Recurrent bacterial meningitis. Secondary to malformation of the inner ear

Hearing loss diagnosis followed by meningitis in Danish children, 1995–2004

Objective

A higher risk of meningitis associated with cochlear implants may be explained in part by a generally higher risk of meningitis in children with severe to profound hearing loss. We investigated whether children with hearing loss have an increased risk of meningitis.

Study Design and Setting

A historical cohort study of all children born in Denmark between January 1, 1995, and December 31, 2004, was conducted. The cohort was selected through the Danish Medical Birth Registry, and information on hearing loss and meningitis was obtained from the National Hospital Registry.

Results

We identified 39 children with both hearing loss and meningitis. Of these children, five were diagnosed first with hearing loss and later with meningitis. The relative risk of meningitis in the group of children with a hearing loss diagnosis, as compared with the non-hearing loss group, was 5.0 (95% CI, 2.0 to 12.0).

Conclusions

The study provides evidence for an association between hearing loss and the development of meningitis. Parents and health care providers of children with hearing loss should be more alert for possible signs and symptoms of meningitis, and vaccination should be considered.

Contralateral implantation in children affected by postimplant meningitis

This study was designed to investigate the indication and advantages of contralateral implantation after postimplant meningitis (piM). Speech perception assessment, most comfortable levels and high-resolution computer tomography were used to monitor cochlear fibrosis/ossification and clinical changes in outcomes in 5 children affected by meningitis after a variable-time post-cochlear implantation. Ipsilateral ossification was found in 3 children, 1 of whom developed delayed contralateral ossification. These children were implanted on the contralateral side as they all showed deterioration of hearing performance. Results from the present paper and literature analysis suggest that, (1) piM can induce ipsilateral and contralateral ossification, (2) meningitis-induced cochlear ossification is more prone to develop in the presence of a normal cochlear structure and (3) contralateral implantation after piM has proven to be effective in restoring performance when a full electrode insertion is accomplished.

Epidemiology, etiology, pathogenesis, and diagnosis of recurrent bacterial meningitis

Recurrent bacterial meningitis is a rare phenomenon and generally poses a considerable diagnostic challenge to the clinician. Ultimately, a structured approach and early diagnosis of any underlying pathology are crucial to prevent further episodes and improve the overall outcome for the affected individual. In this article, we are reviewing the existing literature on this topic over the last two decades, encompassing 363 cases of recurrent bacterial meningitis described in 144 publications. Of these cases, 214 (59%) were related to anatomical problems, 132 (36%) were related to immunodeficiencies, and 17 (5%) were related to parameningeal infections. The review includes a detailed discussion of the underlying pathologies and microbiological aspects as well as recommendations for appropriate diagnostic pathways for investigating this unusual entity.

Meningitis in cochlear implant recipients: the North American experience

INTRODUCTION

Until recently, postimplant meningitis was infrequently reported and felt to be uncommon. However, in the spring of 2002, there was a sudden increase in the number of reported cases of postimplantation meningitis in both Europe and North America.

OBJECTIVE

Because complications of surgery often tend to be underreported, we decided to survey all cochlear implant centers in North America to determine the true incidence of postimplant meningitis and to learn more about the demographics and risk factors.

STUDY DESIGN

We conducted a prospective study. A survey instrument was designed asking surgeons the number of implants performed and whether they had seen any cases of meningitis after implantation. If the answer was affirmative, they were asked to respond to a 20-point questionnaire. This instrument was sent to all 401 cochlear implant centers in North America.

SETTING

Tertiary care referral centers.

PATIENTS

We studied all patients having received cochlear implants in North America.

MAIN OUTCOME MEASURES

Number of cases of postimplant meningitis, age of patients, device used, cochlear and temporal bone abnormalities, treatment, and outcomes.

RESULTS

Meningitis is more common than previously thought. Risk factors included young age, cochlear dysplasia, temporal bone abnormalities, and the use of a two-part electrode system. This survey led to the involvement by the U.S. Food and Drug Administration and the Centers for Disease Control and Prevention in a much more intensive analysis of a subset of the cases.

CONCLUSIONS

Postimplant meningitis is related to patient, surgical, and device factors. By being aware of the risk factors involved, adhering to sound surgical principles such as packing of the cochleostomy with soft tissue, appropriately vaccinating patients, and eliminating any potentially traumatic electrode arrays, the incidence of meningitis should be significantly diminished.

Risk of bacterial meningitis in children with cochlear implants

BACKGROUND

In June 2002, the Food and Drug Administration received reports of bacterial meningitis in patients with cochlear implants for treatment of hearing loss. Implants that included a positioner (a wedge inserted next to the implanted electrode to facilitate transmission of the electrical signal by pushing the electrode against the medial wall of the cochlea) were voluntarily recalled in the United States in July 2002.

METHODS

We identified patients with meningitis and conducted a cohort study and a nested case-control investigation involving 4264 children who had received cochlear implants in the United States between January 1, 1997, and August 6, 2002, and who were less than six years of age when they received the implants. We calculated the incidence of meningitis in the cohort and assessed risk factors for meningitis among patients and among 199 controls, using data from interviews with parents and abstracted from medical records.

RESULTS

We identified 26 children with bacterial meningitis. The incidence of meningitis caused by Streptococcus pneumoniae was 138.2 cases per 100,000 person-years--more than 30 times the incidence in a cohort of the same age in the general U.S. population. Postimplantation bacterial meningitis was strongly associated with the use of an implant with a positioner (odds ratio, 4.5 [95 percent confidence interval, 1.3 to 17.9], with adjustment for medical, surgical, and environmental factors) and with the joint presence of radiographic evidence of a malformation of the inner ear and a cerebrospinal fluid leak (adjusted odds ratio, 9.3 [95 percent confidence interval, 1.2 to 94.5]). The incidence of meningitis among patients who had received an implant with a positioner remained higher than the incidence among those whose implants did not have a positioner for the duration of follow-up (24 months from the time of implantation).

CONCLUSIONS

Parents and health care providers should ensure that all children who receive cochlear implants are appropriately vaccinated and are then monitored and treated promptly for any bacterial infections after receiving the implant.

Recurrent bacterial meningitis

To characterize recurrent bacterial meningitis in children, we reviewed the charts of all patients treated for more than one episode of bacterial meningitis at the Würzburg University Children's Hospital from 1980 to June 1995. Twenty-five children suffered 2-13 episodes of bacterial meningitis. Most patients were referred from other hospitals to our paediatric neurosurgical service. No immunodeficiency was found. In all patients, the cause of recurrent meningitis was an anatomical lesion with 13 intracranial defects including encephaloceles, skull fractures, Mondini dysplasias, neurenteric cyst, fibrous dysplasia, persistent craniopharyngeal duct, and 12 lumboscral defects with a dermoid cyst within the lumbosacral spine. A first episode of meningitis at school age did not exclude a congenital defect. In total, 84 episodes of meningitis were treated, a pathogen was isolated in 77%. The most common pathogen was Streptococcus pneumoniae, followed by Escherichia coli, Staphylococci and others. The pathogen isolated often gave a clue to the location of the defect. Personal history was often unrewarding and in some cases the search for the anatomical lesion required repeated imaging and explorative surgery. In 24 of 25 cases, final treatment of recurrent meningitis was by surgical intervention.

CONCLUSION

In recurrent bacterial meningitis, excessive diagnostic and therapeutic procedures are indicated. An anatomical defect is a very probable cause.