Severe pneumonia caused by Parvimonas micra: a case report.

BACKGROUND: Parvimonas micra (P. micra) is a gram-positive anaerobic coccus that is detected widely on the skin, in the oral mucosa and in the gastrointestinal tract. In certain circumstances, P. micra can cause abdominal abscesses, bacteraemia and other infections. To the best of our knowledge, there have been no case reports describing the biological characteristics of P. micra-related pneumonia. These bacteria do not always multiply in an aerobic organ, such as the lung, and they could be easily overlooked because of the clinical mindset. CASE PRESENTATION: A 35-year-old pregnant woman was admitted to the emergency department 4 weeks prior to her due date who was exhibiting 5 points on the Glasgow coma scale. A computed tomography (CT) scan showed a massive haemorrhage in her left basal ganglia. She underwent a caesarean section and brain surgery before being admitted to the ICU. She soon developed severe pneumonia and hypoxemia. Given that multiple sputum cultures were negative, the patient's bronchoalveolar lavage fluid was submitted for next-generation sequencing (NGS) to determine the pathogen responsible for the pneumonia; as a result, P. micra was determined to be the causative pathogen. Accordingly the antibiotic therapy was altered and the pneumonia improved. CONCLUSION: In this case, we demonstrated severe pneumonia caused by the anaerobic organism P. micra, and the patient benefited from receiving the correct antibiotic. NGS was used as a method of quick diagnosis when sputum culture failed to distinguish the pathogen.

Pituitary tuberculosis presented with pituitary coma.

BACKGROUND: Pituitary tuberculosis is very rare. Its diagnosis is difficult unless a bacteriological or histological evidence of tuberculosis. OBSERVATION: We report the case of a 54 years old woman who presented with a pituitary coma that occurred two weeks after the initiation of antituberculous therapy for cervical lymph node tuberculosis. Resonance magnetic imaging showed a pseudotumoral aspect of the pituitary gland. She had hormonal replacement and anti-tuberculous therapy. Outcome was favourable with the normalization of both the pituitary function and the pituitary volume. However, an acute hypopituitarism happened eight months after the withdrawal of antituberculous, which were taken during 12 months. The re initiation of anti tuberculous therapy and its extension to two years leaded to a prolonged remission. CONCLUSION: the three-phase outcome confirms the tuberculous origin of the hypophysitis in our patient.

Sepsis-induced brain dysfunction.

Systemic infection is often revealed by or associated with brain dysfunction, which is characterized by alteration of consciousness, ranging from delirium to coma, seizure or focal neurological signs. Its pathophysiology involves an ischemic process, secondary to impairment of cerebral perfusion and its determinants and a neuroinflammatory process that includes endothelial activation, alteration of the blood-brain barrier and passage of neurotoxic mediators. Microcirculatory dysfunction is common to these two processes. This brain dysfunction is associated with increased mortality, morbidity and long-term cognitive disability. Its diagnosis relies essentially on neurological examination that can lead to specific investigations, including electrophysiological testing or neuroimaging. In practice, cerebrospinal fluid analysis is indisputably required when meningitis is suspected. Hepatic, uremic or respiratory encephalopathy, metabolic disturbances, drug overdose, sedative or opioid withdrawal, alcohol withdrawal delirium or Wernicke's encephalopathy are the main differential diagnoses. Currently, treatment consists mainly of controlling sepsis. The effects of insulin therapy and steroids need to be assessed. Various drugs acting on sepsis-induced blood-brain barrier dysfunction, brain oxidative stress and inflammation have been tested in septic animals but not yet in patients.

Risk factors for death and severe sequelae in Malawian children with bacterial meningitis, 1997-2010.

BACKGROUND: Acute bacterial meningitis (ABM) causes significant death and disability in children worldwide, with HIV recognized as an established risk factor for infection and negative outcomes. However, additional major risk factors for death and disability in pediatric ABM remain unclear. METHODS: We conducted a retrospective analysis of case data from 3 departmental studies of ABM involving 1784 children <15 years old who attended Queen Elizabeth Central Hospital in Blantyre, Malawi during 1997 to 2010. Univariate and multivariate logistic regression models were used to estimate the effects of HIV seropositivity, impaired consciousness and causative organism on death and severe sequelae. RESULTS: Impaired consciousness or coma at the time of admission was strongly associated with death (coma: odds ratio [OR] = 14.4, 95% confidence interval [CI]: 9.42, 22.1) and severe sequelae (Coma: OR = 3.27, 95% CI: 2.02, 5.29) in multivariate logistic regression models. HIV seropositivity was significantly associated with increased odds of death (OR = 1.65, 95% CI: 1.20, 2.26) but not with developing severe sequelae (OR = 0.88, 95% CI: 0.56, 1.38). After adjustment, infection with Salmonella spp. was associated with increased odds of death (OR = 2.11, 95% CI: 1.06, 4.08) and pneumococcal meningitis was associated with increased odds of severe sequelae (OR = 1.84, 95% CI: 1.03, 3.29). CONCLUSIONS: Impaired consciousness and HIV infection increased the odds of death from ABM in Malawian children. Use of pneumococcal conjugate vaccine could greatly reduce the burden of ABM in Malawi.

Clinical features and course of bacterial meningitis in children.

AIM: To analyze the clinical features and course of and to define the risk factors for bacterial meningitis in children. MATERIAL AND METHODS: Retrospective study of 100 cases of bacterial meningitis in patients aged 0-18 years admitted to the Iasi Infectious Diseases Hospital between 2005 and 2010. RESULTS: We found a clear prevalence in male children (58%) from rural area (67%), with the highest incidence in the age group 2-5 years. A significant percentage of patients (43%) had previous hospitalization, condition which is known as predisposing factor for bacterial meningitis, the most common being ear infections (20%) and height and weight deficit (9%). 71% of patients were admitted within the first 48 h. The most common onset clinical manifestations were fever (84%), vomiting (70%), signs of meningeal irritation (59%), somnolence (23%), loss of appetite (19%), and coma in 5% of patients. In 36% of cases CSF was opalescent with moderate pleocytosis (35%); in 29% of patients CSF albumin level ranged between 0.7-1.0 g, the majority presenting normal glycorahia (71%). In only 21% of cases the microbial agent was identified (pneumococcal and meningococcal etiology, 8% and 6%, respectively). The course was generally favorable, and mortality rate was low (5%). Complications occurred in 3% of patients consisting in hydrocephalus and brain abscess. CONCLUSIONS: Bacterial meningitis remains a disease with potentially severe course. Clinical onset, most commonly atypical in children, requires differential diagnosis at the time of admission in order to initiate the most appropriate antibiotic therapy.

Early outcomes of group B streptococcal meningitis in the 21st century.

BACKGROUND: Group B streptococcal (GBS) meningitis is diagnosed less frequently than in the 1970s and 1980s. There are few contemporary data regarding outcomes from GBS meningitis and factors that might predict an adverse outcome. METHODS: A retrospective evaluation was conducted of term and near-term infants (≥36 weeks' gestation) with GBS meningitis hospitalized at Texas Children's Hospital from 1998 to 2006 to assess outcomes and to define features predictive of adverse outcomes. RESULTS: Six infants had early-onset (<7 days) meningitis and 47 had late-onset (≥7 days) GBS meningitis. Three infants died. Infants received broad-spectrum antibiotics initially and then penicillin (68%), ampicillin (28%), or cefotaxime (4%) for a mean of 21 (range, 15-44) days. Among survivors, 11 (22%) were neurologically impaired at hospital discharge with manifestations including persistent seizures (10), hypertonicity (9), and dysphagia (3). The 14 infants who died or had adverse outcomes at hospital discharge were more likely to present with seizures within hours of admission (P < 0.001), have coma or semicoma (P < 0.001), require pressor support (P = 0.001), and have an initial cerebrospinal fluid protein ≥300 mg/dL (P = 0.005) or glucose <20 mg/dL (P = 0.03) than were the 39 with infants with normal neurologic examinations. Seizures at admission remained a significant risk factor (P = 0.024) by multivariate analysis. CONCLUSIONS: Despite advances in intensive care, 26% of term and near-term infants with GBS meningitis die or have neurologic impairment at hospital discharge. Additional strategies to prevent GBS meningitis are needed.

Acute neurological involvement in diarrhea-associated hemolytic uremic syndrome.

BACKGROUND AND OBJECTIVES: Neurologic involvement is the most threatening complication of diarrhea-associated hemolytic uremic syndrome (D+HUS). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We report a retrospective multicenter series of 52 patients with severe initial neurologic involvement that occurred in the course of D+HUS. RESULTS: Verotoxigenic Escherichia coli infection was documented in 24. All except two patients had acute renal failure that required peritoneal dialysis, hemodialysis, or both techniques. A first group of eight patients remained with normal consciousness; five of them had protracted seizures. A second group of 23 patients had stuporous coma; five of these had protracted severe seizures, and 18 had a neurologic defect including pyramidal syndrome, hemiplegia or hemiparesia, and extrapyramidal syndrome. A third group of 21 patients had severe coma. Plasma exchanges were undertaken in 25 patients, 11 of whom were treated within 24 hours after the first neurologic sign; four died, two survived with severe sequelae, and five were alive without neurologic defect. Magnetic resonance imaging (MRI) for 29 patients showed that (1) every structure of the central nervous system was susceptible to involvement; (2) no correlation seemed to exist between special profile of localization on early MRI and the final prognosis; and (3) MRI did not exhibit any focal lesions in three patients. The overall prognosis of the series was marked by the death of nine patients and severe sequelae in 13. CONCLUSIONS: Neurologic involvement is associated with a severe renal disease but does not lead systematically to death or severe disability.

Time-related increase of staphylococci, Enterobacteriaceae and yeasts in the oral cavities of comatose patients.

BACKGROUND/PURPOSE: The composition of oral microbiota in comatose patients remains uncertain. Some pulmonary pathogens may be found in dental biofilms or as part of the saliva microbiota. It is supposed that some pneumopathogenic microorganisms may overgrow in the mouths of comatose patients and spread to their lungs. METHODS: The oral colonization dynamics of staphylococci, Enterobacteriaceae and yeasts in nine comatose patients (group 1), and in 12 conscious patients that brushed their teeth at least twice a day (group 2) was evaluated. Both groups were followed up for 7 days after hospitalization. Daily samples of saliva were obtained, dispersed and plated on selective culture media and colony forming units of each microbial group were obtained. RESULTS: For patients in group 1, the counts of total viable bacteria, staphylococci, Enterobacteriaceae and yeasts progressively increased in a time-dependant manner. For the conscious patients of group 2, there was no increase. CONCLUSION: It would appear that concomitant consciousness and brushing teeth are determinants in controlling the selected pneumopathogen counts in resting saliva. The increase in microbial counts in comatose patients is understandable because these microorganisms could spread to the lungs.

[Clinical aspects of tuberculous meningitis in children]. / Aspecte clinico-evolutive ale meningitei tuberculoase la copil.

UNLABELLED: The aim of the study was to investigate the particularities of the clinical manifestation and evolution of tuberculous meningitis at children. MATERIAL AND METHOD: The study was made between January 2000 and December 2008 in Clinic of Infectious Diseases IaSi and Emergency County Hospital ,,Sf. Ioan cel Nou" Suceava on a group of 169 children with tuberculous meningitis. RESULTS: The majority (78.1%) of patients had poor socio-economic conditions and 22.4$ had a family TB contact. The onset of the symptoms was atypical in infants and small children with fever associated with digestive, neurological or pulmonary manifestations. The admission in hospital was delayed in 56.8% of patients and 39.05% had a severe general status with coma. The positive diagnosis was based on cytological and biochemical features of CSF, results of QuantilFERON. TB Gold, pulmonary images, family TB contact and evolution under anti-tuberculous therapy. We observed a high rate of complications represented by hydrocephaly (28.9%). 18 patients died (4 infants), the cause of dead being meningeal coma or complications. CONCLUSION: The diagnosis of tuberculous meningitis at children remains a problem because of the atypical clinical manifestation, the delay of initiating the therapy causing high mortality and frequent complications.

Community-acquired bacterial meningitis in elderly patients: experience over 30 years.

Clinical characteristics, etiologies, evolution, and prognostic factors of community-acquired bacterial meningitis in elderly patients are not well known. To improve this knowledge, all episodes of community-acquired bacterial meningitis were prospectively recorded and cases occurring in patients >or=65 years old were selected. During the period 1977-2006, 675 episodes in adults (aged >or=18 yr) were recorded, with 185 (27%) in patients aged >or=65 years old; 76 were male and 109 were female, with a mean age of 73 +/- 6 years (range, 65-93 yr). Causative microorganisms were Streptococcus pneumoniae 74, Neisseria meningitidis 49, Listeria monocytogenes 17, other streptococcal 9, Escherichia coli 6, Haemophilus influenzae 4, Klebsiella pneumoniae and Staphylococcus aureus 2 each, Capnocytophaga canimorsus and Enterococcus faecalis 1 each, and unknown in 20. On admission 91% had had fever, 32% were in a coma (Glasgow Coma Scale or=65 yr), who showed a higher frequency of diabetes and malignancy as underlying disease; pneumonia, otitis, and pericranial fistula as predisposing factors; and S. pneumoniae and L. monocytogenes as etiology. There were also differences in clinical presentation, complications, sequelae, and mortality. Factors independently related with mortality were age, pneumonia as a predisposing factor, coma on admission, and heart failure and seizures after therapy. Dexamethasone therapy was a protective factor. In conclusion, bacterial meningitis in elderly patients is associated with greater diagnostic difficulties and neurologic severity and more complications, as well as with increased mortality. Antiseizure prophylaxis might be useful in these patients.

[Community acquired acute bacterial meningitis--a 10 year review]. / Meningite bacteriene comunitare: analiza pe 10 ani.

UNLABELLED: Bacterial meningitis is still an important topic for the infectious diseases specialist, due to it's high incidence, severity and it's high mortality rate. MATERIAL AND METHOD: We retrospectively studied 679 patients diagnosed with community acquired bacterial meningitis in the Infectious Diseases Hospital Iasi, Romania between 1998 and 2007. RESULTS: The annual number of admissions slightly decreased in the last years. Most patients were males (62.1%). Predisposing factors were present in 34.9% of cases. Seizures were described in 19.6% of cases, more frequent in children. The CSF was purulent only in 69.4% of patients, 29.6% of them receiving antibiotics prior to admission; the albumin level in the CSF of pneumococcal meningitis was higher than in other meningitis. The etiology was established in 51.6% of cases, more frequent in sucklings (68.1%). N. meningitidis was the most common cause of community acquired acute bacterial meningitis (CABM) (28.5%) followed by S. pneumoniae (14%). S. pneumoniae was susceptible to penicillin in 79% of cases. The mean mortality rate was 13.1%. CONCLUSION: Factors associated with a poor prognosis were: pneumococcal etiology, age over 60, and the presence of seizures or coma at admission.

Coma as a presenting symptom of primary HIV infection.

Primary HIV infection (PHI) is symptomatic in 50-90% of patients. The diagnosis, however, is seldom made at first presentation. This is probably because of the multifaceted and unspecific manifestations, the omission to perform adequate diagnostic testing and the failure to assess risks for PHI. Meningoencephalitis has been described as a fairly common presenting condition in PHI, with nuchal rigidity, fatigue, photophobia and headache; therefore, PHI should be considered in the differential diagnosis of aseptic meningitis. We present the case of a man with acute coma and a presumptive diagnosis of viral encephalitis in whom serological testing showed HIV encephalitis during PHI.

Endovascular treatment for a unusually large mycotic aneurysm manifesting as intracerebral hemorrhage - case report.

A 62-year-old male presented with an unusually large mycotic aneurysm mimicking a saccular aneurysm manifesting as coma and hypotension. Computed tomography showed intracerebral and intraventricular hemorrhage. He was in septic shock due to acute infectious endocarditis. Cerebral angiography disclosed a large distal anterior cerebral artery aneurysm. The diagnosis was mycotic aneurysm based on the morphological features and associated endocarditis. The aneurysm and the parent artery were successfully occluded by endovascular embolization. High-dose antibiotic therapy in the following 6 weeks resulted in resolution of the infectious endocarditis. Early exclusion of ruptured mycotic aneurysm is mandatory because of the high risk of rerupture. Endovascular treatment is an effective alternative for mycotic aneurysms, especially if the patient's general condition is poor. Parent artery occlusion can be safely tolerated if the aneurysm is located distally.

Community-acquired Escherichia coli meningitis in adult.

We report a case of E. coli meningitis presented initially without nuchal rigidity. Despite intensive care treatment, CSF was not sterilized and the patient died at 17 days after his admission. Patients with an unexplained altered sensorium with fever should undergo LP to evaluate for this rare entity and to direct early antimicrobial treatment which possesses efficacy for meningeal infection.

Mycoplasma pneumoniae: a cause of coma in the absence of meningoencephalitis.

Mycoplasma pneumoniae encephalitis is a recognized cause of reversible coma in children. As an etiology of infectious encephalitis, it yields a relatively poorer prognosis than most other causes of infectious encephalopathies. Encephalitis is generally diagnosed by a constellation of clinical symptoms and confirmed by a cerebrospinal fluid (CSF) examination revealing cell pleocytosis and elevated protein. That Mycoplasma pneumoniae encephalopathy can occur in the presence of a normal CSF examination is less well appreciated. The authors report two children who presented with coma and normal CSF findings in whom a diagnosis of acute Mycoplasma pneumoniae infection was made. The two children both had rapid and complete recovery over several days. These cases exemplify that coma can result from acute infection with Mycoplasma pneumoniae in the absence of an inflammatory CSF response and that a normal CSF may herald a more favorable prognosis.

[Mycoplasma pneumoniae meningoencephalitis]. / Méningoencéphalite à Mycoplasma pneumoniae.

BACKGROUND: Severe central nervous system diseases, such as encephalitis, have been reported in association with Mycoplasma pneumoniae infections. CASE REPORT: After an ENT infection, a 9-year-old boy with Down's syndrome developed encephalitis revealed by an acute alteration in consciousness. Head computed tomography showed, after 2 weeks, an infiltration in the basal ganglia region. The diagnosis of Mycoplasma pneumoniae encephalitis was made; recovery was complete in a few weeks. CONCLUSION: Mycoplasma pneumoniae infection should be considered in all cases of acute encephalopathy; yet the pathogenesis of the disorder is unknown and the treatment uncertain.

Coma in fulminant pneumococcal meningitis: new MRI observations.

We report a 45-year-old man with fulminant pneumococcal meningitis. Fluid attenuated inverse ratio MR images showed the ravaging consequences of occlusive vasculopathy and a transient purulent basal exudate. Bilateral thalamic lesions may have explained the failure to awaken despite appropriate antibiotic therapy.