Isolated Oculomotor Nerve Palsy: A Unique Presentation of Haemophilus influenzae Type A Meningitis.

In this case report, we describe a unique case of Haemophilus influenzae type A meningitis in a 7-month-old previously healthy girl that presented with an isolated cranial nerve (oculomotor) palsy without other signs and symptoms classically associated with this entity such as fever, meningismus, or a generally ill appearance. Oculomotor nerve abnormalities are rare in pediatrics. Congenital oculomotor palsy is the most common cause followed by trauma, infection, inflammatory conditions, neoplasm, aneurysm or other vascular events, and ophthalmoplegic migraines, respectively. Therefore, had it not been for the unusual magnetic resonance imaging findings identified in this patient prompting an extensive infectious workup with lumbar puncture, the diagnosis and treatment of meningitis may have been delayed further or missed all together. This fact emphasizes the importance of maintaining a broad differential when children present with neurologic abnormalities such as cranial nerve palsies.

Ventriculitis in infants: diagnosis by color Doppler flow imaging.

A color Doppler flow imaging technique was used to study the dynamics of cerebrospinal fluid (CSF) in infants with meningitis. Eight infants with bacterial meningitis (6) or aseptic meningitis (2) were studied with color Doppler imaging of CSF flow for a total of 18 times. In 2 infants with bacterial meningitis, Doppler sonograms of CSF flow were obtained in the aqueduct during the acute stage. The CSF flow demonstrated a to-and-fro motion which was synchronized with cardiac pulsations and respiration. The detection of CSF flow on color Doppler flow imaging in the aqueduct may indicate the existence of ventriculitis. Color Doppler flow imaging is useful for the evaluation of CSF flow dynamics in infants.

Does computed tomography have a role in the evaluation of complicated acute bacterial meningitis in childhood?

The authors examined the records of 30 children with bacterial meningitis to review the role of computed tomography (CT) of the brain in acute management of the disease. CT was normal for 10 patients, six of whom had clinical evidence of raised ICP. CT identified an underlying surgical abnormality in two patients with progressive focal neurological signs. One patient had unsuspected gross hydrocephalus diagnosed by CT, which required neurosurgery. This study shows that the management of bacterial meningitis is influenced by CT in only a minority of cases; for patients with clinical signs of raised ICP, it was found to be insensitive in confirming the clinical diagnosis and establishing an underlying cause. However, CT remains valuable in the management of children with progressive neurological signs for whom neurosurgical intervention may be necessary.

Computed tomography in bacterial meningitis of childhood.

The hospital records of 85 children with bacterial meningitis were reviewed and a subset of 25 children who underwent computed tomography of the head were identified. The major stated indications for computed tomography were fever (8 patients), seizures (4 patients), signs of increased intracranial pressure (4 patients), focal neurologic dysfunction (3 patients) and recurrent meningitis (2 patients). Abnormal findings were demonstrated by computed tomography in 20 of 25 patients but in 8 patients consisted solely of nonspecific dilatation of spaces containing cerebrospinal fluid or of basilar enhancement. The yield of information that was useful either diagnostically or therapeutically was low; positive findings of obvious clinical relevance were present in only 2 cases. Computed tomography provides an accurate means of diagnosing intracranial complications of bacterial meningitis. It must be used conservatively, however, to limit expense and radiation exposure and enhance the yield of potentially relevant information. Computed tomography is indicated for children with persistent neurologic dysfunction, persistently positive cerebrospinal fluid cultures or recurrent meningitis, whereas it is of little value for children with prolonged fever alone.

Prospective study of computed tomography in acute bacterial meningitis.

We performed serial CT scans at the time of admission and discharge, and again after 6 to 18 months, in children older than 2 months of age with bacterial meningitis. During the 2-year study period, 60 patients with bacterial meningitis were admitted to British Columbia's Children's Hospital. Forty-one were included in the study, two of whom died soon after admission. The infecting organism was Haemophilus influenzae in 29, Neisseria meningitidis in six, and Streptococcus pneumoniae in six. Abnormalities on the first two CT scans included subdural effusion in eight patients, focal infarction in five, and pus in the basal cisterns in one. All patients with focal infarction or cisternal pus had hemiparesis. Marked cerebral edema was seen in the two patients who died. Transient mild dilation of the subarachnoid space was a common finding; the size of the ventricles or subarachnoid space was increased on the second scan in 29 of 36 patients, and decreased to normal on the third scan in 30 of 33 patients. Clinical management was not influenced by the CT findings, which failed to reveal any clinically significant abnormalities that were not suspected on neurologic examination.

Computed tomography in childhood intracranial infections.

Delay in treatment or inadequate therapy with inappropriate antibiotics can result in a progressive cycle of inflammation, edema and infarction in children with bacterial meningitis. Early use of computed tomographic (CT) scanning and effective antibiotic therapy may significantly alter both the initial and long-term clinical courses. CT scanning also facilitates the early detection and treatment of suppurative intracranial complications.

CT evaluation of Haemophilus influenzae meningitis with clinical and pathologic correlation.

Ten proven cases of Haemophilus influenzae meningitis have been reviewed, in which all had CT scans during their first 3 weeks of illness. An attempt was made to correlate the neuropathologic basis of the disease with the CT findings. Progression of the CT changes with the course of illness and treatment is emphasized. Usual indications for CT imaging of the brain in patients with meningitis are: detection of subdural empyema or effusion, hydrocephalus, infarct, cerebritis and abscess. Widespread cerebral damage can be more fully evaluated with iodine contrast infusion if clinically indicated. CT scanning has proven to be a valuable indicator of such complications and useful predictor of clinical recovery or residual neurologic sequelae.

CT parenchymal abnormalities in bacterial meningitis: clinical significance.

Over a 5 year period, 80 children with acute bacterial meningitis underwent computed tomography (CT) because of neurologic complications. In nine children, CT disclosed parenchymal abnormalities. The type of parenchymal abnormality was classified as mild, moderate, or severe on the basis of the severity and location of brain injury. All children had neurologic deficits at the time they underwent CT. The seven surviving children were followed for a mean of 32 months. The four children with either mild or moderate CT changes recovered without neurologic sequelae. The five children with severe CT abnormalities either died (two) or survived with major neurologic (two mentally retarded; three major motor deficits) sequelae. Computed tomography is of prognostic value in children with bacterial meningitis.

Computed tomography in purulent meningitis.

Of 102 patients with bacterial meningitis admitted to the Children's Hospital of Buenos Aires, 25 were selected for computed tomographic (CT) scans on the basis of altered consciousness for more than 96 hours after admission, persistent or recurrent seizures after 72 hours of antibiotic therapy, development of focal neurologic signs, increased intracranial pressure or prolonged fever. Scan findings included hydrocephalus, cerebritis, vasculitis, subdural effusion, cerebral atrophy, abscess, and ependymitis. Serial CT scans demonstrated the progression or regression of some complications. The CT scan was very useful in indicating the need for neurosurgical procedures.

Serial CT scans in Haemophilus influenzae meningitis of childhood.

Eleven children admitted to hospital with H. influenzae meningitis had computerized tomographic head scans during the acute stage of the illness. 10 of the 11 had at least one other scan between two weeks and 30 months later. This study evaluated the changes seen in the scans in relation to the evolution of the illness, especially with reference to subdural effusions and communicating hydrocephalus. The early scans were found to have no significance in predicting clinical outcome. However, a temporary developmental lag occurred in those children with subdural effusions, transient communicating hydrocephalus, and without permanent neurological deficit.

Detection of extracerebral fluid collections by real-time sector scanning through the anterior fontanelle.

Real-time sector sonography through the anterior fontanelle has proved useful in detecting extracerebral fluid collections when a water bath is utilized. With this technique, six patients had their extracerebral fluid collections visualized. The role of this procedure in following the course of these patients is discussed.

Imaging the intracranial complications of Hemophilus influenzae meningitis.

Computed tomography (CT) and radionuclide imaging of the central nervous system (CNS) are important modalities in both the diagnosis and management of CNS complications from Hemophilus influenzae meningitis. Both examinations are sensitive indicators of CNS abnormalities associated with bacterial meningeal infections and are important determinants of the therapy and ultimate prognosis of such complications. Representative findings from CT and radionuclide imaging of children with complications from H. influenzae infection of the meninges are presented.

Computed tomography in childhood bacterial meningitis.

Computed tomography has been applied to childhood bacterial meningitis in an attempt to analyze the structural basis for neurologic complications. The CT findings in meningitis patients include acute cerebral swelling; moderate widening of basal cisterns, interhemispheric fissue, and subarachnoid convexity space; ventricular widening; subdural collection; focal cortical necrosis; cerebral infarcts; contrast enhancing basal meninges, ependymitis, and generalized cerebral atrophy. Bacterial meningitis in childhood is more than an inflammation of the subarachnoid space. It is a disease process which often exerts a profound effect on the brain parenchyma.

Computed tomography in leptomeningeal infections.

In a review of CT scans of 6,078 patients, 47 patients with well documented leptomeningeal infections were identified; 45 were infants or children. Most of the infections were bacterial; 53% were due to Haemophilus influenzae. The 47 patients were divided into two groups according to whether the initial scan was obtained during the acute illness (group A) or after initial treatment had been completed (group B). The 30 patients in the acute group A had 24 complications: 18 with areas of diminished attenuation in the brain parenchyma and six with dilated ventricles. Eleven patients had initially normal scans, but three of these subsequently developed complications. In group B, the 17 patients had 28 complications: nine with enlarged ventricles; eight with subdural effusion; seven with areas of diminished attenuation; and four with abscess formation. An unusually high percentage (40%) of the patients with areas of diminished attenuation had involvement of the anterior poles of the frontal lobes. Of the patients who showed this predilection for the frontal lobes, 72% had Haemophilus influenzae meningitis. CT was found to be useful in early detection of complications of leptomeningeal infections, as well as in evaluation of the extent of the lesions.