Estudio en el grupo de meningitis bacteriana, influencia de la malnutricion en el curso de niños con meningitis bacteriana / Study group of bacterial meningitis, malnutrition influence the course of children with bacterial meningitis

La meningitis bacteriana sigue siendo un problema importante a nivel mundial, a pesar de la virtual eliminación inducida por la vacuna del Haemophilus influenzae tipo b y en menor medidadel neumococo. Una de las razones de su mal pronóstico en los países en desarrollo es la asociación con bajo peso.

Risk of Guillain-Barré syndrome after measles-mumps-rubella vaccination.

OBJECTIVE: To assess the postulated causal association between measles-mumps-rubella (MMR) vaccination and Guillain-Barré syndrome (GBS). STUDY DESIGN: Active retrospective study based on linkage of the nationwide hospital discharge register with individual vaccination records. All patients hospitalized for treatment of GBS in Finland between November 1982 and December 1986 were included in the study. RESULTS: During the study period, 189 patients were hospitalized for treatment of GBS, and approximately 630,000 vaccine recipients received 900,000 doses of MMR vaccine; 24 of the 189 patients represented the prevailing target population for MMR vaccination, of whom 20 were vaccinated. MMR vaccination did not cause any increase over the background incidence of GBS, and no clustering of cases of GBS occurred at any time point after administration of MMR vaccine. The interval between vaccination and onset of symptoms of GBS exceeded the designated risk period of 6 weeks in all cases, varying from 80 days to years. MMR vaccination after recovery from GBS did not cause relapses of the illness. Respiratory or gastrointestinal tract infection predated the onset of GBS by 3 to 30 days in 20 (83%) of the 24 patients. CONCLUSIONS: No causal association seems to prevail between MMR vaccination and GBS.

C-reactive protein is useful in distinguishing Gram stain-negative bacterial meningitis from viral meningitis in children.

OBJECTIVE: To clarify to what extent Gram stain-negative bacterial meningitis can be distinguished from viral meningitis by assessment of cerebrospinal fluid (CSF) and blood indices and serum C-reactive protein (CRP) in children over 3 months of age. DESIGN: Common CSF indices, blood leukocyte counts, and serum CRP values were compared between patients with bacterial meningitis who had a positive CSF bacterial culture but a negative Gram stain and patients with viral meningitis. POPULATION: Three hundred twenty-five consecutive patients with CSF culture-proven bacterial meningitis, for whom Gram stain was negative in 55 cases, and 182 children with proven or presumed viral meningitis. RESULTS: Significant differences between patients with bacterial and viral meningitis were found in all indices with large overlap in all except serum CRP. In patients with bacterial meningitis, the mean CSF glucose concentration, protein concentration, leukocyte count, blood leukocyte count, and serum CRP were 2.9 mmol/L (52 mg/dL), 1.88 g/L, 4540 x 10(6)/L, 18.0 x 10(9)/L, and 115 mg/L; and in those with viral meningitis, mean values were 3.3 mmol/L (59 mg/dL), 0.52 g/L, 240 x 10(6)/L, 10.6 x 10(9)/L, and <20 mg/L, respectively. Of the tests investigated in this study, only serum CRP was capable of distinguishing Gram stain-negative bacterial meningitis from viral meningitis on admission with high sensitivity (96%), high specificity (93%), and high negative predictive value (99%). CONCLUSION: Exclusion of bacterial meningitis with only the conventional tests is difficult. Combined with careful physical examination and CSF analyses, serum CRP measurement affords substantial aid.

C-reactive protein in measles.

Seventy-two children with early measles (1st-3rd day of rash), presenting at two centres in Santiago, Chile, were classified as having mild ('ordinary measles', n = 50), or moderate to severe measles ('primarily severe measles', n = 22). The level of serum C-reactive protein (CRP) was determined by nephelometry from a finger prick sample. The mean CRP value in ordinary measles, 19 mg/l, was significantly lower (P less than 0.001) than in primarily severe measles where the mean CRP was 65 mg/l. During late measles (5th-8th day of rash), the mean CRP was 19 mg/l if the child recovered uneventfully (n = 35), whereas the mean level of 123 mg/l (P less than 0.001) was encountered when the child suffered from complicating pneumonia (n = 22). We conclude that the simple quantitative CRP determination is a useful alarm signal during the course of measles: elevated levels point to severity or complications in recovery.

Serum C-reactive protein in childhood meningitis in countries with limited laboratory resources: a Chilean experience.

Quantitative C-reactive protein (CRP) was determined sequentially by nephelometry and photometry from a finger prick serum sample in 67 children with bacterial meningitis (BM) and 16 children with aseptic meningitis (AM). The initial mean CRP value of 180 mg/liter in children with BM differed significantly from the 12 mg/liter found in those with AM (P less than 0.001). In BM a slow descent instead of rapid normalization or a secondary increase in sequential CRP values were early indicators of complications during recovery, such as resistance to the antibiotic. A significant difference in the mean CRP values between uneventful and complicated courses of BM was observed from the fourth day on (P less than 0.001). The measurements obtained with nephelometry correlated reliably with the more widely available photometry (r = 0.99). Easily performed rapid CRP determinations can considerably improve the quality of care in meningitis patients, especially in those situations where facilities for performing bacterial cultures or antibiotic susceptibility testing are not available.

C-reactive protein in early detection of bacteremic versus viral infections in immunocompetent and compromised children.

The value of quantitatively determined C-reactive protein (CRP), measured from a finger prick sample for rapid detection of septicemia, was examined in 76 blood culture-positive infections in 54 immunocompetent and 18 compromised children; 73 patients with systemic viral infections served as controls. Development of a positive CRP reaction was also studied in 40 cases of acute epiglottitis. Beyond the neonatal age, an increased CRP value (greater than or equal to 20 mg/L) was found in 60 of 64 (94%) children with a positive blood culture for bacteria or fungus. By contrast, CRP remained below this value in 56 of 73 (77%) with viral infections. The immunologic status did not influence the CRP response. However, time had a highly significant (p less than 0.001) effect on CRP; a history of 6 to 12 hours of illness was required before CRP increased above normal. We conclude that CRP is a sensitive and rapidly reacting index in bacteremic infections. However, because other factors than septicemia also increase CRP, we deem a negative CRP value most informative; if two determinations taken several hours apart are less than 20 mg/L, the patient is very unlikely to have invasive bacterial infection.

C-reactive protein as a detector of organic complications during recovery from childhood purulent meningitis.

Twenty-eight bacteriologically proved episodes of purulent meningitis in 27 infants and children were monitored prospectively with sequential determinations of serum C-reactive protein. Except in one rapidly fatal case, all the patients showed decreasing CRP values for about 1 week. In five patients the CRP values than returned to a high level (P less than 0.001). Each of these patients developed an organic complication (subdural effusions in three, transient widening of the ventricles in one, purulent arthritis with osteomyelitis in one). Except for one infant with sensorineural hearing loss, which probably had developed early in the course of meningitis, no permanent sequelae were found in the patients with uncomplicated courses. One infant later had a relapse of Escherichia coli meningitis, reflected in a sharp increase of CRP. We conclude that sequential CRP measurements may be performed routinely to detect potential complications at an early stage of bacterial meningitis.

Meningococcal disease: still with us.

In spite of considerable success in the development of drugs and vaccines, the problem of disease due to Neisseria meningitidis is far from solved. As late as the 1970s, epidemics of meningococcal disease occurred in at least 30 countries in all parts of the world. Most of the epidemics were caused by group A organisms, but epidemics due to groups B and C also took place occasionally. The case/fatality rate was usually less than 10% among patients with true meningitis; among those with "pure" septicemia, it was as high as 70%. Children less than five years old are most prone to meningococcal disease, but mortality is often highest among young adults. Because close contacts of the index case are at considerable risk--at least several hundred times higher than in the rest of the population--they should be protected immediately with an appropriate antibiotic and, if possible, with a vaccine as well. At the present time, however, no vaccine is available for use against group B organisms, which in nonepidemic conditions are the most prevalent of all meningococci.

Meningococcus group A vaccine in children three months to five years of age. Adverse reactions and immunogenicity related to endotoxin content and molecular weight of the polysaccharide.

Vaccination of 21,007 children between the ages of three months and five years was completed with five different lots of the meningococcal group A capsular polysaccharide vaccine. A correlation was found between the frequency and severity of adverse reactions and the endotoxin content of the vaccine lots. All vaccine lots elicited a serum antibody response. The endotoxin content of the vaccines did not correlate with the serum antibody response.