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Polymicrobial anaerobic meningitis is a rare event secondary to a contiguous infection in the head or neck. Anaerobic meningitis due to a meningo-intestinal fistula is a rare event with only two cases reported in the literature. We describe a new case of adult polymicrobial anaerobic meningitis after colorectal surgery and radiotherapy and review the previous two cases.
One hundred and one cases of nosocomial meningitis in children from a national survey over 8 years have been analyzed for risk factors and outcome. From 101 cases, 115 organisms were isolated. Seventy six were Gram-positive bacteria, 29 were Gram-negative and there were ten fungal isolates. Major risk factors for acquisition of nosocomial meningitis were neurosurgery (70.2%), ventriculoperitoneal shunt (42.9%), prior therapy with broad spectrum antibiotics (64.1%), central venous catheter (94.5%), premature neonates with very low birth weight (32.8%) and total parenteral nutrition (68.8%). Overall attributable mortality was 14. 9%; in bacterial infection it was 13.2% and in fungal nosocomial meningitis, 30.0%. Higher mortality was significantly related to perinatal pathology with CNS abnormality, prematurity polymicrobial infection with Enterobacteriaceae and concomitant bacteraemia. Prematurity in neonates, very low birth weight and infection with Enterobacteriaceae were significantly associated with a worse outcome.
Trovafloxacin is a recently approved fluoroquinolone with excellent activity against gram-positive and gram-negative organisms that offers a potential alternative for treatment of beta-lactam-resistant pneumococcal meningitis. Using the rabbit meningitis model, we sought to characterize the pharmacodynamic properties of trovafloxacin in the cerebrospinal fluid (CSF). Animals were given single doses of trovafloxacin of 10, 15, 20 or 30 mg/kg; 1 h after Infusion mean CSF concentrations were 0.59+/-0.18, 0.74+/-0.14, 1.12+/-0.12 and 1.07+/-0.35 mg/L, respectively. The bacterial killing rate Increased with increasing dosages of trovafloxacin, indicating that its activity is concentration dependent. All three pharmacodynamic Indices (area under the concentration curve (AUC)/MBC, peak concentration (Cmax)/MBC, and time above MBC (T > MBC)) correlated with bacterial killing; however, AUC/MBC correlated best (r = 0.71). In a second experiment we found comparable bacterial killing with multiple doses of trovafloxacin given either every serum half-life or every two serum half-lives. In both experiments bacterial regrowth occurred when the concentration of trovafloxacin in CSF fell below the MBC. These data have been used in formulating an appropriate regimen for trovafloxacin treatment of bacterial meningitis in children.
The Amplicor Enterovirus PCR test was compared with viral culture for the detection of enteroviruses in cerebrospinal fluid (CSF) specimens. In a multicenter study in which nine laboratories participated, a total of 476 CSF specimens were collected from patients with suspected aseptic meningitis. Sixty-eight samples were positive by PCR (14.4%), whereas 49 samples were positive by culture (10.4%), demonstrating that the Amplicor Enterovirus PCR test was significantly more sensitive than culture (P < 0.001). After discrepancy analysis the sensitivity and specificity of the Amplicor Enterovirus PCR test obtained by using viral culture as the "gold standard" were 85.7 and 93.9%, respectively. Our results with the CSF specimens collected in different countries demonstrate that the Amplicor test is capable of detecting a large variety of enterovirus serotypes and epidemiologically unrelated isolates in CSF specimens from patients with aseptic meningitis. The Amplicor Enterovirus PCR test is a rapid assay which can be routinely performed with CSF samples and is an important improvement for the rapid diagnosis of enteroviral meningitis.
The diffusion of metioprim (MTP), tetroxoprim (TXP) and sulphadiazine (SDZ) in cerebrospinal fluid (CSF), following single intravenous doses and continuous infusions, was studied in dogs. The drugs penetrated well into the CSF of animals with and without experimental Staphylococcus aureus meningitis. In dogs with healthy meninges, the CSF bioavailability - expressed as the ratio of CSF/plasma area under the curve 0-5-hour values - following continuous infusion was determined to be 86.7% for MTP, 58.2% for TXP and 38.8% for SDZ. In infected animals, CSF availability following continuous infusion increases slightly to ratios of 96% (MTP), 70% (TXP) and 50% (SDZ). For all drugs, the concentrations reached in CSF were above the minimum inhibition concentrations for the majority of Enterobacteriaceae, indicating their potential value in treatment of gram-negative bacillary meningitis.
Intracranial hypotension is a cause of diffuse enhancement of the pachymeninx with gadolinium, which often is associated with subdural fluid collections. We reviewed the results of meningeal biopsy in six patients with intracranial hypotension and diffuse pachymeningeal enhancement to correlate the MRI findings with histopathologic observations and to explain the abnormalities seen on MRI. Grossly, the dura mater was unremarkable in all patients, as were the leptomeninges, except for one patient with prolonged (18 months) intracranial hypotension in whom the arachnoid was thickened and opaque. Microscopically, the dura mater was entirely normal on its epidural aspect; however, a fairly thin zone of fibroblasts and thin-walled small blood vessels in an amorphous matrix was noted on the subdural aspect. In the patient with longstanding symptoms, diffuse benign arachnoidal cell proliferation was also noted, probably a reaction triggered by longstanding changes in the subdural area, as noted in the five other patients. There was no evidence of inflammation, infection, or metastatic neoplasia. These findings suggest that in intracranial hypotension, the dural-meningeal abnormalities probably represent reactive secondary phenomena, likely related to hydrostatic changes in the CSF, and not a primary meningeal process.
Meningeal (MM) and perivascular macrophages (PVM) constitute major populations of resident macrophages in the CNS that can be distinguished from microglial cells. So far, there is no direct evidence that demonstrates a possible role of MM and PVM in the CNS during normal or pathologic conditions. To elucidate the role of the MM and PVM during CNS inflammation, we have developed a strategy using a single intraventricular injection of mannosylated clodronate liposomes, which results in a complete and selective depletion of the PVM and MM from the CNS. Depletion of the MM and PVM during experimental pneumococcal meningitis resulted in increased illness, which correlated with higher bacteria counts in the cerebrospinal fluid and blood. This was associated with a decreased influx of leukocytes into the cerebrospinal fluid, which occurred despite an elevated production of relevant chemokines (e.g., macrophage-inflammatory protein-2) and a higher expression of vascular adhesion molecules (e.g., VCAM-1). In contrast, the higher bacterial counts correlated with elevated production of local and systemic inflammatory mediators (e.g., IL-6) indicating enhanced local leukocyte and systemic immune activation, and this may explain the worsening of the clinical signs. These findings show that the PVM and MM play a protective role during bacterial meningitis and suggest that a primary action of these macrophages is to facilitate the influx of leukocytes at the blood-brain barrier. More in general, we demonstrate for the first time that the PVM and MM play a crucial role during inflammation in the CNS.
INTRODUCTION: Bacterial meningitis in adult patients, produced by streptococci other than Streptococcus pneumoniae, is not common. CASE REPORT: We report the case of a 74 year old male patient with meningitis and endocarditis due to Streptococcus bovis (group D, not enterococcus), sensitive to penicillin (CMI< 0.1 mg/L), with no characteristic clinical or analytical discoveries. A gastrointestinal exploration revealed only diverticles in the colon and two lesions compatible with splenic infarction, observed by using computerised axial tomography of the abdomen. The patient responded favourably to a four week course of antibiotics; he remained asymptomatic, afebrile and culture negative after the therapy was stopped. CONCLUSIONS: In many previously reported cases, there is an association with gastrointestinal illness, endocarditis or oral lesions. Gram staining of the cerebrospinal fluid is usually negative and the neurological signs are often subtle. In the case of bacteraemia, endocarditis or S. bovis meningitis, the presence of an underlying pathology of the colon due to the frequent association between these processes must be ruled out. Treatment with penicillin G is usually sufficient.
We reported a 59-year-old woman with four episodes of recurrent self-limited aseptic meningitis. Her episodes had resolved in 14-20 days without residural and all were marked clinically by acute headache, back pain, and nausea with fever. No concurrent systemic or genital symptoms or signs were present. CSF analysis performed on the third day of her fourth episode of recurrent meningitis showed the DNA of herpes simplex virus type 2 by means of the polymerase chain reaction method. Acyclovir therapy may be useful in a further possible occurrence of meningitis.
Out of 200 patients diagnosed of acute of chronic brucellosis, cases were first selected who had neurologic involvement (14%) and then those who had brucellar meningitis (CDC criteria) which corresponds to 4% of the total of the series. The clinical course, evolution time, neurologic manifestations and serologic and bacteriologic characteristics in blood and specifically in the cerebrospinal fluid (CSF). This study was contrasted with the literature review and the conclusion is reached that brucellar meningitis is a peculiar form of clear fluid meningitis, not exceptional in our environment considering the prevalence of brucellosis.
The absence of reliable laboratories for culture of Neisseria meningitidis, Haemophilus influenzae and Streptococcus pneumoniae, the three main causes of bacterial meningitis in Africa, hampers microbiological surveillance in these countries. To compensate for this situation in Niger, a multiplex single-tube PCR method has been implemented at a central level to test cerebrospinal fluid (CSF) samples. The overall confirmation rate for PCR (N=3791) was 40.8% compared with 16.0% for culture (N=945) (P<10(-6)). Among 850 CSF specimens tested by both methods, the overall confirmation rate was 29.4% for PCR and 16.4% for culture (P<10(-8)). PCR was also efficient for the CSF specimens stored in Trans-isolate medium. In conclusion, PCR assay is currently a key tool in Africa to improve microbiological surveillance of bacterial meningitis.
Benign recurrent aseptic meningitis (Mollaret's meningitis) is rare. Only five cases have been reported in this country. This article reports another case and briefly reviews the characteristic manifestations of this disorder.
Definite diagnosis of meningeal seeding by systemic cancer relies on the presence of malignant cells in the cerebrospinal fluid (CSF). In the absence of such cells in the CSF, only two other tests strongly suggest the diagnosis--a CT scan and a myelogram. We report a case in which the diagnosis was strongly suggested by an unusual uptake of Tc-99m methylene diphosphonate by the leptomeninges during a skeletal scan and later established by the presence of malignant cells in the CSF. We believe that radionuclide scan may be an additional diagnostic test in some cases with meningeal seeding by systemic cancer. We therefore are extending our studies to validate this possibility.
BACKGROUND: Splenic lymphoma with villous lymphocytes (SLVL) is a low grade, non-Hodgkin's lymphoma with a stable or slowly progressive clinical course. To the authors' knowledge, central nervous system involvement has not been described previously in patients with SLVL. METHODS: Morphologic, immunocytochemical, and immunohistochemical analyses were conducted to determine the nature of villous lymphocytes in the peripheral blood, spleen, and cerebrospinal fluid (CSF) of a patient with massive splenomegaly. RESULTS: A diagnosis of SLVL was made, based on tartrate-resistant acid phosphatase-negative peripheral villous lymphocytosis with CD19+, CD20+, HLA-DR+ phenotypes, and the involvement of spleen white pulp with these cells. Mononuclear cells in the CSF showed the same morphologic and immunocytochemical features seen in the villous lymphocytes in the peripheral blood and spleen. Splenectomy and intrathecal chemotherapy were successful in clearing leukemic cells from the CSF. CONCLUSION: In this patient with SLVL in whom leukemic meningitis developed, meningitis was found to be a possible initial manifestation of SLVL.
Tuberculous meningitis (TBM) is still a major cause of serious illness in many parts of the world. The newer diagnostic tests and neuroimaging methods are unlikely to be available in many developing countries. We attempt to identify simple parameters for early diagnosis. A retrospective study was performed to compare the clinical and laboratory features of cultured-confirmed, TBM (134) and other bacterial meningitis (709). Features independently predictive of TBM were studied by multivariate logistic regression to develop a diagnostic rule. Six features were found predictive: length of clinical history >5 days, headache, total cerebrospinal fluid (CSF) white blood cell count of <1000/mm3, clear appearance of CSF, lymphocyte proportion of >30%, and protein content of >100 mg/dL. Application of 3 or more parameters revealed 93% sensitivity and 77% specificity. Applying this diagnostic rule can help in the early diagnosis of TBM, in both children and adults.
Patients with bacterial meningitis and posttraumatic and/or postsurgical access to the CSF are at risk for superinfection with Candida species. Patients who are not improving on appropriate antimicrobial chemotherapy for bacterial meningitis or are deteriorating after initial improvement should have a CSF reexamination for Candida superinfection.
Usefulness of cell count and concentrations of glucose and total protein in CSF are analysed with regard to the diagnosis of leptomeningeal metastasis from solid and hematological malignancy. A group of patients with pleiocytosis in CSF of non-neoplastic origin served as a reference group. It is concluded that these routine tests have limited value for the determination of the viral, bacterial or neoplastic etiology of meningeal disorders. The most important value of these tests appears to be the discriminating capacity of the finding of an increased number of polymorphonuclear leucocytes, regularly found in patients with acute bacterial meningitis.
We describe two cases of aseptic meningitis occurring some time after pneumococcal meningitis. Both cases may have resulted from an inflammatory response to persistent pneumococcal cell membrane components, as the cerebrospinal fluid samples were positive by the Binax NOW Streptococcus pneumoniae antigen test. Potential mechanisms and diagnostic impact are discussed.