A nine-day-old girl with fever. / En ni dager gammel jente med feber.

Nowadays severe illness in neonates is fortunately rare in Norway. However, newborns present with non-specific symptoms, making diagnostics in this age group challenging, and neonatologists need to think broadly in order not to overlook serious illness. We present the case of a nine-day-old who was severely ill when she arrived at hospital. She was born in gestational week 37 after a normal pregnancy. The birth was complicated by shoulder dystocia, rupture of the umbilical cord and fracture of the clavicle. Thereafter she had a normal stay in the maternity ward for three days. At home she appeared healthy and gained weight until she returned to hospital after thirteen hours of poor feeding, irritability and fever. The symptoms turned out to be caused by bacterial meningitis. During the first week of hospitalisation she developed ventriculitis, brain abscesses and sinus vein thrombosis. It was later discovered that she had severely impaired hearing, and thereafter she developed hydrocephalus requiring surgical drainage. The mortality from neonatal bacterial meningitis has dropped from almost 50 % in the 1970s to less than 10 % today, but the morbidity has remained unchanged. It is crucial that clinicians are alert to this diagnosis, as delayed treatment can worsen the prognosis.

Mesenchymal stem cells transplantation attenuates brain injury and enhances bacterial clearance in Escherichia coli meningitis in newborn rats.

OBJECTIVE: Neonatal meningitis caused by Escherichia coli results in significant mortality and neurological disabilities, with few effective treatments. Recently, we demonstrated that human umbilical cord blood-derived mesenchymal stem cell (hUCB-MSC) transplantation attenuated E. coli-induced severe pneumonia, primarily by reducing inflammation and enhancing bacterial clearance. This study aimed to determine whether intraventricular transplantation of hUCB-MSCs attenuated the brain injury in E. coli meningitis in newborn rats. METHODS: Meningitis without concomitant bacteremia was induced by intraventricular injection of 5 × 102 colony forming units of K1 (-) E. coli in rats at postnatal day (P)11, and hUCB-MSCs (1 × 105) were transplanted intraventricularly 6 h after induction of meningitis. Antibiotics was started 24 h after modeling. RESULT: Meningitis modeling induced robust proliferation of E. coli in the cerebrospinal fluid and increased mortality in rat pups, and MSC transplantation significantly reduced this bacterial growth and the mortality rate. Impaired sensorimotor function in the meningitis rats was ameliorated by MSCs injection. MSCs transplantation also attenuated meningitis caused brain injury including cerebral ventricular dilatation, brain cell death, reactive gliosis, and inflammatory response. CONCLUSION: Intraventricular transplantation of hUCB-MSCs significantly improved survival and attenuated the brain injury via anti-inflammatory and antibacterial effects in experimental neonatal E. coli meningitis.

Full Neurological Recovery From Escherichia coli Meningitis Associated With Near-Death Experience.

A 54-year-old otherwise healthy man presented with altered mental status. On admission, the patient was confused and agitated, with a Glasgow Coma Scale (GCS) score of 11, suggesting moderate brain injury. He was sedated, placed on a ventilator, and started on tobramycin and ceftazidime for presumed bacterial meningitis, but switched to ceftriaxone once cultures returned as Escherichia coli. During his 8-day hospitalization, his mental status fluctuated from confused to nonresponsive, with GCS scores between 6 and 11. Although E. coli meningitis has a high rate of neurological complications and death, this patient recovered completely without any deficits, and recalled an elaborate near-death experience that occurred during his coma. This case highlights the importance of studying near-death experiences occurring during compromised brain function to further our understanding of the brain and consciousness.

Bacteroides fragilis concealed in an infant with Escherichia coli meningitis.

Anaerobic meningitis in infants is rare, therefore a high index of clinical suspicion is essential as routine methods for processing cerebrospinal fluid (CSF) do not detect anaerobes and specific antimicrobial therapy is required. We present an infant with Escherichia coli meningitis where treatment-resistance developed in association with culture negative purulent CSF. These features should have alerted us to the presence of anaerobes, prompting a search for the causes of polymicrobial meningitis in infants.

Escherichia coli Meningitis in a 72-year-old Woman.

Spontaneous community-acquired meningitis caused by E. coli is rare in the adult population. It is associated with a high risk of morbidity and mortality. We describe a case of a 72-year-old woman who presented with altered mental status and neck stiffness and was found to have E. coli meningitis. Urine cultures grew E. coli, representing a likely source. The E. coli strain was identified as sequence type 73 (E. coli ST73). Her symptoms and laboratory values improved following antibiotic initiation, and she was discharged from the hospital to a rehabilitation facility.

Clinical Features and a Prediction Nomogram for Prognosis in Children with Escherichia coli Meningitis.

BACKGROUND: We aimed to build a prediction nomogram for early prediction of poor prognosis in children with Escherichia coli meningitis and analyzed the course of treatment and discharge criteria. METHODS: Eighty-seven pediatric patients with E coli meningitis were retrospectively recruited from the Children's Hospital of Chongqing Medical University between June 2012 and November 2021. Univariate analysis and binary logistic analysis were used to evaluate the risk factors, and the prediction model was built. RESULTS: E coli meningitis is more common in children <3 months old in our study (86.2%). Common complications were subdural effusion (39.1%), followed by hydrocephalus (13.8%) and repeated convulsions (12.6%). The mortality rate and sequelae rate of E coli meningitis in children was ∼10.9% and ∼6.3%, respectively. Univariate analysis showed that 13 clinical indicators were associated with poor prognosis of E coli meningitis in children. In binary logistic analysis, risk factors were seizures (P = .032) and the last cerebrospinal fluid glucose content before discharge (P = .002). A graphical nomogram was designed. The area under the receiver operating characteristic curve was 0.913. The Hosmer-Lemeshow test showed that the model was a good fit (P = .648). Internal validation proved the reliability of the prediction nomogram. CONCLUSIONS: E coli meningitis is more common in children <3 months old in our study. The rate of complications and sequelae are high. The prediction nomogram could be used to assess the risk of poor prognosis in children with E coli meningitis by clinicians.

First initial community-acquired meningitis due to extended-spectrum beta-lactamase producing Escherichia coli complicated with multiple aortic mycotic aneurysms.

We report the first case of extended-spectrum beta-lactamase producing E. coli community-acquired meningitis complicated with multiple aortic mycotic aneurysms. Because of the acute aneurysm expansion with possible impending rupture on 2 abdominal CT scan, the patient underwent prompt vascular surgery and broad spectrum antibiotic therapy but he died of a hemorrhagic shock. Extended-spectrum beta-lactamase producing E. coli was identified from both blood and cerebrospinal fluid culture before vascular treatment. The present case report does not however change the guidelines of Gram negative bacteria meningitis in adults.

Superior effect of hypertonic saline over mannitol to attenuate cerebral edema in a rabbit bacterial meningitis model.

OBJECTIVE: Adjunctive therapies that reduce the cerebral edema in bacterial meningitis include osmotic agents. There is a lack of information comparing mannitol vs. hypertonic saline as an osmotic agent for adjunctive therapy of bacterial meningitis. We attempted to elucidate the impact of hypertonic saline in cerebral edema in the setting of bacterial meningitis as well as to explore potential mechanisms of action. DESIGN: Randomized controlled in vivo study. SETTING: University research laboratory. SUBJECTS: Rabbits. INTERVENTIONS: A rabbit model of bacterial meningitis was used comparing 3% hypertonic saline with 20% mannitol as adjunctive therapy. MEASUREMENTS AND MAIN RESULTS: Adjunctive 3% hypertonic saline treatment persistently elevated mean arterial pressure as compared with the model or ampicillin group (p < .01). Although both 20% mannitol and 3% hypertonic saline efficiently elevated serum osmolality for almost 5 hrs (p < .01), 20% mannitol lowered intracranial pressure for only a short time (<2 hrs) and did not elevate cerebral perfusion pressure. Three percent hypertonic saline treatment efficiently lowered intracranial pressure and elevated cerebral perfusion pressure for almost 5 hrs (p < .01). Furthermore, 3% hypertonic saline treatment efficiently elevated serum Na+ concentration for >5 hrs (p < .01). Three percent hypertonic saline treatment was superior to 20% mannitol in lowering leukocyte number and protein content in cerebrospinal fluid (p < .01). Three percent hypertonic saline treatment reduced water content and Evans blue incorporation in the brain (p < .01). Three percent hypertonic saline treatment inhibited aquaporin 4 expression (p < .01) and attenuated pathologic brain damage more efficiently compared with adjuvant 20% mannitol treatment (p < .01). CONCLUSIONS: Adjunctive 3% hypertonic saline treatment significantly elevated mean arterial pressure, reduced intracranial pressure, greatly improved cerebral perfusion pressure, inhibited brain aquaporin 4 expression, reduced cerebral edema, and attenuated brain damage with a superior effect over 20% mannitol in a rabbit bacterial meningitis model.

Septicemia, meningitis, and skull osteomyelitis complicating infected cephalhematoma caused by ESBL-producing Escherichia coli.

An infected cephalhematoma is a rare condition in neonates. We report a case of an 18-day-old neonate who was diagnosed with an infected cephalhematoma caused by an extended spectrum beta-lactamase (ESBL)-producing Escherichia coli complicated with septicemia, meningitis, and skull osteomyelitis. He was successfully treated with meropenem and surgical incision and drainage. ESBL-producing E. coli may cause infection of a cephalhematoma in neonates.

Bacterial meningitis and COVID-19: a complex patient journey.

A woman in her 70s presented to the emergency department with fever, fluctuating cognition and headache. A detailed examination revealed neurological weakness to the lower limbs with atonia and areflexia, leading to a diagnosis of bacterial meningitis, alongside a concurrent COVID-19 infection. The patient required critical care escalation for respiratory support. After stepdown to a rehabilitation ward, she had difficulties communicating due to new aphonia, hearing loss and left third nerve palsy. The team used written communication with the patient, and with this the patient was able to signal neurological deterioration. Another neurological examination noted a different pattern of weakness to the lower limbs, along with new urinary retention, and spinal arachnoiditis was identified. After more than 10 weeks in the hospital, the patient was discharged. Throughout this case, there were multiple handovers between teams and specialties, all of which were underpinned by good communication and examination to achieve the best care.

Combination therapy with ciprofloxacin and third-generation cephalosporin versus third-generation cephalosporin monotherapy in Escherichia coli meningitis in infants: a multicentre propensity score-matched observational study.

OBJECTIVES: Escherichiacoli is the second cause of bacterial meningitis in neonates. Despite the use for 35 years of third-generation cephalosporins (3GCs), high morbidity and mortality rates with E. coli meningitis continue to occur. Because ciprofloxacin has good microbiologic activity against E. coli and good penetration in cerebrospinal fluid and brain, some authors have suggested adding ciprofloxacin to a 3GC regimen. The objective of this study was to assess combining 3GCs with ciprofloxacin versus 3GCs alone in a cohort of infants with E. coli meningitis. METHODS: We included all cases of E. coli meningitis diagnosed in infants <12 months of age that were prospectively collected through the French paediatric meningitis surveillance network between 2001 and 2016. The main outcome was the proportion of short-term neurologic complications with versus without ciprofloxacin. The analysis was conducted retrospectively by multivariable regression and propensity score (PS) analysis. RESULTS: Among the 367 infants enrolled, 201 (54.8%) of 367 had ciprofloxacin and 3GC cotreatment and 166 (45.2%) of 367 only a 3GC. Median age and weight were 15 days (range, 1-318 days) and 3.42 kg (range, 0.66-9.4 kg). A total of 86 (23.4%) of 367 infants presented neurologic complications (seizures, strokes, empyema, abscesses, hydrocephalus, arachnoiditis); 57 received ciprofloxacin cotreatment. Complications were associated with ciprofloxacin cotreatment on multivariable analysis (odds ratio (OR) = 1.9; 95% confidence interval (CI), 1.1-3.4) and PS analysis (OR = 1.9; 95% CI, 1.1-3.3). Mortality rate did not differ with and without ciprofloxacin: 22 (10.9%) of 201 versus 16 (9.6%) of 166 deaths (OR = 0.7; 95% CI, 0.3-1.6; PS analysis). CONCLUSIONS: Ciprofloxacin added to 3GCs at least offers no advantage for neurologic outcome and mortality in infants with E. coli meningitis.

Spinal Intradural Escherichia coli Abscess Masquerading as a Neoplasm in a Pediatric Patient with History of Neonatal E. coli Meningitis: A Case Report and Literature Review.

BACKGROUND: Central nervous system abscesses frequently can be seen in the immunocompromised population and most commonly consist of intracranial collections in the adult patient. Spinal intradural abscesses are less commonly encountered, and there are even fewer numbers in the pediatric population with a concordant absence of documentation in the published literature. CASE DESCRIPTION: In this case report, we describe the presentation of a 2-year-old boy with a history of perinatal Escherichia coli meningitis at 2.5 months of age who was found to have an intradural spinal lesion, initially concerning for neoplasm, but later confirmed as an E. coli abscess following biopsy. He was managed with surgical aspiration of the abscess and a long course of intravenous antibiotics. The patient was treated with antibiotics with repeat imaging studies that revealed residual abscess that required re-aspiration at a later date. CONCLUSIONS: Here we present an unusual disease process with an unusual disease pathogenesis in a pediatric patient currently residing in a developed country.

[Clinical outcome and bacterial characteristics of 99 Escherichia coli meningitis in young infants]. / Méningite à Escherichia coli de l'enfant : analyse descriptive clinique et microbiologique de 99 cas.

OBJECTIVE: To conduct a descriptive analysis of clinical, biological and prognostic aspects of Escherichia coli meningitis in young infants. METHODS: Clinical and biological data on young infants diagnosed with neonatal E. coli meningitis (NECM) between 1988 and 2004 were collected retrospectively and analyzed with respect to the isolates'phenotypic and genotypic characteristics. The molecular analyses focused on the phylogenetic group, the sequence-O-type, and genetic virulence traits. The virulence of lethal strains was tested in a newborn rat meningitis model. RESULTS: The median age of the 99 children analyzed was 10 days (0 to 90 days), and 83 of the patients were newborns. Thirty-three children were premature. Hyper- or hypothermia was the most frequent clinical sign at admission. Intercurrent urinary tract infection was present in 28% of cases, all over 6 days of age. 81% of blood cultures were positive. The CSF cytology was abnormal in 97% of cases. Twelve hours after admission, 34% of infants were transferred to intensive care. One-third of transfontanellar ultrasound scans done on admission were abnormal. CSH sterilization was slow in 15 % of cases, despite appropriate antibiotic therapy. The use of ciprofloxacin was associated with more rapid CSF sterilization (94 % vs 77 %, p=0.03). Six children relapsed. The average follow-up was eight months, and 21 % of children had sequelae. The case lethality rate was 14%. Fatal outcome was associated with signs of septic shock (57% vs 3%, p<10(-4)) and neurological failure (76% vs 19%, p<10(-4)) within the first 24 hours, and with abnormalities on the first ultrasound scan (63% vs 27%, p=0.03). The risk of death was higher among children infected by strains belonging to unusual sequence-O-types (50% vs 18%, p=0.01), which harbored fewer virulence factors (4.8 vs 5.9, p<10(-4)). Only aerobactin was less frequent in lethal strains (71 % vs 94%, p=0.02). Strains belonging to unusual sequence-O-types and that were lethal in the animal model induced a significantly lower level of bacteremia than strains belonging to frequent sequence-O-types (p<0.001). CONCLUSION: E. coli meningitis remains highly lethal in infants. Clinical and molecular analyses showed a link between lethality and infrequent sequence-O-types. The avirulence of these strains in animal models suggests that fatal outcome could be due to host susceptibility more than to strain virulence.

Severe progressive late onset myelopathy and arachnoiditis following neonatal meningitis.

This case series describes four children who had meningitis in the neonatal period. After a stable period of years, they developed a myelopathy caused by chronic arachnoiditis. The myelopathy was precipitated by a fall in two cases, and in two cases there was an acute deterioration after surgery. A history of neonatal meningitis should be taken into consideration before planning surgery or anaesthesia. Careful intra-operative positioning, immobilisation of the neck, and maintenance of blood pressure is important but may not prevent this complication.

Spontaneous Escherichia coli meningitis associated with hemophagocytic lymphohistiocytosis.

Spontaneous Escherichia coli meningitis has not been previously reported in association with hemophagocytic lymphohistiocytosis (HLH). A previously healthy 72-year-old woman was admitted due to fever, nuchal rigidity, disturbed consciousness and splenomegaly. Anemia, thrombocytopenia and hyperferritinemia developed on the 8th day of hospitalization. Cultures of cerebrospinal fluid and blood grew E. coli. Abundant macrophages overwhelmed erythrocytes in the bone marrow aspirate, confirming the presence of hemophagocytosis. E. coli meningitis was managed with a 40-day course of antibiotic treatment. However, the severity of anemia and thrombocytopenia progressed despite intensive transfusion therapy. The patient died of HLH on the 60th day of hospitalization.

Cerebral white matter injury in the newborn following Escherichia coli meningitis.

MR findings from six newborns with Escherichia coli (E. coli) meningitis are reported. Five of the six infants were infected with the K1 strain. All the infants displayed significant white matter injury on MR imaging. E. coli remains a serious cause of meningitis and MR imaging in this case series provides additional important information highlighting the vulnerability of the cerebral white matter in this condition in the newborn infant.

Neonatal meningitis associated with osteomyelitis and epidural empyema.

Neonatal meningitis is a serious disease with significant mortality and morbidity. Its signs and symptoms are subtle, non-specific, atypical or absent. Cephalohaematoma is frequent in newborns and complications are uncommon, including local infection after haematogenous spread in the setting of bacteraemia or meningitis with a possibility of osteomyelitis, epidural abscess and subdural empyema. We report the case of a late preterm newborn, with an unremarkable pregnancy, born by vacuum-assisted vaginal delivery that presented in the fifth day of life with irritability, fever and grunting. Cerebrospinal fluid and blood cultures were positive for Escherichia coli. The patient had neurological deterioration despite adequate antibiotic therapy and brain MRI showed a right parietal epidural empyema, subcutaneous abscess, osteomyelitis and supratentorial hydrocephalus. The culture of the cephalohaematoma's abscess material was positive for E coli. Antibiotic therapy was continued for 8 weeks. The child, now 2 years old, has spastic tetraparesis with global development delay.