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.

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.

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.

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.

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.

Meningitis and a safe dexamethasone-eluting intracochlear electrode array.

OBJECTIVES: To evaluate the potential risk of pneumococcal meningitis associated with the use of a dexamethasone-eluting intracochlear electrode array as compared with a control array. METHODS: In two phases, adult Hooded-Wistar rats were implanted via the middle ear with an intracochlear array and were inoculated with Streptococcus pneumoniae 5 days post-surgery. Phase I created a dosing curve by implanting five groups (n = 6) with a control array, then inoculating 5 days later with different numbers of S. pneumoniae: 0 CFU, 10(3) CFU, 10(4) CFU, 10(4) CFU repeated, or 10(5) CFU (colony forming units). A target infection rate of 20% was aimed for and 10(4) CFU was the closest to this target with 33% infection rate. In phase II, we implanted two groups (n = 10), one with a dexamethasone-eluting array, the other a control array, and both groups were inoculated with 10(4) CFU of S. pneumoniae 5 days post-surgery. RESULTS: The dexamethasone-eluting array group had a 40% infection rate; the control array group had a 60% infection rate. This difference was not statistically significant with a P value of ≥0.5. CONCLUSION: The use of a dexamethasone-eluting intracochlear electrode array did not increase the risk of meningitis in rats when inoculated with S. pneumoniae via the middle ear 5 days following implantation.

Brain parenchymal TNF-α and IL-1ß induction in experimental pneumococcal meningitis.

Triggers of brain inflammation in pneumococcal meningitis are unknown. TNF-α and IL-1ß were upregulated (real time PCR and in situ hybridization) in neurons and astrocytes time-dependently and maximally in the hippocampus during murine pneumococcal meningitis. Upregulation of TNF-α and IL-1ß mRNA in the brain parenchyma was independent of cerebrospinal fluid leukocytosis, pneumococcal pneumolysin and H2O2, but it was potently induced by pneumococcal cell wall (PCW) fragments. Brain TNF-α mRNA was downregulated by a matrix metalloproteinases inhibitor. PCW fragments were located in the brain parenchyma. In conclusion, PCW fragments and matrix metalloproteinases trigger cytokine induction in the brain parenchyma during pneumococcal meningitis.

Vaccination recommendations and risk of meningitis following cochlear implantation.

PURPOSE OF REVIEW: The Centers for Disease Control and Prevention has established vaccination guidelines for cochlear implant recipients to address the concern for implant-associated bacterial meningitis. Since their inception in 2002, these guidelines have undergone several revisions. We review the rationale and development of the current vaccination schedule. RECENT FINDINGS: Bacterial meningitis is a rare yet potentially life-threatening complication of cochlear implantation. The recommendations for pneumococcal vaccination have evolved to a state in which nearly all cochlear implant patients receive a combination of both the PCV7 or PCV13 and PPSV23. SUMMARY: Streptococcus pneumoniae vaccinations have dramatically decreased the incidence of serotype-specific invasive pneumococcal disease across all age groups. However, the optimal timing of immunization remains unclear in cochlear implant candidates.

An 11-year-old girl with recurrent bacterial meningitis due to liquorrhea caused by bone malformation of the skull base.

The patient is a healthy 11-year-old girl with no history of trauma or hearing impairment. She developed pneumococcal meningitis three times, at ages 7, 10, and 11. Intracranial examination revealed, pore expansion and cerebrospinal fluid leakage in the right internal acoustic foramen, which were attributed to a bone malformation of the base of the skull. A procedure was performed to close the cerebrospinal fluid leakage; no relapse has been observed thus far. Previous case reports indicate that repetitive bacterial meningitis is often caused by internal ear malformation, trauma, tumors, or surgical operation. This case suggests the possibility that underlying disorders may not be apparent in cases of repetitive bacterial meningitis and, more proactive investigations are required to prevent further recurrence of meningitis.

[A case report of Streptococcus pneumoniae-induced hemolytic uremic syndrome: appropriate transfusional management by T-antigen determination]. / Un cas de syndrome hémolytique et urémique à Streptococcus pneumoniae : prise en charge transfusionnelle adaptée par la recherche de l'antigène T.

Pediatric hemolytic uremic syndrome (HUS) is a rare complication of infections usually caused by Escherichia coli; Streptococcus pneumoniae may be a causative agent in 5% of cases and is often more serious in terms of morbidity and mortality. We report a case of pediatric HUS following an infection by a serotype of S. pneumoniae not included in the vaccine administered to the child. Bacterial neuraminidase revealed a T-antigen and a Tk-antigen and red blood cells polyagglutinability in the laboratory test. Transfusion has been reoriented by an indication of secondary preparations: deplasmatisation of red blood cells and platelets and abstention of therapeutic plasma administration. HUS evolved favorably in a few days but the child retains consequences of meningitis cerebral anoxia.

Cerebrospinal fluid otorrhea and recurrent bacterial meningitis in a pediatric case with Mondini dysplasia.

Mondini dysplasia is a congenital malformation of the inner ear, which is characterized by a short and large cochlear canal of 1.5 turn rather than 2.5 turns and an apical region with cystic dilatation. Patients present with congenital deafness, when both cochlea are affected. Unilateral disease may cause recurrent meningitis, otorrhea or rhinorrhea. In this article, we report a three-year-old pediatric case with a history of meningitis and cerebrospinal fluid otorrhea following tympanostomy tube placement for serous otitis media.

Bacterial meningitis secondary to stapes footplate malformation in a child with an auditory brainstem implant.

OBJECTIVE: We report a rare presentation of otogenic bacterial meningitis secondary to a stapes footplate malformation in a paediatric patient with an auditory brainstem implant. CASE REPORT: A patient with Mondini's dysplasia developed meningitis six years after auditory brainstem implantation. The aetiology was believed to be otogenic, secondary to stapes footplate malformation. CONCLUSION: To our best knowledge, this is the first report of otogenic bacterial meningitis secondary to stapes footplate malformation in a paediatric patient with an auditory brainstem implant. Subjects with inner ear malformations, especially Mondini's dysplasia, need to be carefully evaluated pre-operatively to reduce or eliminate any anatomical conditions which may predispose to meningitis. In children with an auditory brainstem implant and suspected ear malformation, we recommend pre-operative radiological investigation to look for the 'bulging oval window' sign. When radiological signs are positive, bilateral exploratory tympanotomy should be performed to detect any undiagnosed anatomical stapes footplate defects, which may predispose to bacterial meningitis.

Pneumocephalus and pneumococcal meningitis after thoracic surgery.

A 62-year-old man with adenocarcinoma underwent complete resection with a right upper lobectomy and en-bloc resection of the chest wall, with metallic clips applied to the vertebral nerve roots. A sudden deterioration in neurological status occurred due to pneumocephalus and ascending bacterial meningitis resulting from a subarachnoid-pleural fistula. The neurological status normalized after thoracoplasty and ceftriaxone treatment.

[Post-traumatic meningitis in children: eleven years' analysis]. / Meningite bacteriana pós-traumática em idade pediátrica: análise de onze anos.

INTRODUCTION: Traumatic brain injury is a frequent reason for admission at pediatric emergency services. In severe cases, with basilar skull fracture, bacterial meningitis is a serious and potentially fatal complication to be considered. OBJECTIVE: To describe clinical and laboratory features, bacteriology and outcome of children with post-traumatic meningitis, and evaluate the proportion of meningitis in the population who suffered head trauma. METHODS AND MATERIALS: Retrospective review of medical records of children with this diagnosis admitted to a level 3 pediatric hospitals in the Central Region of Portugal, contextualized in the evaluation of the number of head injuries, fractures and cerebrospinal fluid leakages, during a 11-year period (January 1999 to December 2009). RESULTS: Four children were identified, corresponding to 0,7% of the children with skull fractures, 4,1% of children with basilar skull fractures and 13,8% of those with documented cerebrospinal fluid leakage. Three were boys, with a median age of 8 years (2-10 years). The median time between head trauma and meningitis was 1,1 years (3 days-3,4 years). In all cases a basilar skull fracture was identified and cerebrospinal fluid leakage documented. Two children required surgery. Streptococcus pneumonia was the pathogen identified in two cases with positive cerebrospinal fluid culture. One child died and other has post-traumatic peripheral facial palsy. CONCLUSIONS: Bacterial meningitis is a complication to be considered in head injury with basilar skull fracture, particularly when associated with cerebrospinal fluid leakage, even though the injury occurred several years earlier, and is usually a serious condition. One of our children died. Similar to what is described, S. pneumoniae was the most common bacteria, and this fact supports that children with head trauma and cerebrospinal fluid leakage should receive pneumococcal vaccine. The follow-up of these children requires constant vigilance and should include a multidisciplinary approach.

Recurrent meningitis associated with frontal sinus tuber encephalocele in a patient with tuberous sclerosis.

Tuberous sclerosis complex (TSC) is a genetic neurocutaneous disorder that commonly affects the CNS. The most commonly associated brain tumors include cortical tubers, subependymal nodules, and subependymal giant cell astrocytomas (SEGAs). The authors report an unusual case of recurrent meningitis due to a tuber-containing encephalocele via the posterior wall of the frontal sinus. An 11-year-old girl presented with a history of TSC and previous SEGA resection via interhemispheric approach. She presented twice within 4 months with classic bacterial meningitis. Cerebrospinal fluid cultures revealed Streptococcus pneumoniae. Computed tomography and MR imaging of the brain showed a right frontal sinus encephalocele via a posterior frontal sinus wall defect. Both episodes of meningitis were treated successfully with standard regimens of intravenous antibiotics. The neurosurgical service was consulted to discuss surgical options. Via a bicoronal incision, a right basal frontal craniotomy was performed. A large frontal encephalocele was encountered in the frontal sinus. The encephalocele was herniating through a bony defect of the posterior sinus wall. The encephalocele was ligated and resected followed by removing frontal sinus mucosa and complete cranialization of frontal sinus. Repair of the sinus floor was conducted with fat and pericranial grafts followed by CSF diversion via lumbar drain. Histopathology of the resected encephalocele showed a TSC tuber covered with respiratory (frontal sinus) mucosa. Tuber cells were diffusely positive for GFAP. The patient underwent follow-up for 2 years without evidence of recurrent meningitis or CSF rhinorrhea. This report demonstrates that frontal tubers of TSC can protrude into the frontal sinus as acquired encephaloceles and present with recurrent meningitis. To the authors' knowledge, recurrent meningitis is not known to coincide with TSC. Careful clinical and radiographic follow-up for frontal tubers in patients with TSC is recommended.

Pneumococcal meningitis post-cochlear implantation: potential routes of infection and pathophysiology.

OBJECTIVE: This review describes the current concept of pneumococcal meningitis in cochlear implant recipients based on recent laboratory studies. It examines possible routes of Streptococcus pneumoniae infection to the meninges in cochlear implant recipients. It also provides insights into fundamental questions concerning the pathophysiology of pneumococcal meningitis in implant recipients. DATA SOURCES: Medline/PubMed database; English articles after 1960. Search terms: cochlear implants, meningitis, pneumococcus, streptococcus pneumonia. REVIEW METHODS: Narrative review. All articles relating to post-implant meningitis without any restriction in study designs were assessed and information extracted. RESULTS: The incidence of pneumococcal meningitis in cochlear implant recipients is greater than that of an age-matched cohort in the general population. Based on the current clinical literature, it is difficult to determine whether cochlear implantation per se increases the risk of meningitis in subjects with no existing risk factors for acquiring the disease. As this question cannot be answered in humans, the study of implant-related infection must involve the use of laboratory animals in order for the research findings to be applicable to a clinical situation. The laboratory research demonstrated the routes of infection and the effects of the cochlear implant in lowering the threshold for pneumococcal meningitis. CONCLUSION: The laboratory data complement the existing clinical data on the risk of pneumococcal meningitis post-cochlear implantation.

Pneumococcal meningitis post-cochlear implantation: preventative measures.

OBJECTIVE: Both clinical data and laboratory studies demonstrated the risk of pneumococcal meningitis post-cochlear implantation. This review examines strategies to prevent post-implant meningitis. DATA SOURCES: Medline/PubMed database; English articles after 1980. Search terms: cochlear implants, pneumococcus meningitis, streptococcus pneumonia, immunization, prevention. REVIEW METHODS: Narrative review. All articles relating to post-implant meningitis without any restriction in study designs were assessed and information extracted. RESULTS: The presence of inner ear trauma as a result of surgical technique or cochlear implant electrode array design was associated with a higher risk of post-implant meningitis. Laboratory data demonstrated the effectiveness of pneumococcal vaccination in preventing meningitis induced via the hematogenous route of infection. Fibrous sealing around the electrode array at the cochleostomy site, and the use of antibiotic-coated electrode array reduced the risk of meningitis induced via an otogenic route. CONCLUSION: The recent scientific data support the U.S. Food and Drug Administration recommendation of pneumococcal vaccination for the prevention of meningitis in implant recipients. Nontraumatic cochlear implant design, surgical technique, and an adequate fibrous seal around the cochleostomy site further reduce the risk of meningitis.