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PubMed2005

Contrast-enhanced FLAIR in the early diagnosis of infectious meningitis.

We investigated the accuracy of MRI in the early diagnosis of infectious meningitis with emphasis on the value of gadolinium-enhanced fluid-attenuated inversion recovery (FLAIR) sequence. Twenty-seven patients with clinical suspicion of infectious meningitis were included. MRI was performed within 3 h of clinical evaluation. For all patients, T1-weighted spin-echo, dual-echo T2-weighted fast-spin-echo and FLAIR sequences were performed, followed by gadolinium-enhanced T1-weighted spin-echo and FLAIR sequences. Final diagnosis was based on the clinical findings and the analysis of cerebrospinal fluid, obtained by lumbar puncture after the MRI. Infectious meningitis was confirmed in 12 patients. In all of these patients of the plain studies, FLAIR was positive in only four patients. MRI gadolinium-enhanced FLAIR showed abnormal meningeal enhancement in all 12 patients, while gadolinium-enhanced T1-weighted spin-echo was positive only in six cases. There were no false-positive or false-negative results. It is concluded that MRI could have an important role in the early screening for infectious meningitis, provided a gadolinium-enhanced FLAIR sequence is used.

Adult↗
PubMed1998

High-dose gadolinium-enhanced MRI for diagnosis of meningeal metastases.

We compared high-dose (0.3 mmol/kg) and standard-dose (0.1 mmol/kg) gadolinium-enhanced MRI for diagnosis of meningeal metastases in 12 patients with suspected meningeal metastases. They were imaged with both standard-dose and high-dose gadolinium. All patients with abnormal meningeal enhancement underwent at least one lumber puncture for cerebrospinal fluid (CSF) cytology, while patients with normal meningeal enhancement were followed clinically. All patients with negative CSF cytology also were followed clinically. A single observer reviewed all the images, with specific attention to the enhancement pattern of the meninges. Abnormal leptomeningeal enhancement was present in three cases, and abnormal pachymeningeal enhancement in three other patients. All of these patients had abnormal CSF analyses. In two of the three cases of abnormal leptomeningeal enhancement the disease was more evident on high-dose than on standard-dose imaging; in one case the abnormal enhancement was visible only on high-dose imaging. In one of the three cases with abnormal pachymeningeal enhancement, the disease was evident prospectively only with high-dose imaging.

Adult↗
PubMed1999

Incidence of Haemophilus influenzae type b meningitis among children less than 5 years of age in Slovakia.

Owing partly to a lack of disease burden data, Eastern and Central European countries have not introduced universal infant immunization against Haemophilus influenzae type b. To determine the incidence of Haemophilus influenzae type b meningitis among children less than 5 years of age, data were examined from eight districts in Slovakia that formed part of a national Haemophilus influenzae type b surveillance system. All invasive isolates of Haemophilus influenzae type b identified from these districts during 24 months (1996-1997) were sent to a single central laboratory for serotype confirmation. Thirty-five cases of confirmed Haemophilus influenzae type b meningitis were identified, for a disease incidence among children under 5 years of 17.3 per 100,000 population per year. Only 13 cases were identified during 1996, the first full year of the surveillance system. Records were available for review at six of the eight district laboratories and showed that, using World Health Organization definitions, almost half of the cases of probable bacterial meningitis were culture negative, suggesting that the true incidence of Haemophilus influenzae type b meningitis may be considerably higher than 17.3. The rate of Haemophilus influenzae type b meningitis among children less than 5 years of age in Slovakia is comparable to that found in Western Europe and North America during the prevaccine era. Thus, universal, publicly funded infant vaccination in Slovakia can be expected to have the same dramatic effect on Haemophilus influenzae type b disease morbidity and mortality as has been demonstrated in other countries that have adopted this approach.

Child, Preschool↗
PubMed1976

A fatal case of strongyloidiasis with Strongyloides larvae in the meninges.

A case of fatal strongyloidiasis associated with pyogenic meningitis in an adult male African is reported. Strongyloides larvae were present in the purulent exudate in the the meninges, an observation not, to the authors knowledge, hitherto reported in man. Fatal strongyloidiasis due to autoinfection has been reported by several authors and De Paula (1962) reviewed the literature in 40 cases and added 10 others which he had studied. In Uganda fatal cases have been reported by Craven et al. (1971) and Poltera (1974). Although in some cases of fatal strongyloidiasis there was associated pyogenic meningitis (BROWN & PERNA, 1958; WILSON & THOMPSON, 1964; BASSAN-TREMINGER & EL-LANSHAR, 1968) we have not found in the literature any case in which Strongyloides stercoralis larvae or adult worms were found in the brain or meninges. We are, therefore, now reporting a case of fatal strongyloidiasis with pyogenic meningitis in which S. stercoralis larvae were present in the subarachnoid space.

Humans↗
PubMed1994

Bacterial meningitis in the pediatric population: paradigm shifts and ramifications for otolaryngology-head and neck surgery.

Various population-based studies have suggested that the incidence and epidemiology of bacterial meningitis is changing. No studies have been published which examine a sample population of the United States at large. Records of pediatric patients age 5 and under who were treated for bacterial meningitis (n = 470) at all US Army medical facilities between 1986 and 1991 were reviewed. The incidence of bacterial meningitis declined by 75% in the study group during this period. The largest decrease occurred in infants less than 1 year of age. The bacterial organisms isolated most commonly, in decreasing frequency were: Haemophilus influenza type b (HIB), pneumococcal, streptococcal, and staphylococcal. The most dramatic abatement occurred in Haemophilus meningitis following the introduction of HIB vaccinations. Neurologic sequelae were identified in 10% of meningitis survivors. The 2 most common impairments were hearing loss and speech/language delay. Economic modeling demonstrates tremendous savings in health care dollars from the decrease in disease incidence. These changes will have substantial bearing on training programs and practitioners, since the management of neurologic sequelae requires the expertise of multiple subspecialists. In the face of a medical onslaught, once devastating diseases are in retreat.

Child, Preschool↗
PubMed2006

Serum procalcitonin and other biologic markers to distinguish between bacterial and aseptic meningitis.

OBJECTIVE: To identify the biologic tests that best distinguish between bacterial and aseptic meningitis in an emergency department (ED). STUDY DESIGN: All children hospitalized for bacterial meningitis between 1995 and 2004 or for aseptic meningitis between 2000 and 2004 were included in a retrospective cohort study. Predictive values of blood (C-reactive protein, procalcitonin [PCT], white blood cell [WBC] count, neutrophil count) and cerebrospinal fluid (CSF) findings (protein, glucose, WBC count, neutrophil count) available in the ED were determined. Tests with the best predictive value were identified by using univariate and multivariate analyses and ROC curves comparison. RESULTS: Among the 167 patients included, 21 had bacterial meningitis. The CSF gram-stain and bacterial antigen test had 86% and 60% sensitivity rates, respectively. PCT (>/=0.5 ng/mL) and CSF protein (>/=0.5 g/L) were the best biologic tests, with 89% and 86% sensitivity rates, 89% and 78% specificity rates, adjusted odds ratios of 108 (95% CI, 15-772) and 34 (95% CI, 5-217), and areas under the ROC curves of 0.95 and 0.93, respectively. CONCLUSION: PCT and CSF protein had the best predictive value to distinguish between bacterial and aseptic meningitis in children.

Adolescent↗
PubMed2005

Contralateral meningeal artery supply of paramedian meningiomas.

BACKGROUND: When resecting at falcine or parasagittal portion of paramedian meningiomas, intraoperative hemostasis often is difficult despite effective management of ipsilateral meningeal arteries. We attribute such difficulties to meningeal artery blood supply from the contralateral side. We retrospectively studied feeding arteries from both sides in case of paramedian meningioma in terms of patient and tumor characteristics. METHODS: Forty-three patients with paramedian meningiomas underwent selective internal and external carotid angiography. We investigated how contralateral meningeal arterial feeders related to patient profiles and imaging, histopathologic, and immunohistochemical findings. RESULTS: Contralateral meningeal supply existed for 14 of 25 falcine meningiomas and 6 of 18 parasagittal meningiomas. Patients with contralateral feeders were 8.5 years younger than the others (P=.027) and were more likely to have larger tumors (P=.028). These were histopathologically malignant (P=.048), while showing more proliferation followed by monoclonal antibody against the Ki-67 antigen index (P=.012) and angiogenetic potential associated with vascular endothelial growth factor expression (P=.0085). CONCLUSIONS: Contralateral meningeal supply may reflect strong angiogenetic recruitment from rapid tumor growth followed by high expression of vascular endothelial growth factor. This angiographical feature may predict the aggressive growth of paramedian meningiomas.

Adult↗
PubMed1998

Measurement of glutamine and glutamate by capillary electrophoresis and laser induced fluorescence detection in cerebrospinal fluid of meningitis sick children.

OBJECTIVES: Cerebrospinal fluid glutamine and glutamate concentrations were measured by CZE-LIFD in normal and meningitis sick children. DESIGN AND METHODS: A derivatization procedure for glutamine was optimized using CZE-LIFD. Cytochemical and bacteriological analysis were made to 152 CSF from children suspicious of suffering meningitis. RESULTS: CSF-glutamine concentration was lower in children with viral and bacterial meningitis. In addition, the group infected with Haemophilus influenzae had the lowest concentrations. By contrast, glutamate concentration was higher in children with meningitis. Glutamine concentration increased as the clinical condition of the patient improved. CONCLUSIONS: Lower concentrations of glutamine in children with bacterial meningitis might be due to the use of this amino acid for bacterial growth while higher concentrations of glutamate might be due to cell destruction. The results indicate that CZE-LIFD is an alternative tool for the determination of amino acids in CSF.

Adolescent↗
PubMed1996

Excess glutamate in the cerebrospinal fluid in bacterial meningitis.

We investigated possible neurotoxic components in the cerebrospinal fluid (CSF) of patients with bacterial meningitis. On murine cerebellar neuronal cell cultures, CSF exerted a dose-dependent toxic effect, which was attenuated by the NMDA receptor antagonist MK-801. Glutamate concentrations in the CSF of patients with bacterial meningitis were measured by an enzymatic assay and found to be significantly elevated (p < 0.001) as compared to viral meningitis and non-inflammatory neurological diseases. The concentration of glutamate in the CSF of patients with bacterial meningitis varied considerably and correlated with the severity of the disease as scored by the Glasgow Coma Scale. Cells in the CSF, mainly comprising polymorphonuclear granulocytes, did not release any glutamate into the culture medium, whereas blood monocytes produced remarkable amounts. These findings implicate an important role of monocytic inflammatory cells in bacterial meningitis by the release of glutamate, which may contribute to neuronal cell death.

Adult↗
PubMed1999

Cerebrospinal fluid levels of soluble CD14 in inflammatory and non-inflammatory diseases of the CNS: upregulation during bacterial infections and viral meningitis.

The CD14 antigen, an important cell surface molecule of monocytic cells, is involved in cellular activation: it binds lipopolysaccharide and other cellular lipid structures. Brain macrophages play a pivotal role during inflammatory reactions of the CNS parenchyma, ventricles and meninges. A soluble form of CD14 (sCD14) was measured in paired cerebrospinal fluid (CSF) and serum samples from 91 patients with different neurological diseases. Mean levels of circulating sCD14 in CSF in a control group of 22 patients with neurologic complaints but no neurological deficit on clinical examination were 0.19 +/- 0.06 (mean +/- SD) mg/l. The CSF/blood ratios of sCD14 was 49 +/- 16 x 10(-3), while those of albumin were 4.4 +/- 1.4 x 10(-3). These extremely high CSF/blood ratios of the sCD14 molecule compared to albumin indicate a local cerebral production. No significant changes in CSF sCD14 levels were found in patients with non-inflammatory neurological diseases (NID). In contrast, CSF sCD14 levels were markedly elevated during acute meningitis, but there was no direct correlation between sCD14 and monocyte count in the CSF. Thus, sCD14 could not originate in the CSF compartment from monocytes alone. The highest values for sCD14 were found in CSF during infections with various pathogens such as Staphylococcus aureus or Listeria monocytogenes. While sCD14 serum levels dramatically increased during acute bacterial meningitis, sCD14 ratios did not correlate with albumin ratios during the course of disease. Therefore, increased CSF sCD14 may originate from cerebral production by activated or infiltrated macrophages rather than passive diffusion from the blood, while elevated sCD14 serum levels resulted from enhanced local production. Increased CSF and serum sCD14 values were also observed in meningitis caused by viral infection. As in bacterial meningitis, sCD14 in CSF specimens did not correlate with the function of the blood/CSF barrier. Repeated lumbar punctures revealed a normalization of CSF sCD14 levels during clinical recovery. These results provide the first evidence for local production of sCD14 within the CNS. Our findings further indicate that sCD14 in CSF is a reliable marker for activation of macrophages within the CNS during inflammatory processes.

Acute Disease↗
PubMed2004

[Meningitis with direct negative bacteriological examination. Prospective assessment of a decision making tree].

OBJECTIVE: Elaboration of a decision-making tree for differential diagnosis of bacterial and viral meningitis, when initial Gram's staining is negative. Method One-Year prospective study in an adult emergency department. Comparison with the immediately-preceding period. RESULTS: 56 patients were included. Only 4 bacterial meningitis, but none misdiagnosed. 86% sensitivity and 83% specificity for viral meningitis (n=40). Rate of patients hospitalised more than 24 hours decreasing from 62.5 to 41% (p=0.05). Antibiotic chemotherapy decreasing from 55 to 16% (p<0.001). CONCLUSION: This decision-making tree safely allows emergency differentiation between bacterial and viral meningitis, when initial Gram's staining is negative. It consequently leads to decreased rates of useless hospitalisations and antibiotic treatments. We believe that this method can be helpful during outbreaks of viral meningitis.

Adult↗
PubMed2005

[Carcinomatous meningitis as a rare presentation of gastric cancer].

INTRODUCTION: Carcinomatous meningitis is a rare complication of gastric cancer. CASE: A 46 year-old man with an unremarkable medical history was hospitalized for treatment of suspected meningitis. Despite treatment, his clinical state rapidly worsened and he died without regaining consciousness, shortly after transfer to the ICU. Autopsy showed that he had anchorage-independent cell gastric carcinoma, with simultaneous lymphatic, pulmonary, cutaneous and meningeal metastases. DISCUSSION: The rising incidence of secondary meningeal lesions in the last two decades is probably associated with the treatment-related improvement in life expectancy. Prognosis is very grave, and median survival time is only several weeks. Carcinomatous meningitis is difficult to diagnosis, especially as the first sign of a primary tumor. This rare presentation of gastric cancer indicates diffuse metastatic spread and extremely poor prognosis.

Autopsy↗
PubMed2006

Pneumococcal meningitis in adults: new approaches to management and prevention.

Since the virtual eradication of meningitis due to Haemophilus influenzae type B by vaccination in the developed world, pneumococcal meningitis has become the leading cause of bacterial meningitis beyond the neonatal period. Clinical and experimental research has increased our knowledge about the pathophysiology and pathogenesis of the disease over the past decades. Despite the availability of effective antibiotics, supportive care facilities, and recent advances in adjunctive strategies-ie, adjunctive dexamethasone-mortality and morbidity rates associated with pneumococcal meningitis remain unacceptably high. Although preliminary results after the introduction of the pneumococcal conjugate vaccine are promising, the incidence of multidrug-resistant pneumococcal strains is rising worldwide. Here we discuss clinical aspects of pneumococcal meningitis in adults, with focus on pathophysiology, and stress the urgent need for adequate preventive measures and new effective treatments.

Anti-Infective Agents↗
PubMed1998

Geographic differences in bacterial meningitis: less may be as interesting as more.

Many reports in the last decade have described populations with a high incidence of bacterial meningitis, especially amongst indigenous groups in industrialised countries, such as North American Eskimos and Apache Indians and Australian Aborigines, particularly with meningitis due to Haemophilus influenzae type b (Hib). Lack of evidence that invasive Hib disease, including meningitis, is a significant health problem has been attributed to lack of appropriate data, either due to lack of laboratory and clinical facilities, such as in most less industrialised countries, or lack of study. Host differences in immune response, though known to be important for individual susceptibility to Hib disease and bacterial meningitis, have not been thought important on a population level. Good quality epidemiologic data now available from Hong Kong and Japan, based on sound laboratory methods, have shown bacterial meningitis, particularly due to Hib and Neisseria meningitidis, to be significantly less common than in predominantly Caucasian populations in various industrialised countries. Differences in host immune response to these capsular polysaccharides seems the most likely explanation for this observation. It is interesting that other immunologically mediated disorders such as Kawasaki disease and systemic lupus erythematosis have a relatively high incidence in Sino Japanese populations, lending plausibility to inherited differences in immune response as a mechanism for these observations.

Global Health↗
PubMed1999

Preventive immunisation could reduce the risk of meningococcal epidemics in the African meningitis belt.

Control of meningitis epidemics is based on early case detection followed by mass campaigns of immunisation. However, this strategy showed severe inadequacies during recent outbreaks in Africa. In Niamey, Niger, meningococcal vaccinations began in 1978 and detailed bacteriological and epidemiological surveillance of meningitis started in 1981. When vaccine coverage rates were higher than 50%, the prevalences of Neisseria meningitidis A meningitis were low in Niamey, although there was a concurrent epidemic in rural Niger. A massive outbreak of meningitis in Niamey in 1994-1995 followed a 6-year period during which the mean rate of vaccine coverage remained < 25%. The data indicate that, in the meningitis belt, preventive immunization should avoid a great number of deaths and be less expensive than mass immunisation campaigns performed after epidemics have begun.

Bacterial Vaccines↗
PubMed2002

Pathophysiology of bacterial meningitis: mechanism(s) of neuronal injury.

No bacterial disease has undergone a more dramatic change in epidemiology during the past decade than acute bacterial meningitis. This review describes the changing epidemiology and considers some important recent observations that contribute to our understanding of the pathogenesis and pathophysiology of meningitis. The major focus is on the mechanisms of neuronal injury and the pathophysiologic concepts responsible for death and neurologic sequelae. In recent years, experimental studies have amplified our understanding of the substantial body of evidence that now implicates cytokines and chemokines, proteolytic enzymes, and oxidants in the inflammatory cascade leading to tissue destruction in bacterial meningitis. The molecular mechanisms responsible for oxidant-induced neuronal injury in meningitis are explored in some depth. Genetic targeting and/or pharmacologic blockade of the implicated pathways may be a future strategy for therapeutic adjunctive measures to improve outcome and may hold substantial promise, in concert with antimicrobial agents, in humans with acute bacterial meningitis.

Adolescent↗
PubMed1998

Favorable prognosis of purulent meningitis in patients infected with human immunodeficiency virus.

We prospectively reviewed all cases of purulent meningitis among human immunodeficiency virus (HIV) type 1-infected patients > 14 years old that occurred at the Hospital General Vall d'Hebron (Barcelona) during the period 1 January 1985 through 31 March 1997. There were 12 episodes of purulent meningitis in nine of 2,150 HIV-1-infected patients. The annual rate of purulent meningitis was 0.465 cases per 1,000 patients, a rate that is 150 times higher than that for the general population. During 10 episodes, CD4+ lymphocyte counts were < 200/mm3. The etiologic organism was Streptococcus pneumoniae in nine episodes (seven episodes occurred in four splenectomized patients), and Escherichia coli, Streptococcus agalactiae, and Enterococcus faecium each caused one episode. Clinical features and cerebrospinal fluid abnormalities were similar to those observed among patients without HIV-1 infection. All patients had bacteremia. The overall mortality was 8.3%. We conclude that purulent meningitis, particularly pneumococcal meningitis, is more frequent among HIV-1-infected patients than in the general population. The prognosis for HIV-1-infected patients is better than for HIV-1-negative patients.

Adult↗
PubMed1982

Complement-mediated opsonic activity in normal and infected human cerebrospinal fluid: early response during bacterial meningitis.

A local defense mechanism in bacterial meningitis was evaluated in humans by measuring complement-mediated opsonic activity (CMOA) in normal and infected cerebrospinal fluid (CSF) with a complement-dependent phagocytic bactericidal assay. CMOA was absent in normal untreated CSF and remained undetectable in 20 samples of CSF from patients with viral meningitis and five samples from patients with acute meningococcemia. In contrast, 15 of 27 samples of CSF from patients with acute bacterial meningitis had a measurable CMOA, which was correlated with protein concentrations (P less than 0.01) and C4 hemolytic activity (P less than 0.001) in the CSF. A favorable outcome of bacterial meningitis was associated with the presence of CMOA in CSF (P less than 0.005). Recovery was also correlated with higher levels of C4 (P less than 0.01) and C3 (P less than 0.05) in CSF and with lower concentrations of microorganisms in the sample of CSF collected at the time of admission (P less than 0.01). Thus, CMOA, although absent in normal CSF, can appear in CSF during acute bacterial meningitis, particularly in patients who recover completely.

Adolescent↗