Meningitis por estreptococo ß-hemolítico del grupo B en lactantes / Meningitis in breast-fed infants caused by Group B ß-hemolytic streptococcus

Introducción: el estreptococo ß-hemolítico del grupo B es causa frecuente de sepsis y muerte neonatal.Objetivo: caracterizar el comportamiento de la meningitis por estreptococo ß-hemolítico del grupo B en Cuba.Métodos: se realizó un estudio observacional (descriptivo y analítico) de 57 casos de meningitis por ß-hemolítico del grupo B, con inicio de los síntomas entre el 1ro de enero de 1998 y 31 de diciembre de 2010. Se estimó el riesgo según el año de ocurrencia, la edad, el sexo, la provincia y el municipio, así como la letalidad y la asociación de la demora en la consulta médica y el ingreso hospitalario, con la muerte.Resultados: la incidencia de todo el período fue 0,03/1 000 nacidos vivos y la letalidad alcanzó 31,58 por ciento. La proporción de casos en el sexo masculino (50,9 por ciento) fue muy similar al femenino (49,1 por ciento). Los menores de 2 meses fueron más afectados por la enfermedad (38 casos) y aportaron el 100 por ciento de los fallecidos (18). Las provincias con mayor riesgo fueron Pinar del Río (0,09/1 000 nacidos vivos) y Santiago de Cuba (0,08/1 000 nacidos vivos). El municipio con mayor riesgo fue San Luis, en Santiago de Cuba (0,31/1 000 nacidos vivos). La media de tiempo para la consulta médica fue alrededor de 17 horas, y para el ingreso fue aproximadamente 5 horas. No hubo asociación de la demora para la consulta (RR= 0,66) y el ingreso (RR= 1,22) con la muerte.Conclusiones: la meningitis por estreptococo ß-hemolítico del grupo B constituye una causa importante y prevenible de meningitis y muerte neonatal en Cuba(AU)

Introduction: group B ß-hemolytic streptococcus is a common cause of sepsis and neonatal death,Objective: to characterize the behavior of the Group B ß-hemolytic streptococcus meningitis in Cuba.Methods: an observational, descriptive and analytical study was performed on 57 patients suffering meningitis caused by Group B ß-hemolytic streptococcus, with the onset of symptoms ranging from January 1st 1998 to December 2010. The risk was estimated according to the year of occurrence, the age, the province and the municipality as well as the fatality rate and the association of delay in medical diagnosis and in admission to the hospital and death.Results: the incidence rate of the whole period was 0.03 per 1 000 livebirths and the fatality rate amounted to 31.58 percent. The propo9rtion of cases between males and females was very similar (50.9 percent and 49.1 percent respectively). The infants aged younger than 3 months were more affected by the disease (38 cases) and they accounted for 100 percent of those children who died (18 cases). The most risky provinces were Pinar del Rio (9.09 percent) 1 000 livebirths) and Santiago de Cuba (0.08 percent 1 000 livebirths). The municipality with the highest risk index was San Luis in Santiago de Cuba (0.31 percent 1 000 livebirhts). The average length of time for medical diagnosis was 17 hours and for admission to the hospital was 5 hours. No association was found between delay in medical diagnosis (RR= 0.66) and in admission to the hospital (RR= 1.22) and death occurrence.Conclusions: Group B ß-hemolytic streptococcus is a significant preventable cause of meningitis and neonatal death(AU)

Reibergram of intrathecal synthesis of C4 in patients with eosinophilic meningitis caused by Angiostrongylus cantonensis.

Angiostrongylus cantonensis produces eosinophilic meningitis in humans and is endemic in Thailand, Taiwan, China, and the Caribbean region. During infection with this parasite, it is important to know if the complement system may be activated by the classical or lectin pathway. Cerebrospinal fluid and serum samples from 20 patients with meningitic angiostrongyliasis were used to quantify C4 levels and albumin. Results were plotted on a C4 CSF/serum quotient diagram or Reibergram. Twelve patients showed intrathecal synthesis of C4. Antibody-dependent complement cytotoxicity should be considered as a possible mechanism that destroys third-stage larvae of this helminth in cerebrospinal fluid of affected patients.

Toxocara infection is not associated with viral or bacterial central nervous system infection in children.

BACKGROUND: Helminth infections with larvae that migrate through the tissues have been considered risk factors for CNS infections. OBJECTIVES: The present work was designed to investigate the prevalence of anti- TOXOCARA antibodies in the serum and/or in the cerebrospinal fluid (CSF) of children with infectious meningitis or meningoencephalitis and of a control group, without meningitis, admitted at the Children's Hospital NS Glória, Vitória, ES, Brazil. PATIENTS AND METHODS: After adsorption with ASCARIS LUMBRICOIDES antigen, serum and/or cerebrospinal fluid of 381 inpatients (201 with meningitis and 180 without meningitis) were submitted to an ELISA IgG, for anti- TOXOCARA antibodies using secretion/excretion antigens of third stage larvae of T. CANIS. RESULTS: No significant differences between the meningitis and the control groups were observed in the frequencies of positive tests for anti- TOXOCARA antibodies in the serum or CSF (respectively for the meningitis and control group: 33/103 or 32 % and 52/152 or 34.2 % for the serum, p = 0.821; 48/184 or 26.1 % and 23/121 or 19.0 % for the CSF; p = 0.196. CONCLUSION: The results demonstrated that TOXOCARA infection, evaluated by detection of anti- TOXOCARA antibodies in serum or CSF, is not associated with viral or bacterial meningitis or meningoencephalitis in children in our country.

Use of neuron-specific enolase for assessing the severity and outcome in patients with neurological disorders.

Neuron-specific enolase (NSE) is a glycolytic enzyme present almost exclusively in neurons and neuroendocrine cells. NSE levels in cerebrospinal fluid (CSF) are assumed to be useful to estimate neuronal injury and clinical outcome of patients with serious clinical manifestations such as those observed in stroke, head injury, anoxic encephalopathy, encephalitis, brain metastasis, and status epilepticus. We compared levels of NSE in serum (sNSE) and in CSF (cNSE) among four groups: patients with meningitis (N=11), patients with encephalic injuries associated with impairment of consciousness (ENC, N=7), patients with neurocysticercosis (N=25), and normal subjects (N=8). Albumin was determined in serum and CSF samples, and the albumin quotient was used to estimate blood-brain barrier permeability. The Glasgow Coma Scale score was calculated at the time of lumbar puncture and the Glasgow Outcome Scale (GOS) score was calculated at the time of patient discharge or death. The ENC group had significantly higher cNSE (P=0.01) and albumin quotient (P=0.005), but not sNSE (P=0.14), levels than the other groups (Kruskal-Wallis test). Patients with lower GOS scores had higher cNSE levels (P=0.035) than patients with favorable outcomes. Our findings indicate that sNSE is not sensitive enough to detect neuronal damage, but cNSE seems to be reliable for assessing patients with considerable neurological insult and cases with adverse outcome. However, one should be cautious about estimating the severity of neurological status as well as outcome based exclusively on cNSE in a single patient.

Relevance of common tests of cerebrospinal fluid in screening for bacterial meningitis.

This study tests the hypothesis that if cerebrospinal fluid (CSF) has a nucleated blood cell count (NucBC) of less than 6/mm3, CSF tests other than bacterial culture need not be performed to exclude the diagnosis of bacterial meningitis in patients not receiving antimicrobial agents. The results of tests performed on the first specimen of CSF obtained for a given hospital visit from children younger than 3 years of age, exclusive of newborn infants admitted to the hospital on their date of birth, were analyzed. Of 3356 CSF specimens evaluated, 122 were from patients with bacterial meningitis; 460 specimens were analyzed separately because the erythrocyte count was greater than 1000/mm3. A negative CSF screening test result was defined as a CSF NucBC less than 6/mm3. In facilitating the diagnosis of bacterial meningitis, this screening test had a sensitivity of 98.4%, a specificity of 75.2%, and a negative predictive value of 99.9%. The other CSF tests varied widely in screening effectiveness: a Gram-stained smear had a sensitivity of 53% and a specificity of 97%. Receiver operating characteristic curve analysis was used to assess the screening relevance of CSF tests. The CSF NucBC and CSF segmented NucBC performed indistinguishably and superiorly compared with the CSF protein or glucose concentration and the ratio of CSF glucose to serum glucose concentration. Logistic regression analysis showed that the NucBC alone is superior to any combination of the other CSF tests. In a prospective study of 215 children younger than 3 years of age undergoing a lumbar puncture in our emergency department, 85% had empiric criteria identifying them as appropriate for an abbreviated CSF evaluation. The CSF NucBC was less than 6/mm3 in 70% of the 181 patients who would have been eligible for an abbreviated CSF evaluation. These data suggest that a strategy for the sequential testing of CSF could be adopted that would exclude unnecessary determinations and thereby save time, effort, and health care dollars.

Cerebral blood flow and carbon dioxide reactivity in children with bacterial meningitis.

We examined total and regional cerebral blood flow (CBF) by stable xenon computed tomography in 20 seriously ill children with acute bacterial meningitis to determine whether CBF was reduced and to examine the changes in CBF during hyperventilation. In 13 children, total CBF was normal (62 +/- 20 ml/min/100 gm) but marked local variability of flow was seen. In five other children, total CBF was significantly reduced (26 +/- 10 ml/min/100 gm; p less than 0.05), with flow reduced more in white matter (8 +/- 5 ml/min/100 gm) than in gray matter (30 +/- 15 ml/min/100 gm). Autoregulation of CBF appeared to be present in these 18 children within a range of mean arterial blood pressure from 56 to 102 mm Hg. In the remaining two infants, brain dead within the first 24 hours, total flow was uniformly absent, averaging 3 +/- 3 ml/min/100 gm. In seven children, CBF was determined at two carbon dioxide tension (PCO2) levels: 40 (+/- 3) mm Hg and 29 (+/- 3) mm Hg. In six children, total CBF decreased 33%, from 52 (+/- 25) to 35 (+/- 15) ml/min/100 gm; the mean percentage of change in CBF per millimeter of mercury of PCO2 was 3.0%. Regional variability of perfusion to changes in PCO2 was marked in all six children. The percentage of change in CBF per millimeter of mercury of PCO2 was similar in frontal gray matter (3.1%) but higher in white matter (4.5%). In the seventh patient a paradoxical response was observed; total and regional CBF increased 25% after hyperventilation. Our findings demonstrate that (1) CBF in children with bacterial meningitis may be substantially decreased globally, with even more variability noted regionally, (2) autoregulation of CBF is preserved, (3) CBF/CO2 responsitivity varies among patients and in different regions of the brain in the same patient, and (4) hyperventilation can reduce CBF below ischemic thresholds.

Normalization of plasma arginine vasopressin concentrations when children with meningitis are given maintenance plus replacement fluid therapy.

We hypothesized that plasma arginine vasopressin (AVP) concentrations in children with meningitis are appropriate for the children's degree of hypovolemia, even though the concentrations were higher than expected for the serum osmolality. A randomized study was conducted to compare the effect on plasma AVP concentrations of giving maintenance fluid requirements plus replacement of any deficit versus restricting fluids to two thirds of maintenance requirements for 24 hours. Plasma AVP concentrations and serum osmolality were measured before fluid therapy was begun and again after 24 hours. Nineteen children, 2 months to 17 years of age, were studied; 13 had bacterial meningitis (12 with Haemophilus influenzae type b). Ten children (seven with bacterial meningitis) received a mean of 1.42 times the calculated maintenance fluid requirements, and nine (six with bacterial meningitis) were restricted to a mean of 0.65 times maintenance. Children in the maintenance group also received significantly more sodium (mean = 6.3 mEq/kg/24 hr) than children in the fluid-restricted group (mean = 2.0 mEq/kg/24 hr). The two groups were comparable for plasma AVP concentration and serum osmolality before fluid therapy was begun. The plasma AVP concentration was significantly lower after 24 hours of maintenance plus replacement fluids than after fluid restriction (p = 0.005), and the change in AVP concentration correlated with the amount of sodium given (p less than 0.02). This study supports the hypothesis that serum AVP concentrations are elevated in patients with meningitis because of hypovolemia and become normal when sufficient sodium is given to facilitate reabsorption of water by the proximal tubule of the kidney. Patients with meningitis can be given maintenance plus replacement fluids but should be monitored for the development of the syndrome of inappropriate secretion of antidiuretic hormone.

Brucella meningitis.

A 36-year-old Hispanic man came into the emergency department with nonspecific symptoms (headache, myalgias, low-grade temperature, and low white blood cell count) and was diagnosed with brucella meningitis. The patient said he had consumed unpasteurized goat's milk and cheese in Mexico, and had been treated 3 months previously for a febrile illness diagnosed as Malta fever (brucellosis). Cultures of both the blood and cerebrospinal fluid yielded Brucella melitensis. Blood agglutinin results for B abortus were positive at greater than 1:160. Unpasteurized milk and cheese are consumed in many countries where brucellosis is endemic. Emergency physicians are occasionally confronted with patients from developing countries with diseases that require rapid and specific diagnosis for optimal treatment.

[Pleural empyemas in children due to Hemophilus influenzae]. / Empiemas pleurales por Hemophilus influenzae en niõs.

22 consecutive cases of pleural empyema due to H. influenzae in children are reported. An increment of its incidence during the 1975-76 period is observed. All cases were in children under 3 years of age, with a mean of 15.5 months. The presenting syndrome at admission was varied. In 50% of cases, pleuropulmonary infection was ignored. Nearly one half of cases of pleural empyema due to H. influenzae had simultaneous purulent meningitis caused by the same microorganism. This type of empyemas, though having a prolonged evolution, apparently appear to have a good prognosis, compared with that produced by S. aureus. There are some differences, being the most outstanding: low frequency of pyoneumothorax and the lack of radiological evidences of abscesses and or pneumotoceles, in any phase of the clinical course. Stress is placed on the value of the bacteriological study of blood and CSF in children under 3 years of age with pleural empyema. A high rate of positive blood cultures was found. (75%). Pieuropulmonary complications, as a frequent event during severe infections (septicemic disease) due to H. influenzae is considered. A clinical characterization of children in whom a pleural empyema could occur is proposed. A discussion is made about diagnostic, therapeutic and prognostic implications of these complications.

The syndrome of inappropriate secretion of antidiuretic hormone in children with bacterial meningitis.

Plasma concentrations of arginine vasopressin were determined by radioimmunoassay in 13 normal children, 21 patients with febrile illnesses (not bacterial meningitis), and 17 patients with bacterial meningitis. The mean +/- 1 SD concentrations of AVP in the normal children and patients with various febrile illnesses were 0.7 +/- 0.6 and 1.0 +/- 1.2 muU/ml, respectively. The mean +/- 1 SD concentration of AVP in patients with bacterial meningitis was 3.3 +/- 2.3 muU/ml. The concentrations of AVP in the patients with bacterial meningitis were significantly greater (P less than 0.001) than those noted in the normal children or children with other febrile diseases.

The necessity for monitoring chloramphenicol levels when treating neonatal meningitis.

Chloramphenicol can be an effective agent in the treatment of ampicillin-resistant E. coli meningitis due to susceptible organisms in the premature or term infant. However, it can be used safely and effectively only if careful monitoring of serum levels is undertaken.