Méningites à examen bactériologique direct négatif

[Macular tuberculoma and optic neuritis: rare association with tuberculosis meningoencephalitis]

INTRODUCTION

Tuberculosis is an endemic disease responsible for death and morbidity in developing countries.

OBSERVATION

A 50-year-old man with no medical history was admitted to the emergency department for meningism associated with fever and confusion. The ophthalmic exam showed a decline in left visual acuity, reduced to light perception, VIth nerve left oculomotor paralysis, ocular fundus demonstrating a yellow tumor located on the posterior segment, measuring 1.5-2mm, papillomatous and prominent in the vitreous cavity. Fluorescein angiography showed a peritumoral choroiditis area, miliary tubercles of the choroid, and sectorial papillomatous edema. Color retinography unmasked inflamed posterior vitreous areas. Echography demonstrated a 4- to 5-mm oval hyperechogeneous and calcified tumor along with hyperechogeneous vitreous areas. Lumbar puncture showed lymphocytic meningitis associated with hyponatremia. The CT scan and MRI demonstrated optic neuritis. The antibiotic therapy was initiated and the outcome was favorable.

CONCLUSION

This case report shows the importance of systematic ocular fundus in the presence of systemic tuberculosis and outlines the assessment of color retinography to unmask vitreous lesions. It shows the importance of radiological imaging in the semiological study of orbital and cerebral lesions.

Biomarkers of sepsis: clinically useful?

PURPOSE OF REVIEW

The purpose of this review is to indicate recent developments in biomarkers of sepsis and to evaluate their impact on clinical use. According to the 'surviving sepsis campaign,' diagnosis of sepsis and infection is urgent; early and specific treatment is most effective to reduce complications and to decrease mortality.

RECENT FINDINGS

A variety of biomarkers of sepsis is presently available. The diagnostic spectrum of the various markers, however, is different. Some primarily indicate severity of inflammation (e.g. interleukin-6), others respond to infection, but do not indicate the host response well (endotoxin, lipoprotein binding protein, triggering receptor on myeloid cells). There are new markers with limited clinical experience, for example triggering receptor on myeloid cells or mid-pro atrial natriuretic peptide (Seristra, Brahms AG, Hennigsdorf, Germany). Procalcitonin is a well-established biomarker of sepsis that fulfills several criteria of clinical needs: it responds both to infection and severity of inflammation and thus has an impact on therapy. Recent studies indicate that antibiotic treatment can also be guided by procalcitonin. Further indications, including diagnosis of invasive bacterial infections and diagnosis of sepsis in neonates and children have been reported recently.

SUMMARY

Recent data and cumulative analyses indicate that biomarkers of sepsis improve diagnosis of sepsis. However, only a few markers have impact on therapy and fulfill the clinical requirements. Procalcitonin is a well-established marker, indicating infection, sepsis, and progression to the more severe stages of the disease. Today, this biomarker should be in the diagnostic portfolio of an intensive care unit or emergency ward.

Méningites puriformes aseptiques chez l’adulte

OBJECTIVE

The objective of this study was to analyze the characteristics of a series of acute aseptic meningitis (AAM) (defined by sterile cerebrospinal fluid (CSF) with more than 10 leucocytes per mm3 and a neutrophilic polynuclear-rich formula). We analysed the initial management, the reasons for antibiotic and/or antiviral treatment, the aetiologies, the need for lumbar puncture and the progression...

METHOD

We retrospectively analyzed 32 cases of AAM (out of a total of 130 cases of meningitis) from two departments of internal medicine in Lyon, diagnosed between January 1996 and January 2003. Only the files fulfilling the AAM criteria were retained, selecting those with a minimum neutrophilic polynuclear level of 30% in the CSF.

RESULTS

The mean age was 32.6 years (range: 18-75) and predominantly male patients (59%). On admission, 87% of the patients exhibited fever, but only 9% remaining so for 72 hours. Viral syndrome before admission was noted in 59% of cases, with seasonal predilection (summer: 39%, winter: 35%). The motivation for lumbar puncture (LP) was meningeal syndrome (44%), headache (94%) and vomiting (47%). The average rate of neutrophils in the CSF on admission was 63% (range: 30-96). A control LP on Day 3 was performed 16 times (50%): mean PNN rate at 18% (range: 0-80), lymphocyte rate=68% (range: 20-95). Most of the patients (77.4%) had a C reactive protein (CRP) lower than 50 mg/l on admission (range: 5-320). A cerebral scan was performed 10 times (31%) and was abnormal 2 times (multiple cerebral abscesses, possible intracranial hypertension). An antibiotic (84%) and/or antiviral (34%) treatment was initiated. The evolution on Day 3 was favourable (87.5%): no fever, regression of the meningeal syndrome, with a mean duration of hospitalisation of 8.3 days (range: 1-60). Search for Herpes simplex virus and Enterovirus was made with PCR analysis in 20 cases (62.5%): no positivity for the herpes, but 9 for the Enterovirus. The systematic blood cultures were positive only once (staphylococcal infective endocarditis with cerebral abscesses). The diagnosis of bacterial meningitis was evoked 3 times (prior antibiotic treatment).

DISCUSSION

The frequency of Enterovirus AAM should encourage this type of investigation in order to withdraw the often initiated anti-infectious treatment rapidly, and hence avoid a second lumbar puncture.