the diagnosis of impending cerebral circulatory arrest in a child with meningococcal septicemia. We discuss how TCD can be used in emergency and intensive care settings, reviewing relevant literature and our own experience. CONCLUSIONS: Non-invasive testing using TCD can aid clinical decisions. More widespread use of this technique will allow for better care of children with neurologic insults.

Cystic Encephalomalacia following Vasculopathy and Vasospasm of Proximal Intracranial Arteries Due to Pneumococcal Meningitis in a Infant.

Despite the availability of modern antibiotics, pneumococcal meningitis in both children and adults remains a severe disease-one known to frequently cause grave complications and residual disability. Although the appearance of arterial vasospasms in bacterial meningitis systematically has been investigated and reported on for adult patients, such research is lacking when it comes to infants. We report on a 4-week-old infant who, 6 days after onset of pneumococcal meningitis, suffered severe neurological deterioration with treatment-resistant seizures and coma. Generalized cortical and subcortical edema developed in conjunction with diminished cerebral blood flow, as depicted in magnetic resonance angiography and serial Doppler-sonographic examinations. The ischemia resulted in extensive cystic encephalomalacia. We propose that the degree of variation in cerebral blood flow in the acute phase was the result of an extensive arterial vasculopathy involving vasospasms. Awareness of this complication and prospective serial Doppler-sonographic examinations may improve our understanding of the connection between brain edema and vasculopathy. At present, however, no effective treatment appears available.

Permanent Central Diabetes Insipidus as a Complication of S. pneumoniae Meningitis in the Pediatric Population.

Diabetes insipidus is a rare but recognized complication of meningitis. The occurrence of diabetes insidipus has been previously attributed to Streptococcus pneumoniae (S. pneumoniae) in a handful of patients and only once within the pediatric subpopulation. We present the clinical course of a previously healthy 2-year, 8-month-old male child ultimately diagnosed with central diabetes insipidus (CDI) secondary to S. pneumoniae meningitis. Permanent CDI following S. pneumoniae meningitis is unique to our case and has not been previously described. Following the case presentation, we describe the etiology, pathophysiology, diagnosis, and treatment of CDI. The mechanism proposed for this clinical outcome is cerebral herniation for a sufficient duration and subsequent ischemia leading to the development of permanent CDI. Providers should be aware of CDI resulting from S. pneumoniae meningitis as prompt diagnosis and management may decrease the risk of permanent hypothalamo-pituitary axis damage.

Late onset invasive pneumococcal disease in a liver transplanted patient: beyond the Austrian syndrome.

Invasive disease caused by Streptococcus pneumoniae is a major cause of morbidity and mortality in high-risk individuals with severe comorbidities, including asplenia, chronic alcoholism, and altered immune status. The risk of invasive pneumococcal disease has been significantly higher in transplant patients compared with the general population. Here, we report an unusual case of a disseminated pneumococcal infection with meningitis, endocarditis, spondylodiscitis, and muscle abscess in an asplenic patient on chronic immunosuppressive therapy for liver transplantation performed 17 years before.

[Meningitis can resemble subarachnoid haemorrhage]. / Meningitis kan ligne subaraknoidal blødning.

A 70 year-old man was admitted under the diagnosis of subarachnoid haemorrhage and presented with a history of ear pain, followed by acute onset of severe headache, nausea, vomiting, impaired consciousness, and fever. However, a computed tomography (CT) showed an acute mastoiditis and pneumocephalus, and a lumbar puncture confirmed the diagnosis meningitis. The increased middle ear pressure relative to the intracranial pressure had caused air and bacteria to penetrate intracerebrally. This case illustrates the importance of a rapid diagnostic workup in acute onset headache including a careful anamnesis, CT and lumbar puncture.

Cervicomedullary injury after pneumococcal meningitis with brain edema.

OBJECTIVES: To demonstrate a rare but potential mechanism of quadriplegia in a patient with fulminant pneumococcal meningitis complicated by severe intracranial hypertension. DESIGN: Case report. SETTING: Intensive care unit. PATIENT: A 21-year-old man who presented with 3 days of headache, combativeness, and fever. INTERVENTION: Antibiotics and steroids were initiated after lumbar puncture yielded purulent cerebrospinal fluid and streptococcus pneumoniae. RESULTS: The patient's course was complicated by severe cerebral edema necessitating intracranial pressure monitoring and intracranial pressure-targeted therapy. Within 5 days he developed quadriplegia and areflexia. Brain and cervical spine magnetic resonance imaging revealed patchy areas of T2 signal hyperintensity with associated gadolinium enhancement in the superior cervical spinal cord, cerebellar tonsils, and medulla. CONCLUSIONS: Quadriplegia secondary to tonsillar herniation in fulminant meningitis is rare but should be considered in patients with acute quadriparesis after treatment of increased intracranial pressure. Magnetic resonance imaging signal changes and gadolinium enhancement may be demonstrated. Significant improvement of cord symptoms can be expected.

Preoperative and postoperative intracranial complications of acute mastoiditis.

OBJECTIVES: We determined the clinical characteristics and treatment outcomes of an unusual cluster of intracranial complications seen in acute mastoiditis (AM). METHODS: We performed a retrospective review of pediatric patients treated for AM in a tertiary care hospital from March 2006 to March 2007. RESULTS: Eleven children, 6 months to 10 years of age (mean age, 3.8 years), were treated for AM confirmed by computed tomography, which identified asymptomatic intracranial complications in 8 of the 11 patients: these were sigmoid sinus thrombosis (4 patients), epidural abscess (4), perisigmoid abscess or bony erosion (2), and tegmen mastoideum dehiscence (1). All patients required operative intervention with tympanomastoidectomy, although only 2 patients required neurosurgical intervention, consisting of evacuation of epidural abscess and sigmoid sinus thrombosis, respectively. Cultures yielded routine organisms and 1 multidrug-resistant strain of Streptococcus pneumoniae. One patient developed reaccumulation of the subperiosteal abscess that required revision mastoidectomy, and another patient developed postoperative sigmoid sinus thrombosis. CONCLUSIONS: Although uncommon, intracranial complications of AM may present without clinical signs or symptoms. Computed tomography of the temporal bone with contrast is essential for identifying asymptomatic complications. Mastoidectomy remains the mainstay of surgical treatment. Neurosurgical intervention and anticoagulation may be avoided with protracted postoperative intravenous antibiotics. Postoperative vigilance is crucial, as complications may evolve despite aggressive therapy.

Twelve episodes of meningitis in the same patient!

Recurrent bacterial meningitis is potentially life-threatening; resultant complications and adverse events during management take their extra toll on the patient. A rare case with 12 consecutive episodes of pyogenic meningitis, probably the maximum number ever reported in the literature, has been presented. A minor head injury but with no subsequent cerebrospinal fluid (SCF) leak during childhood was the index event in this patient. High resolution computerized tomography (HRCT) scan of the base of the skull clearly revealed a bony dehiscence missed on numerous previous imagings. Culprit micro organisms involved in recurrence were Streptococcus pneumoniae and Neisseriae meningitides. Though surgical repair would have been definitive treatment, medical management with pneumococcal and meningococcal vaccination and prophylactic penicillin have been used in this patient to prevent further recurrences.