Austrian Syndrome: case report

In this report, we describe the case of a 64-year-old male patient, with no history of alcohol consumption, who presented the Osler's triad, which is the association of endocarditis, pneumonia, and meningitis caused by a single agent. This syndrome is called Austrian syndrome, when the infection is caused by Streptococcus pneumoniae. We discuss the clinical manifestations, the pathophysiology, and the therapeutic approach to this condition. Given the rarity of the condition and its high morbidity and mortality, the importance of an early diagnosis and an appropriate treatment to reduce the complications associated with this disease will be emphasized.

[Culture-negative bacterial meningitis diagnosed with polymerase chain reaction]

Aetiological diagnosis of patients with bacterial meningitis and possible secondary complications is crucial for the implementation of optimal treatment. Molecular biological methods such as polymerase chain reaction (PCR) can be used. We here present a clinical case in which the diagnosis of pneumococcal meningitis with a subsequent complication in the form of a secondary cerebral abscess was primarily made by real-time PCR after treatment had been initiated.

Pneumococcal meningitis in the newborn period in a prevaccination era: a 10-year experience at a tertiary intensive care unit

There are few data with respect to pneumococcal meningitis in neonates. Epidemiological aspects, clinical features and outcomes in newborn infants diagnosed with pneumococcal meningitis were evaluated in this study. Nineteen newborn infants in a neonatal intensive care unit diagnosed with culture-proven community-acquired bacterial meningitis between January 1999 and December 2008 were reviewed, and of them, eight patients were diagnosed as pneumococcal meningitis. Overall, among 10,186 hospitalized newborn infants, 132 community-acquired sepsis/meningitis cases (1.3%) were suspected, and blood cultures were performed in all, while cerebrospinal fluid (CSF) cultures could be performed in 124 cases. Rate of blood culture positivity was 45%. Nineteen (15.3%) of 124 were diagnosed as culture-proven community-acquired bacterial meningitis, which was confirmed by CSF growth. Eight (42.1%) of 19 had pneumococcal meningitis. In pneumococcal cases, abundant Gram-positive diplococci were seen on CSF smear and Streptococcus pneumoniae was isolated from CSF cultures. All isolates were susceptible to penicillin and third-generation cephalosporins. Irritability (n: 7), poor sucking (n: 7) and fever (n: 6) were the principal findings on the initial physical examination. Of all patients with pneumococcal meningitis, four were initially given cefotaxime plus amikacin treatment, and the remaining four were initially given cefotaxime plus ampicillin plus vancomycin. Antibiotic treatment in two patients was revised during their clinical course. Additionally, in three patients, vancomycin and ampicillin was discontinued on the third day when antibiogram of CSF cultures revealed penicillin sensitivity. Overall, mortality in pneumococcal meningitis was 50%. In the surviving patients, two had epilepsy, one sensorineural hearing loss, and two mental-motor retardation. Pneumococcal meningitis was the leading cause of community-acquired neonatal meningitis in our patients. Immunization against pneumococcal disease in developing countries would be beneficial for public health and for newborn infants.

Cerebrospinal fluid lymphocytosis in an infant with acute Streptococcus pnuemoniae meningitis: a case report

A 10 month-old female infant presented with one day of high fever with drowsiness and seizures. Physical examination showed meningeal irritation and mild cyanosis. The cerebrospinal fluid (CSF) profile revealed opening pressure of 27 cmH2O, closing pressure of 17 cmH2O, red blood cells 310 cells/microL, white blood cells 100 cells/microL of which 90 percents were lymphocytes, protein 391 mg/dl, sugar 0 mg/dL and blood sugar 74 mg/dl. Numerous gram positive diplococci were found on CSF Gram-stained smear. Bacterial meningitis was diagnosed and cefotaxime 300 mg/kg/day plus vancomycin 60 mg/kg/ day were given empirically. The patient developed hypotension, poor tissue perfusion, dyspnea and disseminated intravascular coagulopathy (DIC). She expired 10 hours after hospitalization. The CSF and blood culture grew out Streptococcus pneumoniae serotype 6B with the minimal inhibitory concentration (MIC) of 0.5 and 1.5 microg/mL for penicillin and cefotaxime respectively. Atypical characteristics of CSF in bacterial meningitis may cause delay in empirical antimicrobial therapy. Gram-stained smear of CSF is helpful for rapid diagnosis and proper management.

[Watery diarrhea with fever: consider the possibility of pneumococcal meningitis]

The purpose of this report is to describe two rare cases of pneumococcal meningitis observed in Africa. Both cases were revealed by gastrointestinal symptoms characterized by abdominal pain and watery diarrhea. Due to the potential severity of bacterial meningitis, early diagnosis is required. Since diarrhea with fever is a common occurrence in Africa, differential diagnosis is necessary. Isolated diarrhea can be caused by meningeal syndrome and calls for testing to detect invasive pneumococcal infection.

Invasive pneumococcal infections in infants up to three years of age: results of a longitudinal surveillance in North-East Italy

Pneumococcus is considered one of the main causes of the infections acquired in the community setting and also seems to be the most frequent cause of community-acquired pneumonia in children under 5 years of age. To establish suitable preventive measures as vaccination policy, it would be important to document the incidence of IPD. The main feature of this study was that it demanded a cooperative effort between family pediatricians and those working in the hospitals to estimate the real burden of IPD in children aged 0-36. From 1 January 2003 to 31 December 2003, a prospective active surveillance of clinical cases due to S. pneumoniae was conducted by 87 specifically-trained sentinel pediatricians [all family pediatricians] randomly selected from among those working in North-East Italy. Suspected pneumococcal infections were confirmed by blood cultures at the laboratories of the hospitals involved in the study. 32 cases were suspected, 12 of those proved positive on blood culture and 6 of these 12 confirmed cases were hospitalized. 2 were cases of meningitis, 1 of pneumonia and 9 of bacteremia. The cumulative annual incidence was 58.9 cases/100,000 infants aged 0-36 months (95% CI 30.38-102.71), meaning that North-East Italy can be classified as a mesoendemic area. This study demonstrated that the incidence of IPD in infants aged (0-36 months) is often under-estimated, documenting the importance of prospective active surveillance for assisting rational choices for public health issues.

Prehospital diagnostic and therapeutic management of otogenic Streptococcus pneumoniae meningitis

Prehospital diagnostics and therapeutic management, as well as clinical and laboratory data from 57 consecutive cases with otogenic pneumococcal meningitis (OPM) in Denmark during a 2-y period (1999-2000) were studied by review of discharge and medical records including a questionnaire sent to the general practitioners responsible for the individual patient. 12 cases were <2 y of age, whereas the remaining 45 cases were >21 y of age. Fever (in 98%) and altered consciousness (in 98%), respectively, were significantly more frequent prehospital symptoms (median duration of symptoms: 2 d (1-4)) than earache (in 71%, p < 0.0001), tympanic perforation (in 38%, p < 0.0001), and back rigidity (in 25%, p < 0.0001) in OPM. Some 82% visited a physician before admission, and an otogenic focus was diagnosed in 57%, a myringotomy was performed in 12%, and antibiotic therapy was initiated in 29% of these cases. Prehospital antibiotic therapy was more likely to be initiated in patients where the physician found an otogenic focus compared to patients where an otogenic was not found (46% vs 6%, respectively, p = 0.01). However, <10% of cases with OPM were treated for otitis media with adequate dosing of antibiotics for more than 1 d based on pharmacodynamic estimates. The clinical course was more severe in adults than in children (e.g. need for assisted ventilation (61% vs 0%, respectively, p < 0.01), development of sequelae (75% vs 8%, respectively, p < 0.01) together with higher CSF WBC and CSF protein levels (3738 vs 1361 cells/microl and 3.8 vs 1.6 g/l, respectively, p < 0.01), whereas corticosteroids were more frequently given to children than to adults (55% vs 3%, p < 0.001). Prehospital antibiotic therapy was not significantly associated with a more favourable outcome of OPM (50% vs 60%, respectively, p = 0.73). In conclusion, our results suggest that an otogenic focus is as frequent in adults as in children with pneumococcal meningitis and that an otogenic examination should be performed on patients presenting with fever and altered consciousness. Moreover, OPM seems predominantly to occur in patients receiving no or inadequate antibiotic therapy for otitis media.

Aetiological diagnostics of acute bacterial meningitis in children

Aetiology of bacterial meningitis (BM) can be confirmed by various microbiological methods. The aim of this study was to assess the role of microbiological methods used for confirmation of BM in children and determine the influence of the aetiological agent, patient age and antibacterial treatment on study results. Over a 5-y period (1998-2002) BM was diagnosed in 90 children at Vilnius University Centre for Paediatrics. Aetiology was confirmed by cerebrospinal fluid (CSF) and blood culture, microscopic CSF smear examination, CSF and blood latex agglutination test. CSF and blood cultures were positive in 53% and 39% of cases, respectively. Microscopic CSF smear examination was positive for 57% of the specimens. CSF latex agglutination was positive in 64% and blood in 47% of cases. Causative agent and received antibiotic therapy prior to investigation of obtained material affected some final microbiological results. However, no influence of patient age was found. Microbiological confirmation was achieved in 59% of cases using CSF and/or blood culture and in 78% of cases using all available methods in practice. The most common pathogens of bacterial meningitis were H. influenzae type b, N. meningitidis and S. pneumoniae.

Pediatric bacterial meningitis surveillance - African region, 2002--2008

Sub-Saharan Africa has one of the world's greatest disease burdens of Haemophilus influenzae type b (Hib), Streptococcus pneumoniae, and Neisseria meningitidis infections. In 2000, Hib and S. pneumoniae infections accounted for approximately 500,000 deaths in the region; during the past 10 years, N. meningitidis has been responsible for recurring epidemics resulting in approximately 700,000 cases of meningitis. Introduction of vaccines against bacterial pathogens in Africa has been constrained by competing public health priorities, limited availability of Hib and S. pneumoniae vaccines, suboptimal N. meningitidis vaccine, inadequate funding, and limited information regarding the disease burden associated with these infections. The World Health Organization (WHO) and CDC analyzed data for 2002--2008 from the Pediatric Bacterial Meningitis (PBM) Surveillance Network, which collects information on laboratory-confirmed bacterial meningitis cases among children aged <5 years at sentinel hospitals in countries throughout the WHO African Region. The results of that analysis determined that, during 2002-2008, a total of 74,515 suspected cases of meningitis were reported. Among the 69,208 suspected cases with known laboratory results, 4,674 (7%) samples were culture-positive for the three bacterial infections under surveillance: 2,192 (47%) were positive for S. pneumoniae, 1,575 (34%) for Haemophilus influenzae, and 907 (19%) for N. meningitidis. The majority of the remaining culture results were negative. These and other PBM network findings will help guide strategies for strengthening laboratory and data management capacity at existing sentinel hospitals and for planning future network expansion in the WHO African Region.

Cerebrospinal fluid lysozyme in bacterial and viral meningitis

The concentration of lysozyme (LZM) in cerebrospinal fluid was determined in 25 patients with bacterial meningitis, in 18 patients with viral meningitis and in 25 control patients who had other fibrile illnesses. The concentration of LZM was less than 1.5 microgram/ml in all control patients, and slightly to markedly raised in 10 patients with viral meningitis and in 11 out of 13 patients with untreated bacterial meningitis. The concentration of LZM was significantly different in the viral and bacterial meningitis patients (p less than 0.001). Most raised concentrations of cerebrospinal fluid LZM persisted for at least one week after the start of antibiotic treatment. The concentrations of LZM correlated well with concentrations of lactic dehydrogenase. These results show that the determination of cerebrospinal fluid LZM is a useful tool in the differential diagnosis of meningitis, particularly when the prehospital treatment with antibiotics may be responsible for a diagnostically misleading negative bacterial culture of the cerebrospinal fluid and altered cerebrospinal fluid cytology.

Enhanced diagnosis of pneumococcal meningitis with use of the Binax NOW immunochromatographic test of Streptococcus pneumoniae antigen: a multisite study

BACKGROUND

Accurate etiological diagnosis of meningitis in developing countries is needed, to improve clinical care and to optimize disease-prevention strategies. Cerebrospinal fluid (CSF) culture and latex agglutination testing are currently the standard diagnostic methods but lack sensitivity.

METHODS

We prospectively assessed the utility of an immunochromatographic test (ICT) of pneumococcal antigen (NOW Streptococcus pneumoniae Antigen Test; Binax), compared with culture, in 5 countries that are conducting bacterial meningitis surveillance in Africa and Asia. Most CSF samples were collected from patients aged 1-59 months.

RESULTS

A total of 1173 CSF samples from suspected meningitis cases were included. The ICT results were positive for 68 (99%) of the 69 culture-confirmed pneumococcal meningitis cases and negative for 124 (99%) of 125 culture-confirmed bacterial meningitis cases caused by other pathogens. By use of culture and latex agglutination testing alone, pneumococci were detected in samples from 7.4% of patients in Asia and 15.6% in Africa. The ICT increased pneumococcal detection, resulting in similar identification rates across sites, ranging from 16.2% in Nigeria to 20% in Bangladesh. ICT detection in specimens from culture-negative cases varied according to region (8.5% in Africa vs. 18.8% in Asia; P< .001), prior antibiotic use (24.2% with prior antibiotic use vs. 12.2% without; P< .001), and WBC count (9.0% for WBC count of 10-99 cells/mL, 22.1% for 100-999 cells/mL, and 25.4% for >or=1000 cells/mL; P< .001 by test for trend).

CONCLUSIONS

The ICT provided substantial benefit over the latex agglutination test and culture at Asian sites but not at African sites. With the addition of the ICT, the proportion of meningitis cases attributable to pneumococci was determined to be similar in Asia and Africa. These results suggest that previous studies have underestimated the proportion of pediatric bacterial meningitis cases caused by pneumococci.

Invasive pneumococcal infections: Austrian syndrome

Austrian syndrome or Osler's triad represents an association of pneumonia, meningitis and endocarditis caused by Streptococcus pneumonia. It is a clinical rarity, with a severe prognosis, mainly due to the very aggressive evolution of endocarditis, together with the underlying pathology of the patients. We present the case of a 54-years-old female with several risk factors for invasive pneumococcal infections (post-traumatic splenectomy, type II DM and hepatic cirrhosis) that was admitted to our service with Austrian syndrome and emphasize some important clinical aspects of the disease and treatment recommendations described in the literature. Our aim is to increase awareness and allow a correct and early treatment which would improve the high mortality observed in Austrian syndrome. We also emphasize the need for antipneumococcal vaccination, especially in high risk patients.

[Pneumococcal meningitis in children--9 1/2-year-experience at Szent László Hospital, Budapest, Hungary]

BACKGROUND AND OBJECTIVE

No recent publications are available about pneumococcal meningitis in Hungarian children. The aim of this study was to collect data of epidemiological, clinical and prognostic features of pneumococcal meningitis in children treated at Szent László Hospital, Budapest, Hungary.

METHODS

We conducted a retrospective review of medical charts and follow-up records of patients aged 1 to 18 years admitted to our Pediatric and Pediatric Intensive Care Units due to pneumococcal meningitis between 1st Jan 1998 and 30th Jun 2007.

RESULTS

31 children with 34 cases of pneumococcal meningitis were admitted to our hospital in the study period. Two children developed recurrent illness. The mean age was 6 years, 26% were under 1 year of age. The mean duration of hospital stay was 21 days, 97% required intensive care. Frequent clinical symptoms were fever (100%), nuchal rigidity and vomiting (78%), altered mental status (71%), Kernig's and Brudzinski's signs (58%) and seizures (41%). Otitis media, sinusitis, mastoiditis were present in 44%, 58%, 41%, respectively. Subdural effusion, parenchymal cerebral lesion and sinus thrombosis were documented in 5, 3 and 2 cases, respectively. One third of the patients received ceftriaxon, two thirds were administered ceftriaxon and vancomycin. Adjunctive therapy with dexamethasone was given to 91% of the children. 70% of patients required mechanical ventilation. 9 patients (25%) required endoscopic sinus surgery. In 13 cases (38%) mastoidectomy, in 5 children (15%) neurosurgery was performed. The case fatality rate was 23.5%. 8 (23.5%) patients had mild or moderate, 1 child (3%) developed severe neurological sequelae.

CONCLUSION

Pneumococcal meningitis in children remains a source of substantial morbidity and mortality in childhood. The long hospital stay, the frequent need for intensive care and severe neurologic sequelae emphasize the importance of early diagnosis, early treatment and prevention with pneumococcal conjugate vaccines.

A new twist on an old problem: a case of pediatric meningitis caused by multidrug-resistant Streptococcus pneumoniae serotype 19A

Recent studies show that multidrug-resistant Streptococcus pneumoniae serotype 19A continues to emerge as a cause of invasive pneumococcal disease after the introduction of Prevnar. We report a case of multidrug-resistant S. pneumoniae serotype 19A meningitis successfully treated with vancomycin and levofloxacin. This case reinforces the need for the empiric use of vancomycin in meningitis and the need for alternative treatments.