Epidemic meningitis, meningococcaemia, and Neisseria meningitidis

Meningococcus, an obligate human bacterial pathogen, remains a worldwide and devastating cause of epidemic meningitis and sepsis. However, advances have been made in our understanding of meningococcal biology and pathogenesis, global epidemiology, transmission and carriage, host susceptibility, pathophysiology, and clinical presentations. Approaches to diagnosis, treatment, and chemoprophylaxis are now in use on the basis of these advances. Importantly, the next generation of meningococcal conjugate vaccines for serogroups A, C, Y, W-135, and broadly effective serogroup B vaccines are on the horizon, which could eliminate the organism as a major threat to human health in industrialised countries in the next decade. The crucial challenge will be effective introduction of new meningococcal vaccines into developing countries, especially in sub-Saharan Africa, where they are urgently needed.

Idiopathic hypertrophic pachymeningitis - case report and literature review

Idiopathic hypertrophic pachymeningitis (IHPM) is a rare pathological state, with still unclear aetiopathogenesis. We present a case of a 63-year-old woman with cranial variety of that disease. The manifestations of the disease included headaches, paresis of VI, IX, X nerves and cerebellar ataxia. The disease was diagnosed with magnetic resonance imaging (MRI) and histopathological assessment of the pachymeninx biopsy specimen. The MRI revealed significant thickening of the cranial base pachymeninx, compressing the pons and medulla oblongata. MRI examinations could be misinterpreted as extensive meningioma of the skull base. Dura mater biopsy revealed however inflammation with abundant lymphocytic infiltrations. Clinical improvement was obtained after the application of corticosteroids. We noted the subsidence of all symptoms of the disease, as well as radiological improvement, manifested through substantial regression of the described changes in the pachymeninx. The patient has been presented in the context of 65 cases of idiopathic hypertrophic pachymeningitis, described in the literature of English-speaking countries in the last five years. Recently, the importance of the autoimmunogenic background of IHPM has been underlined. In that respect IHPM has become an interdisciplinary problem. Its diagnosis and treatment requires not only radiologists, neurologists, pathomorphologists and neurosurgeons, but also specialists in internal medicine, including immunologists, allergologists and rheumatologists as well - in other words, physicians that rarely take part in the processes of diagnosing and treating intracranial pathologies.

Chemotherapy in neoplastic meningitis

Neoplastic meningitis (NM) is the result of the diffuse or multifocal localization of cancer cells in the cerebral spinal fluid (CSF). NM is more often a late complication of solid tumor or lymphoproliferative malignancies. At present, the goal of therapeutic strategies is palliative and the evaluation of high or low risk is important in identifying which patients could benefit from aggressive treatments such as radiation therapy and chemotherapy. Given that NM is a cancer complication that can spread throughout the entire subarachnoid space, chemotherapy, whether intrathecal or systemic, is currently considered the best treatment option, but optimal treatment is still controversial. This review summarizes intrathecal and systemic chemotherapeutic options in the treatment of NM and the related toxicities.

Idiopathic hypertrophic cranial pachymeningitis successfully treated with weekly subcutaneous methotrexate

Idiopathic hypertrophic cranial pachymeningitis is a very infrequent disorder. Adequate management is still a matter of debate. We describe the use of low-dose pulse methotrexate in treating a 63-year-old woman with idiopathic hypertrophic cranial pachymeningitis. A weekly scheme with subcutaneous methotrexate was tried. Clinical improvement occurred in one week. Total remission of the clinical and neuro-imaging abnormalities was evident 6 months later, with minimal side effects. The patient is in complete remission after one year of follow-up without treatment. Hence, low-dose weekly subcutaneous methotrexate may be safe and effective in inducing complete and sustained remission of this condition. The experience with subcutaneous methotrexate to treat this entity has never been reported.

Activin A concentrations in human cerebrospinal fluid are age-dependent and elevated in meningitis

OBJECTIVE

Activin A, and its binding protein, follistatin (FS), are expressed in the central nervous system (CNS). We have previously shown elevated concentrations of FS in the cerebrospinal fluid (CSF) of patients with meningitis and increased concentrations of activin A in the CSF of rabbits with bacterial meningitis.

METHODS

We measured CSF and serum concentrations of activin A and FS in normal subjects and in patients with various neurological diseases using previously validated immunoassays specific for activin A or FS.

RESULTS

In healthy persons, serum concentrations of both activin A and FS were age-dependent. In CSF, concentrations of activin A ranged from 0.03 to 0.33 ng/ml and were strongly correlated with age in both sexes, whereas FS CSF concentrations were below the assay detection limit in most of the patients. Activin A concentrations in CSF of patients with various neurological diseases, including meningitis, chronic inflammatory CNS diseases, neurodegenerative diseases, tumors in the CNS, cerebral ischemia, intracerebral/subarachnoid hemorrhages, subdural hemorrhages and epileptic seizures, were compared with age- and sex-matched control patients. The comparisons revealed significantly elevated concentrations of activin A in patients with meningitis (P=0.017). Serum concentrations of activin A or FS were not affected by any of the neurological diseases examined.

CONCLUSIONS

Our results show for the first time that in normal subjects concentrations of activin A in CSF are correlated with age, and furthermore, that activin A CSF concentrations are elevated in patients with meningitis. The latter underlines a role for activin A in acute inflammatory processes within the CNS.

Adult intranasal meningoencephalocele presenting as a nasal polyp

We present an isolated purely intranasal meningoencephalocele, presenting as a nasal polyp in an adult, which is uncommon. Based on a review of the literature, we emphasize that nasal obstruction may be the only presenting symptom of an intranasal meningoencephalocele.

Character changes from idiopathic cranial pachymeningoencephalitis

A 66-year-old man with idiopathic cranial pachymeningoencephalitis was described. He suffered from left orbital pain, and character changes. He became short tempered, and was very attached to trifles. Two years prior to these symptoms, he had developed transient left abducent nerve palsy. Head MRI showed a thickening and enhancement of the dura mater on gadolinium-enhanced T1-weighted images, and high signal intensity lesions at bilateral frontal lobes predominantly in the white matter on T2-weighted images. Biopsies revealed microglial proliferation in the cerebral parenchyma, and mild lymphocytic perivascular infiltration. No evidence of intracranial infection was detected. We therefore treated him with methylprednisolone pulse therapy followed by oral prednisolone. His character became gradually normalized, and bilateral frontal lobe lesions seen on MRI disappeared. This is the first case to describe recurrent pachymeningoencephalitis with character changes, and symptoms were probably due to frontal lobe dysfunction.

Chronic Meningitis in Thailand

The charts of 114 consecutive patients with chronic meningitis admitted to a general hospital in Bangkok, Thailand, between 1993 and 1999 were retrospectively reviewed. The most common causative agents were Cryptococcus neoformans (54%) and Mycobacterium tuberculosis (37%). HIV and other underlying diseases had a major impact on the presentation of chronic cryptococcal meningitis patients. Compared to HIV-negative cryptococcal meningitis patients (21%), HIV-positives (79%) had a significantly lower incidence of focal signs (p = 0.02), hydrocephalus (p = 0.03) and seizures (p = 0.001) during hospital stay, furthermore, a lower leucocyte level, a significantly higher glucose level (p = 0.02) and a lower protein level (p = 0.03) in the first cerebrospinal fluid examination. Of the 43 patients with chronic tuberculous meningitis, only 3 were HIV positive. Focal neurologic deficits were found more frequently in tuberculous meningitis patients (p = 0.001) when compared to cryptococcal meningitis patients without HIV. Cerebral infarction on cerebral CT was indicative of tuberculous meningitis. Cryptococcal meningitis patients with HIV infection had a worse outcome compared to non-AIDS patients. Advanced stage of the disease on admission, decreased level of consciousness prior to and on the admission day and raised intracranial pressure above 40 cm H(2)O at any given time were predictive of a poor outcome in tuberculous meningitis patients.

Neonatal meningitis in England and Wales: sequelae at 5 years of age

This study determined the prevalence of serious sequelae among a national cohort of 5-year old children, born in England and Wales in 1996-7, who had had neonatal meningitis. The results were compared with those from two matched control groups. In addition the results from this study were compared with those from a previous 5-year follow-up of children who had had neonatal meningitis in 1985-7. Follow-up questionnaires requesting information about the children's health and development were sent to the general practitioners (GPs) and parents of the index children and controls. Information was collected on 166 of 232 (72%) children who had had meningitis as neonates, 109 general practice controls and 191 hospital controls. At 5 years, 39/166 (23%) index children had a serious disability compared to 2% of GP controls and 7% of hospital controls. There was a 16-fold increase in risk of serious disability compared to GP-matched controls and a 4-fold increase in risk compared to hospital controls. The isolation of bacteria from the CSF was the best single predictor of serious long-term disability. Although there was a 70% fall in acute phase mortality between 1985 (22%) and 1996 (6.6%), the overall incidence of serious disability remained alarmingly high, 25.5% in 1985 compared to 23.5% in 1996. In the present study, however, fewer children had cerebral palsy or seizure disorders.

CONCLUSION

Despite the dramatic improvement in acute phase survival following neonatal meningitis, the prevalence of serious sequelae remains alarmingly high.

[Complications and diagnostic limitations of chronic meningitis]

HISTORY AND ADMISSION FINDINGS

A 37-year-old woman was admitted with total loss of vision of the left eye within 24 hours. Additionally, she complained about fatigue, headache, chills, fever, muscle pain and neck stiffness since 4 days. At admission, the body temperature was 38.7 degrees C. Neurological examination revealed papilledema and meningism.

INVESTIGATIONS

Ophthalmologic findings were consistent with a papillitis. The vision was lost, the pattern-shift checkerboard visual evoked potentials were not measurable. MRI of the brain and the optical nerve was without pathological findings, meningeal or cerebral Gadolinium enhancement was not present. The CSF analysis yielded a lymphocytic meningitis with 249 cells/mm (3), the glucose ratio of cerebrospinal fluid and serum was normal.

DIAGNOSIS, TREATMENT AND COURSE

The papillitis was treated unsuccessfully with high-dose methylprednisolone, the left eye remained blind. Persistence of the pleocytosis under initial treatment with aciclovir and ceftriaxone, reduction of the glucose ratio of cerebrospinal fluid and serum and intrathecal immunoglobuline A -- synthesis required a change of the diagnostic and therapeutic regimen. Various common and rare differential diagnoses were considered and ruled out, a chronic meningitis of unclear aetiology with the complication of amaurosis was diagnosed. In consideration of the most probable diagnosis, a tuberculostatic therapy was initiated. A prolonged reduction of the pleocytosis and normalization of cerebrospinal fluid parameters could be observed.

CONCLUSIONS

A large number of aetiologies can cause chronic meningitis; this case report reviews the most important differential diagnoses and highlights the limitations of the diagnostic work-up although various methods are available. Clinical course and symptoms of chronic meningitis are mild to moderate and may even be absent, but it can cause severe complications.

Idiopathic hypertrophic cranial pachymeningitis masquerading as Tolosa-Hunt syndrome

Idiopathic hypertrophic cranial pachymeningitis is a rare condition. A case of idiopathic hypertrophic cranial pachymeningitis presenting as Tolosa-Hunt syndrome is being reported. The importance of neuroimaging in patients with suspected Tolosa-Hunt syndrome is discussed. Tolosa-Hunt syndrome might represent a focal manifestation of Idiopathic hypertrophic cranial pachymeningitis. Future studies are necessary to further clarify the relationship between these two conditions.

A new method for measuring blood-brain barrier permeability demonstrated with Europium-bound albumin during experimental lipopolysaccharide (LPS) induced meningitis in the rat

The blood-brain barrier (BBB) is a critical extrameningeal site of injury during bacterial meningitis, manifested by enhanced BBB permeability (BBBP). Previous methods to measure altered BBBP during meningitis involve radioactive materials, or are poorly quantified. Europium (EU) is a fluorescent, non-radioactive metal that is a sensitive and stable marker. Europium fluorescence can be measured with a spectrophotometer capable of time-resolved fluorescence (TRF). We used EU-albumin (EU-A) to examine BBBP in experimental lipopolysaccharide (LPS) induced meningitis. The results presented here introduce a simple and accurate method for measuring BBB permeability.

Cortical spreading depression, meningeal inflammation and trigeminal nociception

This study investigated whether perivascular inflammation is necessary in the process of cortical spreading depression (CSD)-induced trigeminovascular nociception. CSD was induced by application of potassium chloride on rat parietal surface. Cortical microcirculation was studied using intravital fluorescent videomicroscopy, laser Doppler flowmetry and electron microscopy. Trigeminal nociception was determined using Fos immunoreactivity as the indicator. We found that KCl application caused cyclic cortical hyperaemia and pial microvascular dilation. Neither increased leukocyte-endothelial adhesion nor extravasation of macromolecule was demonstrated. Ultrastructural study revealed increased endothelial pinocytosis but tight junction remained intact. Despite no intense perivascular inflammation, we observed significantly increased Fos-immunoreactivity in trigeminal nucleus caudalis. These results suggest that perivascular inflammation is not necessary in the process of CSD-evoked trigeminovascular nociception.

Uncommon findings in idiopathic hypertrophic cranial pachymeningitis

BACKGROUND

Idiopathic hypertrophic cranial pachymeningitis (IHCP) is a rare, poorly understood, inflammatory disease, usually involving the dura mater of skull base, tentorium, and falx, and presenting with headache, progressive cranial nerve palsies, and cerebellar dysfunction.

PATIENTS AND METHODS

In four patients, the diagnosis of IHCP has been made on the basis of extensive clinical, and radiological investigation, and confirmed by dural biopsy in three patients. The clinical follow-up ranges from 24 to 120 months.

RESULTS

At diagnosis, all the patients complained of severe, progressively increasing headache, two had simple or complex partial seizures, but none had cranial nerve palsies. Two patients had electrophysiological evidence of axonal peripheral neuropathy, biopsy-proved in one of them. In all the patients, MRI showed linear or focal thickening of the dura mater of the tentorium and/or of the convexity, sparing the skull base. In one patient, MRI findings resembled chronic subdural hematoma. Dural biopsy demonstrated fibrosis and prominent CD4+ T-cells inflammatory infiltrate. Pachymeningitis was highly responsive to steroid therapy, as was the peripheral neuropathy. In three patients, temporary steroids withdrawal led to dramatic clinical worsening including status epilepticus in one.

CONCLUSIONS

In the patients here reported, absence of cranial nerve impairment, seizures, MRI findings resembling chronic subdural hematoma, and association with polineuropathy were unusual findings of IHCP. Moreover, the type of inflammatory infiltrate, lacking in previous reported cases, suggests a probable pathogenetic role for cell-mediated immunity of unknown origin.

Traumatic prepontine tension pneumocephalus--case report

OBJECTIVE

A case of prepontine tension pneumocephalus after temporal bone fracture is presented.

CASE REPORT

An 8-year-old girl suffered a head injury due to a fall off her bicycle. She lost her consciousness, and when she was admitted to the local hospital the Glasgow Coma Score (GCS) was 8/15 (eye opening: 2; verbal answer: 2; motor response: 4) and there was bleeding from the right ear. The patient's condition deteriorated rapidly and she needed intubation and ventilation. CT of the brain revealed large amount of air in the prepontine region, displacing the brainstem posteriorly. Patient was kept ventilated, meanwhile cerebrospinal fluid (CSF), as otorrhea appeared on the right side. CT was repeated 36 hours later, showing significantly less air in the prepontine area. The patient was weaned off the respirator, extubated and the level of consciousness improved. Later the patient developed meningitis, which was treated by systemic antibiotics with lumbar CSF drainage applied for five days. A high resolution CT scan of the petrous bone revealed a fracture crossing the middle part of the pyramid. Patient showed a full recovery except a right-sided mixed hearing loss.

CONCLUSION

Rapid neurological deterioration following head injury can be a consequence of tension pneumocephalus. Prepontine pneumocephalus can be caused by minor fracture of petrous bone. High resolution CT is necessary to visualize minor fracture of the petrous bone. Conservative treatment may be satisfactory to treat tension hydrocephalus.

Granulomatous meningitis as a late complication of iodized oil myelography

The present report is an autopsy case of an 83 year old man with severe kyphoscoliosis and granulomatous meningitis as a late complication of iodized oil myelography. He suffered from mild cognitive impairment and died of pneumonia. At autopsy, the brain showed yellow-brown granular material on its surface, mainly in the Sylvian fissure. Microscopically, granulation tissue was seen around areas of ossification encasing the foreign material. Iodized oil apparently changed into two types of foreign bodies: eosinophilic membranous lipodystrophy-like features and homogenous yellow crystals of various sizes. The pathology was identical to foreign-body granulomatous meningitis, caused by iodized oil myelography, and caused cognitive impairment in this patient.

Idiopathic hypertrophic pachymeningitis

BACKGROUND

Hypertrophic pachymeningitis is an uncommon disorder that causes a localized or diffuse thickening of the dura mater and has been associated with rheumatoid arthritis, syphilis, Wegener's granulomatosis, tuberculosis, and cancer. Few series of the idiopathic variety have been described, particularly with respect to MRI correlation to clinical outcome and treatment.

OBJECTIVE

To investigate the clinical and laboratory evaluation, course, and treatment of patients with idiopathic hypertrophic pachymeningitis (IHP), to correlate the MRI findings with the clinical course, and to review the literature on IHP.

METHODS

Retrospective case series of 12 patients (9 men, 3 women), with a mean age of 55 years (range 39 to 88 years), who had IHP by imaging studies, meningeal or orbital biopsy, or both. The clinical features, laboratory evaluation, contrast-enhanced MRI, treatment, and clinical outcome were documented for each case. The mean duration of follow-up was 3.5 years (range 3 months to 16 years).

RESULTS

The main clinical features at presentation were headache (11 cases), loss of vision (7 cases), diplopia (4 cases), papilledema (2 cases), other cranial nerve involvement (3 cases), ataxia (2 cases), and seizures (1 case). On the initial MRI, the location of abnormal enhancement of the dura mater correlated with the clinical findings and the sphenoid wing area was affected in all patients. The sedimentation rate was elevated in five cases. The CSF had increased protein in six cases and lymphocytosis in four cases. Biopsy of the dura mater in five cases and the orbital soft tissue in one case showed infiltrates of small mature lymphocytes, plasma cells, and epithelioid histiocytes, but no neoplasia, vasculitis, or infectious agents. Cultures of the CSF and biopsy material remained sterile. Corticosteroid therapy improved the vision in 7 of 8 cases and controlled headache in 10 of 11 cases. Five cases had partial improvement of other neurologic symptoms and signs. Recurrence developed with steroid tapering in six cases. One case had progressive deterioration and died. In four cases methotrexate or azathioprine was added with reduction of the steroid dose. Follow-up MRI performed in 11 patients correlated 80% with the clinical state (p = 0.01).

CONCLUSION

IHP can be suspected on MRI and defined pathologically on biopsy. Untreated, the clinical course is usually marked by severe headache and progressive neurologic deterioration and vision loss. Although initially steroid-responsive, clinical manifestations frequently recur with corticosteroid taper, requiring the addition of immunosuppressive agents in some cases.

Idiopathic hypertrophic pachymeningitis

Idiopathic hypertrophic pachymeningitis is a rare disorder of unknown origin. It is a fibrosing inflammatory process that involves the dura mater. Herein are described 14 patients with idiopathic hypertrophic pachymeningitis; their clinical, laboratory and radiological findings, as well as their treatment, are analyzed. Neuropathological findings of six cases including two autopsied cases are also presented. The main clinical features were headache and cranial nerve palsies. Many patients had mild to moderate elevation of C-reactive protein, and three patients had perinuclear antineutrophil cytoplasmic antibody. The CSF in most cases showed inflammatory changes. Neuroimaging studies revealed diffuse or localized thickening of the dura, and MRI findings were key to diagnosis of this disorder. The clinical course was chronic. All patients were treated with corticosteroid and improved intially, but half of them experienced relapses. Two patients received surgical intervention. Pathological examination in two autopsied cases revealed diffuse thickening of the dura, especially in the posterior part of the falx cerebri and the tentorium cerebelli. Microscopic examination of the dura showed dense fibrosis with inflammatory cell infiltration composed mainly of lymphocytes. The cell infiltration was marked at the surface of the dura mater. One case had necrotizing vasculitis of the small arteries located in the dura and the cerebral surface. There were no giant cells, caseation necrosis, or epitheloid granuloma. Four patients underwent biopsy of the dura, and the pathological study showed non-specific inflammatory changes. The relationship of idiopathic hypertrophic pachymeningitis with connective tissue disease or vasculitis syndrome is discussed.

Mollaret's meningitis: cytopathologic analysis of fourteen cases

Mollaret's meningitis (MM) is a rare disease of benign nature characterized by recurrent episodes of aseptic meningitis. Cerebrospinal fluid (CSF) examination remains the sole diagnostic modality. Eighteen CSF samples from 14 patients were studied along with the clinical data. Specimens were prepared by cytocentrifugation and Millipore filtration and were stained with Diff-Quik and Papanicolaou stains. Eight patients were men and six were women, with an age range of 17-74 yr (mean age 37 yr). Most common clinical presentation was recurrent episodes of headaches and photophobia followed by a sustained mild fever lasting 5-7 days. The CSF showed markedly increased cellularity with pleocytosis. The differential count showed predominant monocytosis ranging from 84% to 100% (mean 96). In our series, two patients had herpes simplex virus type 2 (HSV-2) DNA detected by polymerase chain reaction (PCR) in the CSF. The monocytes were seen predominantly singly, but three cases showed a strong tendency to aggregate in small groups. Phenotypically, these cells had bean-shaped bilobed nuclei as well as multiple deep nuclear clefts depicting the so-called "footprint" appearance. In four cases, multiple blunt-tipped cytoplasmic pseudopods were noted. Degenerated monocytes with the appearance of the so-called "ghost cells" were noted in one-half of the cases. Background cells were mostly small mature lymphocytes; however, one-half of cases showed a significant amount of plasma cells and/or polymorphonuclear leukocytes (PMNs). Lysed blood with hemosiderin-laden macrophages and numerous leptomeningeal cells were seen in two cases. CSF examination of MM presents a spectrum of cytomorphologic features. When interpreted in light of the appropriate clinical setting. the latter, although nonspecific, provides an accurate diagnosis. The differential diagnosis includes various degenerative, inflammatory/infectious, and lymphoproliferative disorders of the central nervous system.

[Local low pressure in rehabilitation of patients with meningitis]

We studied the validity and effectiveness of interrupted local negative pressure (ILNP) in rehabilitation of patients who had had acute meningitis. ILNP on the lower part of the body was applied in 28 meningitis convalescents having residual manifestations detected at tetrapolar rheography and psychovegetative testing. As the result of the treatment the patients felt better, their psychovegetative status improved, pulse blood filling of cerebral vessels increased while tonicity of microcirculation vessels diminished. Side effects of ILNP were not registered. Thus, ILNP is effective in convalescents after meningitis.