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.

Cerebrospinal fluid analysis is associated with enhancement on MRI in bacterial and tuberculous meningitis: A retrospective observational study.

OBJECTIVE: Along with cerebrospinal fluid (CSF) analysis, enhancement on contrast-enhanced MRI is useful to diagnose meningitis. However, the conditions for its appearance have not been clarified. This study aimed to investigate the association between CSF parameters and enhancement on contrast-enhanced head or spinal MRI in patients with bacterial meningitis (BM) or tuberculous meningitis (TM). METHODS: A total of 12 patients with BM and 23 patients with TM who underwent both CSF analysis and contrast-enhanced MRI were included. The correlation between CSF analysis and MRI findings has been examined using receiver operating characteristic (ROC) analysis. RESULTS: Contrast enhancement was found in 7 and 10 patients with BM and TM, respectively. Both CSF analysis and MRI were useful to distinct between BM and TM, and the enhancement implied the severity of them. In patients with BM, higher CSF protein and lower CSF glucose were associated with enhancement on MRI, while not only CSF protein and glucose but also leukocyte and lymphocyte counts were associated with it in TM. CSF adenosine deaminase (ADA) did not show discriminant ability of the MRI findings. CONCLUSIONS: CSF analysis is associated with enhancement on contrast-enhanced MRI both in BM and TM. Our findings indicate the importance of CSF analysis in assessing the need to perform contrast-enhanced MRI, which may be useful in diagnosis, distinction, and estimation of prognosis in those patients.

Contrast-enhanced modified 3D T1-weighted TSE black-blood imaging can improve detection of infectious and neoplastic meningitis.

OBJECTIVES: To evaluate the diagnostic value of a contrast-enhanced 3D T1-weighted-modified volumetric isotropic turbo spin-echo acquisition sequence (T1-mVISTA) in comparison with a conventional 3D T1-weighted magnetization-prepared rapid gradient-echo (T1-MP-RAGE) sequence for the detection of meningeal enhancement in patients with meningitis. METHODS: Thirty patients (infectious meningitis, n = 12; neoplastic meningitis, n = 18) and 45 matched controls were enrolled in this retrospective case-control study. Sets of randomly selected T1-mVISTA and T1-MP-RAGE images (both with 0.8-mm isotropic resolution) were read separately 4 weeks apart. Image quality, leptomeningeal and dural enhancement, grading of visual contrast enhancement, and diagnostic confidence were compared using the Kruskal-Wallis rank sum test. RESULTS: Image quality was rated to be good to excellent in 75 out of 75 cases (100%) for T1-mVISTA and 74 out of 75 cases (98.7%) for T1-MP-RAGE. T1-mVISTA detected significantly more patients with leptomeningeal enhancement (p = 0.006) compared with T1-MP-RAGE (86.7 vs. 50.0%, p < 0.001), each with specificity of 100%. Similarly, sensitivity of T1-mVISTA for the detection of dural and/or leptomeningeal enhancement was also significantly higher compared with that of T1-MP-RAGE (96.7 vs. 80.0%, p = 0.025) without significant differences regarding specificity (97.8 vs. 95.6%, p = 0.317). No significant differences were found for dural enhancement alone. Diagnostic confidence in T1-mVISTA was significantly higher (p = 0.01). Visual contrast enhancement was tendentially higher in T1-mVISTA. CONCLUSIONS: T1-mVISTA may be an adequate and probably better alternative to T1-MP-RAGE for detection of leptomeningeal diseases. KEY POINTS: • Black-blood T1-mVISTA showed a significant higher sensitivity for the detection of leptomeningeal enhancement compared with MP-RAGE without losses regarding specificity. • Diagnostic confidence was assessed significantly higher in T1-mVISTA. • T1-mVISTA should be considered a supplement or an alternative to T1-MP-RAGE in patients with suspected leptomeningeal diseases.

Comparison of CSF and MRI Findings among Neonates and Infants with E coli or Group B Streptococcal Meningitis.

BACKGROUND AND PURPOSE: Group B Streptococcus and Escherichia coli (E coli) are the 2 most common causes of bacterial meningitis in neonates. The purpose of this study was to determine whether CSF and/or MR imaging findings differ between infants with group B streptococcal or E coli meningitis. MATERIALS AND METHODS: A retrospective review was performed among neonates (younger than 28 days) and infants (younger than 120 days) with proved group B streptococcal (n = 57) or E coli meningitis (n = 50). A CSF or blood culture positive for Streptococcus or E coli and an elevated CSF white blood cell count were used as the criterion standard. Independent, blinded review of brain MRIs obtained within 21 days of presentation were performed by 2 board-certified neuroradiologists. CSF laboratory values and MR imaging findings were compared between the groups. RESULTS: There was no statistically significant difference between the mean age at presentation for patients with group B streptococcal (40 days; range, 2-111 days) versus patients with E coli meningitis (31 days; range, 12-115 days) (P = .18). There was no statistically significant difference in the CSF white blood cell count, glucose, or protein. There was a significant difference between group B streptococcal and E coli meningitis in the frequency of hydrocephalus (0% versus 22%, P = .001) and infarct (40% versus 14%; P = .038), respectively. There was no statistically significant difference in leptomeningeal enhancement, cerebritis, ventriculitis, abscess/granuloma, subdural effusion, extra-axial purulent material, intraventricular purulent material, hemorrhage, and sinus thrombosis. CONCLUSIONS: Although neonates and infants with group B streptococcal or E coli meningitis had similar age and CSF laboratory values, patients with group B streptococcal meningitis more frequently demonstrated infarcts, while those with E coli meningitis more frequently had early onset of hydrocephalus.

Recurrent meningitis in children: etiologies, outcome, and lessons to learn.

PURPOSE: Recurrent meningitis in children is a rare condition. However, its early recognition is important in order to prevent serious complications. This study aims to review cases of recurrent meningitis in children. METHODS: This is a retrospective study that included children diagnosed with recurrent meningitis and who were followed at child neurology clinic at the Jordan University Hospital from January 2001 to June 2017. RESULTS: Thirteen patients were included (nine males and four females). Age of first episode of meningitis ranged from 2 months to 9.5 years. The delay in diagnosis of the underlying cause after the first episode ranged from 6 months to 2.5 years. Underlying causes included inner ear malformation in one patient, skull fractures in two, and dermal sinuses (thoracic spinal and occipital dermal sinus) in two patients. No identifiable cause was found in eight patients. Streptococcus pneumoniae was identified in four (31%) patients, Staphylococcus aureus in two (15%), and no organism was isolated in seven (54%). Three patients (23.1%) developed neurological sequel including developmental delay, limb spasticity, and epilepsy. Two patients had sensorineural hearing loss related to meningitis, and two patients had sensorineural hearing loss mostly related to their original disease. CONCLUSION: A detailed history, examination, and thorough investigations are necessary to determine the underlying cause of recurrent meningitis. In addition, in patients with positive CSF bacterial culture, finding the underlying etiology is very likely.

Síndrome de Austrian: reporte de caso / Austrian syndrome: report of one case

Austrian syndrome is a triad characterized by pneumonia, meningitis and endocarditis, as a result of a Streptococcus pneumoniae bacteremia. We report a previously healthy 49 year-old male, who consulted at the emergency care unit with a history of one week of pleuritic pain, fever leading to an altered level of consciousness and seizures. A diagnosis of community-acquired pneumonia and meningitis was reached, isolating Streptococcus pneumoniae in the cerebrospinal fluid and blood cultures. Antibiotic treatment was started but the patient had an unsatisfactory response. During hospitalization a new heart murmur was found in the physical examination. An echocardiography was performed and a massive aortic valve insufficiency was found along with vegetations and a perforation of the same valve. The valve was replaced by a prosthetic one and the patient responded satisfactorily to the surgical and antibiotic treatment, without complications.

Gradenigo's Syndrome in a Patient with Chronic Suppurative Otitis Media, Petrous Apicitis, and Meningitis.

BACKGROUND Gradenigo's syndrome includes the triad of suppurative otitis media, ipsilateral sixth (abducens) cranial nerve palsy and facial pain in the distribution of the fifth (trigeminal) cranial nerve. Gradenigo's syndrome is rare, and the diagnosis is easily overlooked. This case is the first to report Gradenigo's syndrome presenting with meningitis on a background of chronic suppurative otitis media (CSOM) and petrous apicitis (apical petrositis). CASE REPORT A 58-year-old male African American presented with headaches and confusion. Magnetic resonance imaging (MRI) of the head showed petrous apicitis with mastoiditis and abscess formation in the cerebellomedullary cistern (cisterna magna). The case was complicated by the development of palsy of the fourth (trochlear) cranial nerve, fifth (trigeminal) cranial nerve, and sixth (abducens) cranial nerve, with radiological changes indicating infection involving the seventh (facial) cranial nerve, and eighth (vestibulocochlear) cranial nerve. Cerebrospinal fluid (CSF) culture results were positive for Klebsiella pneumoniae, sensitive to ceftriaxone. The patient improved with surgery that included a left mastoidectomy and debridement of the petrous apex, followed by a ten-week course of antibiotics. Follow-up MRI showed resolution of the infection. CONCLUSIONS This report is of an atypical case of Gradenigo's syndrome. It is important to recognize that the classical triad of Gradenigo's syndrome, suppurative otitis media, ipsilateral sixth (abducens) cranial nerve palsy and facial pain in the distribution of the fifth (trigeminal) cranial nerve, may also involve chronic suppurative otitis media (CSOM), which may lead to involvement of other cranial nerves, petrous apicitis (apical petrositis), and bacterial meningitis.

Reconstructive Endovascular Treatment of an Intracranial Infectious Aneurysm in Bacterial Meningitis: A Case Report and Review of Literature.

BACKGROUND: Intracranial infectious aneurysms (IAs) are rare cerebrovascular lesions that represent only 1%-6% of all intracranial aneurysms. IAs are rare cerebrovascular lesions and pose a significant therapeutic challenge because of their angiographic and pathophysiologic features. We describe a patient with an intracranial IA treated by the use of reconstructive endovascular methods using a balloon-expandable covered stent and discuss the pathophysiologic characteristics of IA based on serial brain imaging findings. CASE DESCRIPTION: A 21-year-old man was admitted to our emergency department with headache and vomiting. Neurologic examination, hematologic workup, and cerebrospinal fluid examination confirmed a diagnosis of bacterial meningitis. Initial brain magnetic resonance angiography revealed no significant stenosis lesions or aneurysm. After 4 weeks of antibiotic treatment, follow-up brain magnetic resonance imaging revealed an 8-mm sized aneurysm on the petrous portion of the right internal carotid artery, and 3 months later, follow-up brain magnetic resonance angiography revealed that the aneurysm had increased in size from 8 to 15 mm. Conventional 4-vessel angiography confirmed the presence of a pseudoaneurysm. Endovascular treatment was then planned via the use of a balloon-expandable covered stent. Postoperatively, the patient was discharged without specific neurologic deficit. CONCLUSIONS: IAs are rare cerebrovascular lesions and pose a significant therapeutic challenge because of their angiographic and pathophysiologic features. Although endovascular treatment is not performed routinely for infectious aneurysms, the covered stent may represent a safe and effective treatment that achieves complete endoluminal reconstruction of the damaged vessel wall.

Evaluation of posttraumatic recurrent bacterial meningitis in adults.

BACKGROUND: Acute bacterial meningitis may develop as a complication after head trauma. The aim of this study was to present the demographic, clinical, microbiological and radiological characteristics of adult patients who presented with recurrent bacterial meningitis attacks after trauma. METHODS: Using a retrospective approach, the medical records of patients with acute recurrent bacterial meningitis (RBM) were reviewed, and those who had a history of trauma were included into the study. RBM was diagnosed based on clinical, bacteriologic and laboratory results. Demographic characteristics, clinical course, laboratory test results including cerebrospinal fluid analysis (CSF), radiological images, and the applied treatments were evaluated. RESULTS: A total of two hundred and twelve patients with acute bacterial meningitis were included into the study. RBM was diagnosed in twenty-five patients (11.8%), and in 18 of these patients (8.5%), the attacks had occurred subsequent to a trauma. In the CSF cultures of four patients, S. pneumoniae growth was observed. CT cisternography indicated CSF leaks in eleven patients. Moreover, bone fractures were observed in the CT images of ten patients. Ceftriaxone therapy was prescribed to 83% of the patients. Eight patients had a history of a fall in childhood, and five were involved in traffic accidents before acute bacterial meningitis. Four of the patients developed epilepsy and one developed deafness as sequelae. CONCLUSION: Since RBM attacks are frequently observed following trauma, in patients with a history of trauma who present with meningitis, the risk of recurrence should be considered.

The art and science of straight lines in radiology.

OBJECTIVE: The purpose of this article is to review the physical basis for straight radiographic lines, identify the possible components that may form a straight line interface in the body, provide illustrative examples across multiple organ systems and modalities, and explore how the detection of these interfaces can support specific diagnoses. CONCLUSION: Detection of a straight line interface can help the radiologist recognize otherwise difficult or subtle pathologic processes, and identification of its components can provide valuable clues to diagnosis.

Pneumocephalus in neonatal meningitis.

Pneumocephalus is collection of gas or air within the cranial cavity. This has been described with trauma, cranial surgery, air embolism, and rarely as a result of central nervous system infections. We report a case of diffuse pneumocephalus secondary to Enterobacter cloacae meningitis. The diagnosis was suspected by cranial ultrasound and confirmed by computer tomography.

Fatal Klebsiella pneumoniae meningitis and emphysematous brain abscess after endoscopic variceal ligation in a patient with liver cirrhosis and diabetes mellitus.

Procedure-related bacterial infections may complicate esophageal variceal ligation in cirrhosis patients. Here, we report a 58-year-old man with underlying diabetes and liver cirrhosis who developed Klebsiella pneumoniae meningitis and brain abscess with gas formation in brain parenchyma and ventricles after this procedure. Despite administration of appropriate antimicrobial therapy, he became comatose on the 3rd day of acute illness and died on the 4th day of hospitalization. This case highlights the indication for antimicrobial prophylaxis in cirrhotic patients with gastrointestinal bleeding, and the need for early and heightened awareness of central nervous system infections in cirrhotic patients with hepatic encephalopathy.

Posterior fontanelle sonography: an acoustic window into the neonatal brain.

BACKGROUND AND PURPOSE: Sonographic brain studies are classically performed through the anterior fontanelle, but visualization of posterior supratentorial and infratentorial structures is poor with this approach. Posterior fontanelle sonography is recommended for better assessment of these structures. Our purpose was 1) to determine whether sonography of the brain through the posterior fontanelle (PF) improves visualization of brain lesions when added to the routine anterior fontanelle (AF) approach and 2) to describe standardized PF coronal and sagittal sections. METHODS: In this prospective study (conducted from February 1999 to January 2001), PF sonography was added to AF sonography in 165 consecutive premature neonates with a birth weight of < 2000 g. Sonograms were recorded in digital format for re-evaluation at the end of the study. Lesions were grouped as congenital, infectious, hemorrhagic, or hypoxic-ischemic. The chi2 test for paired data and the kappa coefficient were used to compare diagnoses with AF alone and diagnoses with AF plus PF. RESULTS: PF sonography was performed in 164 of 165 patients. Results were normal in 86 and abnormal in 78. The single posterior fossa malformation detected in this series was best delineated with the PF approach. PF sonography increased the diagnostic rate of grade II hemorrhage by 32%. Cerebellar hemorrhage (two patients) and cerebellar abscesses (one patient) were diagnosed by using the PF approach. PF sonography did not contribute to the diagnosis of periventricular leukomalacia. CONCLUSION: Study of the neonatal brain with the addition of PF sonography afforded greater accuracy in detecting intraventricular hemorrhage compared with AF sonography alone, especially when the ventricle was not dilated. The PF approach better defines posterior fossa malformations.

Computed tomographic versus surgical findings in complicated acute otomastoiditis.

Computed tomography (CT) plays an important role in planning surgery in cases of complicated middle ear infection. The purpose of this study was to determine, by comparison of radiologic and surgical findings, the diagnostic value of CT in complicated acute otomastoiditis. The study group consisted of 37 patients without a history of chronic ear disease. In this study, CT enabled correct diagnosis of 26 of 27 cases (96%) of subperiosteal abscess, 17 of 18 cases (94%) of mastoid cortex erosion in patients with subperiosteal abscess, and several intracranial complications, including epidural abscess, subdural empyema, and perisinus abscess. The CT scan produced overdiagnosis in some cases: sigmoid sinus thrombosis in 1 patient, mastoid cortex erosion in 2 children with subperiosteal abscess, and bone erosion toward the posterior cranial fossa in 1 patient with meningitis. My findings suggest that subperiosteal abscess is a disease of young children; however, when it develops in an older child, cholesteatoma should be suspected. Furthermore, acute mastoiditis complicated with facial nerve paralysis may be associated with cholesteatoma in 66% of cases. My experience showed that CT had a sensitivity of 97% and a positive predictive value of 94% in the diagnosis of complicated acute otomastoiditis.

Sinusitis complicated by meningitis: current management.

OBJECTIVES: Meningitis is the most common intracranial complication of sinusitis. We review the incidence, current management, outcomes, and complications of this serious infection. Our study also examines the evolving roles of endoscopic sinus surgery and other new therapeutic and diagnostic modalities in our armamentarium. STUDY DESIGN: A retrospective chart review was performed at a tertiary academic medical center of all patients diagnosed with sinusitis with complications between January 1985 and December 1999. METHODS: The patients were divided into two main groups: intracranial versus orbital complications. Meningitis was the most common intracranial complication. Data on patients with sinusitis and meningitis were collected and analyzed. RESULTS: Intracranial complications were present in 39 of 82 patients whereas orbital complications were noted in 43 patients. Twenty-one of the 39 intracranial complications were meningitis. The most common computed tomography finding in adults (54%) was sphenoid sinusitis. All patients with AIDS (6 of 21) had unique cryptococcus meningitis. In patients without AIDS, the most common organism was Streptococcus pneumoniae (10 of 21). The most common sequela was seizure disorder (4 of 21). Endoscopic sinus surgery was performed on 7 of 21 patients. One patient with AIDS who had sinusitis and meningitis died. CONCLUSIONS: Meningitis as a complication of sinusitis may still pose a serious threat. Although outcomes are encouraging, sequelae such as seizure disorders and hearing loss are common complications. The introduction of high-resolution computed tomography scans and magnetic resonance imaging and the availability of wide-spectrum antibiotics have improved our management significantly.

[Intraspinal infections in patients treated with epidural analgesia]. / Intraspinale infeksjoner hos pasienter behandlet med epiduralanalgesi.

BACKGROUND: Intraspinal infections (meningitis, epidural abscess) may occur spontaneously or present as a complication of epidural analgesia. MATERIAL AND METHODS: All cases during the 1991-99 period of clinically significant intraspinal infections in patients treated with epidural analgesia were analysed from clinical records in our institution. RESULTS: One patient with uncertain, three patients with well documented meningitis, and one patient with epidural abscess were identified. The treatment time varied from 12 to 49 days in patients with documented infections; the number of catheters varied from one to six. Skin bacteria were isolated from one patient (Staphylococcus sp), opportunistic bacteria (Pseudomonas, Enterococcus, Micrococcus sp) were isolated from three others. Two of the patients were at risk because of probable immunosuppression and chronic infections. Diagnosis and surgery of the patient who developed epidural abscess were significantly delayed because of three negative MRs with and without gadolinium enhancement. INTERPRETATION: Because of the danger of infection related to epidural analgesia, all patients have to be properly monitored as long as they have epidural catheters and also after the removal of catheters. Some epidural abscesses spread longitudinally and may present as a diffuse process on MR without mechanical compression of the medulla, and may be interpreted as negative findings. Myelography with CT scan is an alternative method of investigation in such cases. Early neurosurgical diagnosis and intervention may prevent serious complications.

Localized pneumocephalus caused by Clostridium perfringens meningitis.

Clostridium meningitis is a rare complication of elective surgery, but the presence of pneumocephalus on CT in the absence of penetrating injuries, should raise the possibility of anaerobic infections. We report a case of fatal Clostridium perfringens meningitis which occurred 4 months after a craniotomy for glioblastoma multiforme. The diagnosis was suspected based on the CT findings. The literature of this rare condition is reviewed.

Prospective neurosonographic study in infantile purulent meningitis.

Fourteen infants or neonates with purulent meningitis underwent prospective brain sonography follow-up for early detection of intracranial complications. Most patients had 12 scans during a 6 month period. The children's ages ranged from 5 days to 11 months. Early surgical intervention is suggested in progressive ventricular dilatation or severe subdural fluid collection. One patient with hydrocephalus had ventriculoperitoneal shunting. Three patients developed subdural empyema. One had subdural external drainage; and repeat subdural tappings were done in the other two. All these patients recovered without obvious neurologic sequelae. Two other patients developed ventricular dilatation one month after the onset of meningitis. Hydrocephalus ex vacuo was suspected and there were no indications for shunt surgery. These latter two cases had developed mild psychomotor retardation on their last follow-up. This primitive observation suggests that early detection with prospective, sequential sonography follow-up and appropriate surgical intervention for hydrocephalus or subdural fluid collection may lessen the neurologic sequelae in infantile and neonatal purulent meningitis.