A multicenter clinical epidemiology of pediatric pneumococcal meningitis in China: results from the Chinese Pediatric Bacterial Meningitis Surveillance (CPBMS) 2019-2020

Objective

To analyze the clinical epidemiological characteristics including clinical features, disease prognosis of pneumococcal meningitis (PM), and drug sensitivity of S. pneumoniae isolates in Chinese children.

Methods

A retrospective analysis was performed on the clinical, laboratory microbiological data of 160 hospitalized children less than 15 years of age with PM from January 2019 to December 2020 in 33 tertiary hospitals in China.

Results

A total of 160 PM patients were diagnosed, including 103 males and 57 females The onset age was 15 days to 15 years old, and the median age was 1 year and 3 months. There were 137 cases (85.6%) in the 3 months to <5 years age group, especially in the 3 months to <3 years age group (109 cases, 68.2%); S. pneumoniae was isolated from cerebrospinal fluid (CSF) culture in 95(35.6%), and 57(35.6%) in blood culture. The positive rates of S. pneumoniae detection by CSF metagenomic next-generation sequencing (mNGS)and antigen detection method were 40.2% (35/87) and 26.9% (21/78). Fifty-five cases (34.4%) had one or more predisposing factors of bacterial meningitis; and 113 cases (70.6%) had one or more extracranial infection diseases Fever (147, 91.9%) was the most common clinical symptom, followed by vomiting (61, 38.1%) and altered mental status (47,29.4%). Among 160 children with PM, the main intracranial imaging complications were subdural effusion and (or) empyema in 43 cases (26.9%), hydrocephalus in 24 cases (15.0%), cerebral abscess in 23 cases (14.4%), intracranial hemorrhage in 8 cases (5.0%), and other cerebrovascular diseases in 13 cases (8.1%) including encephalomalacia, cerebral infarction, and encephalatrophy. Subdural effusion and (or) empyema and hydrocephalus mainly occurred in children < 1 years old (90.7% (39/43) and 83.3% (20/24), respectively). 17 cases with PM (39.5%) had more than one intracranial imaging abnormality. S. pneumoniae isolates were completely sensitive to vancomycin (100.0%, 75/75), linezolid (100.0%,56/56), ertapenem (6/6); highly sensitive to levofloxacin (81.5%, 22/27), moxifloxacin (14/17), rifampicin (96.2%, 25/26), and chloramphenicol (91.3%, 21/23); moderately sensitive to cefotaxime (56.1%, 23/41), meropenem (51.1%, 23/45) and ceftriaxone (63.5, 33/52); less sensitive to penicillin (19.6%, 27/138) and clindamycin (1/19); completely resistant to erythromycin (100.0%, 31/31). The cure and improvement rate were 22.5% (36/160)and 66.3% (106/160), respectively. 18 cases (11.3%) had an adverse outcome, including 6 cases withdrawing treatment therapy, 5 cases unhealed, 5 cases died, and 2 recurrences. S. pneumoniae was completely susceptible to vancomycin (100.0%, 75/75), linezolid (100.0%, 56/56), and ertapenem (6/6); susceptible to cefotaxime, meropenem, and ceftriaxone in the order of 56.1% (23/41), 51.1% (23/45), and 63.5 (33/52); completely resistant to erythromycin (100.0%, 31/31).

Conclusion

Pediatric PM is more common in children aged 3 months to < 3 years old. Intracranial complications mostly occur in children < 1 year of age with fever being the most common clinical manifestations and subdural effusion and (or) empyema and hydrocephalus being the most common complications, respectively. CSF non-culture methods can facilitate improving the detection rate of pathogenic bacteria. More than 10% of PM children had adverse outcomes. S. pneumoniae strains are susceptible to vancomycin, linezolid, ertapenem, levofloxacin, moxifloxacin, rifampicin, and chloramphenicol.

Triad of Terror: Rapidly Progressive Austrian Syndrome in a 62-Year-Old Female

We report a case of a 62-year-old female presenting with shortness of breath, who was subsequently diagnosed with Austrian syndrome. The patient had a complicated clinical course, including invasive central nervous system pneumococcal disease, pneumococcal bacteremia, and mitral valve vegetation with possible leaflet perforation. Despite aggressive treatment, her condition continued to worsen. We will discuss the clinical features of this disease, approaches to diagnosis and treatment, and outcomes in light of this rare condition.

Takotsubo cardiomyopathy in a 4-year-old female with pneumococcal meningitis

A previously healthy 4-year-old female presented in cardiogenic shock with pneumococcal meningitis. Findings on echocardiogram raised suspicion for takotsubo cardiomyopathy. With supportive care, left ventricular systolic function normalised. Findings on cardiac imaging helped determine the aetiology and avoid further invasive studies or unnecessary treatment.

Healthy adults with Streptococcus pneumoniae meningitis and Streptococcus pneumoniae subdural abscess: two case reports and a literature review

We present the cases of two otherwise healthy adults, one with meningitis and another with a subdural abscess, with both conditions attributable to Streptococcus pneumoniae. A 31-year-old man was admitted with a 3-day history of fever, headache, and vomiting. Physical examination revealed intermittent confusion, irritability, and neck stiffness. Cerebrospinal fluid (CSF) culture was positive for S. pneumoniae. Contrast-enhanced magnetic resonance imaging (C-MRI) revealed multiple small lesions on the bilateral frontal lobes. Intravenous ceftriaxone and vancomycin were administered, followed by intravenous moxifloxacin. His symptoms resolved within 3 months. Additionally, a 66-year-old man was admitted for acute fever with confusion, abnormal behavior, and a recent history of acute respiratory infection. Physical examination revealed confusion, neck stiffness, and a positive right Babinski sign. CSF metagenomic analysis detected S. pneumoniae. C-MRI disclosed left occipitotemporal meningoencephalitis with subdural abscesses. Intravenous ceftriaxone was administered for 3 weeks. His condition gradually improved, with resorbed lesions detected on repeat MRI. This study expanded the clinical and imaging spectra of S. pneumoniae meningitis. In healthy adults, S. pneumoniae can invade the brain, but subdural abscess is a rare neuroimaging manifestation. Early diagnosis of S. pneumoniae meningitis by high-throughput sequencing and flexible treatment strategies are necessary for satisfactory outcomes.

Recognition and Outcomes of Pneumococcal Meningitis in 2 Tertiary Pediatric Hospitals Since the Introduction of the 13-Valent Pneumococcal Conjugate Vaccine

OBJECTIVES

The aims of the study were to analyze the demographics, presentation, laboratory findings, and complications of pediatric Streptococcus pneumoniae meningitis since the introduction of the 13-valent pneumococcal conjugate vaccine, to improve recognition, and to minimize patient morbidity and mortality.

METHODS

This study used a retrospective analysis of pediatric pneumococcal meningitis cases at 2 tertiary healthcare systems in the Southeastern United States from 2010 to 2018.

RESULTS

We describe 21 cases of pneumococcal meningitis. All patients presented with fever, 95% had altered mental status by history or examination, and 48% had meningeal signs. Forty-three percent had seen another provider within 48 hours of admission. Forty-eight percent had delay in lumbar puncture (LP) of more than 6 hours after antibiotic administration, decreasing rates of positive cerebrospinal fluid cultures from 100% to 40% (P < 0.001). Decision to delay LP was due to either low suspicion for meningitis (n = 4) or clinical instability (n = 6) and was associated with lower rates of meningeal signs (P = 0.014) and higher rates of altered mental status on examination (P = 0.031). Fourteen patients (67%) were up-to-date on pneumococcal immunization. Serotypes were determined in 16 cases, with 2 patients (13%) immunized against the strain that infected them. Primary outcomes included seizures (48%), hearing loss (48%), cranial nerve palsy (33%), and death (5%). Delay in LP with low suspicion for meningitis was associated with longer hospital length of stay approaching statistical significance (P = 0.053).

CONCLUSIONS

Pneumococcal meningitis remains a relevant and potentially fatal disease despite widespread use of 13-valent pneumococcal conjugate vaccine. Its diagnosis is often delayed during interactions with physicians, which may put patients at increased risk for poor clinical outcomes.

Diagnostic Yield of Pneumococcal Antigen Detection in Cerebrospinal Fluid for Diagnosis of Pneumococcal Meningitis Among Children in China

OBJECTIVE

To determine the diagnostic accuracy of pneumococcal antigen detection in diagnosis of pneumococcal meningitis in children.

METHODS

Purulent meningitis was diagnosed according to European Society for Clinical Microbiology and Infectious Diseases (ESCMID) guideline between July 2014 and June 2016. Along with a cerebrospinal fluid (CSF) culture, pneumococcal antigen detection in cerebrospinal fluid (CSF) was performed, and further identification of pathogens was done with 16S rDNA-PCR and high-throughput sequencing.

RESULTS

CSF samples collected from 184 children (median age of 1.92 mo). CSF culture was used as the gold standard. 46 (25%) had positive results for culture and 10 (5.4%) were pneumococci; 34 (18.5%) were pneumococcal antigen positive. The sensitivity and specificity of pneumococcal antigen detection were 100% (95% CI: 89.4%-100%) and 86.2% (95% CI: 96.4%-99.9%), respectively. 92.3% (12/13) were confirmed by nucleic acid detection to be pneumococci.

CONCLUSIONS

Pneumococcal antigen detection in CSF has adequate sensitivity and specificity in diagnosing pneumococcal meningitis.

Streptococcus suis-Associated Meningitis, Bali, Indonesia, 2014-2017

Streptococcus suis is an emerging agent of zoonotic bacterial meningitis in Asia. We describe the epidemiology of S. suis cases and clinical signs and microbiological findings in persons with meningitis in Bali, Indonesia, using patient data and bacterial cultures of cerebrospinal fluid collected during 2014-2017. We conducted microbiological assays using the fully automatic VITEK 2 COMPACT system. We amplified and sequenced gene fragments of glutamate dehydrogenase and recombination/repair protein and conducted PCR serotyping to confirm some serotypes. Of 71 cases, 44 were confirmed as S. suis; 29 isolates were serotype 2. The average patient age was 48.1 years, and 89% of patients were male. Seventy-seven percent of patients with confirmed cases recovered without complications; 11% recovered with septic shock, 7% with deafness, and 2% with deafness and arthritis. The case-fatality rate was 11%. Awareness of S. suis infection risk must be increased in health promotion activities in Bali.

Association of the FilmArray Meningitis/Encephalitis Panel With Clinical Management

OBJECTIVES

To determine the association of the use of the multiplex assay meningitis/encephalitis panel with clinical management of suspected meningitis.

METHODS

A cross-sectional study was conducted with children 0 to 18 years of age who received a lumbar puncture within 48 hours of admission for an infectious workup. Patient demographic and presenting information, laboratory studies, and medication administration were collected. The primary measure was length of stay (LOS) with secondary measures: time on antibiotics, time to narrowing antibiotics, and acyclovir doses. LOS and antibiotic times were stratified for outcomes occurring before 36 hours. Logistic regression analysis was used to account for potential confounding factors associated with both the primary and secondary outcomes. A value of P < .05 was considered statistically significant.

RESULTS

Meningitis panel use was associated with a higher likelihood of a patient LOS <36 hours (P = .04; odds ratio = 1.7; 95% confidence interval [CI]: 1.03-2.87), a time to narrowing antibiotics <36 hours (P = .008; odds ratio = 1.89; 95% CI: 1.18-2.87), and doses of acyclovir (P < .001; incidence rate ratio = 0.37; 95% CI: 0.26-0.53). When controlling for potential confounding factors, these associations persisted.

CONCLUSIONS

Use of the meningitis panel was associated with a decreased LOS, time to narrowing of antibiotics, and fewer acyclovir doses. This likely is a result of the rapid turnaround time as compared with cerebrospinal fluid cultures. Additional studies to examine the outcomes related to this change in management are warranted.

Diagnosis of bacterial meningitis in Ghana: Polymerase chain reaction versus latex agglutination methods

Bacterial meningitis is a public health crisis in the northern part of Ghana, where it contributes to very high mortality and morbidity rates. Early detection of the causative organism will lead to better management and effective treatment. Our aim was to evaluate the diagnostic accuracy of Pastorex and Wellcogen latex agglutination tests for the detection of bacterial meningitis in a resource-limited setting. CSF samples from 330 suspected meningitis patients within the northern zone of Ghana were analysed for bacterial agents at the zonal Public Health Reference Laboratory in Tamale using polymerase chain reaction (PCR) and two latex agglutination test kits; Pastorex and Wellcogen. The overall positivity rate of samples tested for bacterial meningitis was 46.4%. Streptococcus pneumoniae was the most common cause of bacterial meningitis within the sub-region, with positivity rate of 25.2%, 28.2% and 28.8% when diagnosed using Wellcogen, Pastorex and PCR respectively. The Pastorex method was 97.4% sensitive while the Wellcogen technique was 87.6% sensitive. Both techniques however produced the same specificity of 99.4%. Our study revealed that the Pastorex method has a better diagnostic value for bacterial meningitis than the Wellcogen method and should be the method of choice in the absence of PCR.

Méningite à Streptococcus pneumoniae sérotype 7A chez un nourrisson immunisé par deux doses du vaccin pneumococcique conjugué 13-valent: à propos d’un cas

Cause majeure de morbidité et mortalité, les méningites à pneumocoque (PNO) représentent un fléau mondial. Au Maroc, le vaccin conjugué 13-valent contre le pneumocoque (PCV13) a été introduit dans le Programme National de Vaccination en octobre 2010 selon le calendrier 2 + 1 et remplacé par le PCV10 en juillet 2012, selon le même calendrier. Malgré le recours au PCV13, essentiel dans la lutte contre les maladies pneumococciques, l'émergence de nouveaux sérotypes non vaccinaux entrainent toujours des méningites chez l'enfant et engendrent de lourdes séquelles. Nous rapportons le cas d'une méningite causée par Streptococcus pneumoniae sérotype 7A chez un nourrisson immunisé avec 2 doses de PCV13. La particularité de cette observation réside dans une méningite à PNO sérotype 7A, non contenu dans le PCV13, chez un nourrisson vacciné par 2 doses du PCV13. Les auteurs insistent sur la nécessité et l'importance d'un observatoire PNO et d'une large étude épidémiologique afin de déterminer les sérotypes en circulation au Maroc depuis l'introduction du PCV13 puis PCV10.

Antiphospholipid Syndrome Complicating Pneumococcal Meningitis

BACKGROUND

Antiphospholipid syndrome is a multisystem auto-immune disorder characterized by arterial or venous thrombosis in children.

CASE CHARACTERISTICS

11-year-old child with pneumococcal meningitis also had cerebral sinus vein thrombosis and pulmonary artery segmental thrombosis.

OBSERVATION

Pro-thrombotic evaluation showed positive lupus anticoagulant at baseline and after 12 weeks. Investigations for lupus were negative at admission and after one year of follow-up.

MESSAGE

Antiphospholipid syndrome is a possibility even in thrombosis occurring in the setting of meningitis.

Mannose-binding lectin-deficient genotypes as a risk factor of pneumococcal meningitis in infants

Objectives

The objective of this study was to evaluate to evaluate the role of mannose-binding-lectin deficient genotypes in pneumococcal meningitis (PM) in children.

Methods

We performed a 16-year retrospective study (January 2001 to March 2016) including patients ≤ 18 years with PM. Variables including attack rate of pneumococcal serotype (high or low invasive capacity) and MBL2 genotypes associated with low serum MBL levels were recorded.

Results

Forty-eight patients were included in the study. Median age was 18.5 months and 17/48 episodes (35.4%) occurred in children ≤ 12 months old. Serotypes with high-invasive disease potential were identified in 15/48 episodes (31.2%). MBL2 deficient genotypes accounted for 18.8% (9/48). Children ≤ 12 months old had a 7-fold risk (95% CI: 1.6–29.9; p < 0.01) of having a MBL2 deficient genotype in comparison to those > 12 months old. A sub-analysis of patients by age group revealed significant proportions of carriers of MBL2 deficient genotypes among those ≤ 12 months old with PM caused by opportunistic serotypes (54.5%), admitted to the PICU (Pediatric Intensive Care Unit) (46.7%) and of White ethnicity (35.7%). These proportions were significantly higher than in older children (all p<0.05).

Conclusions

Our results suggest that differences in MBL2 genotype in children ≤12 months old affects susceptibility to PM, and it may have an important role in the episodes caused by non-high invasive disease potential serotypes.

Nationwide Trends in Bacterial Meningitis before the Introduction of 13-Valent Pneumococcal Conjugate Vaccine-Burkina Faso, 2011-2013

BACKGROUND

Following introduction of Haemophilus influenzae type b vaccine in 2006 and serogroup A meningococcal conjugate vaccine in 2010, Streptococcus pneumoniae (Sp) became the leading cause of bacterial meningitis in Burkina Faso. We describe bacterial meningitis epidemiology, focusing on pneumococcal meningitis, before 13-valent pneumococcal conjugate vaccine (PCV13) introduction in the pediatric routine immunization program in October 2013.

METHODS

Nationwide population-based meningitis surveillance collects case-level demographic and clinical information and cerebrospinal fluid (CSF) laboratory results. Sp infections are confirmed by culture, real-time polymerase chain reaction (rt-PCR), or latex agglutination, and CSF serotyped using real-time and conventional PCR. We calculated incidence rates in cases per 100,000 persons, adjusting for age and proportion of cases with CSF tested at national reference laboratories, and case fatality ratios (CFR).

RESULTS

During 2011-2013, 1,528 pneumococcal meningitis cases were reported. Average annual adjusted incidence rates were 26.9 (<1 year), 5.4 (1-4 years), 7.2 (5-14 years), and 3.0 (≥15 years). Overall CFR was 23% and highest among children aged <1 year (32%) and adults ≥30 years (30%). Of 1,528 cases, 1,036 (68%) were serotyped: 71% were PCV13-associated serotypes, 14% were non-PCV13-associated serotypes, and 15% were non-typeable by PCR. Serotypes 1 (45%) and 12F/12A/12B/44/46 (8%) were most common. Among children aged <1 year, serotypes 5 (15%), 6A/6B (13%) and 1 (12%) predominated.

CONCLUSIONS

In Burkina Faso, the highest morbidity and mortality due to pneumococcal meningitis occurred among children aged <1 year. The majority of cases were due to PCV13-associated serotypes; introduction of PCV13 should substantially decrease this burden.

[Not Available]

Zusammenfassung. Die akute bakterielle Meningitis ist ein seltenes Krankheitsbild in der hausärztlichen Praxis mit jedoch hoher Mortalität. Deshalb ist die rasche Diagnose, unmittelbare Hospitalisierung und Einleitung einer empirischen Antibiotikatherapie eine grosse Herausforderung. Die klassische klinische Trias bestehend aus Fieber, Meningismus und Bewusstseinsveränderung ist unspezifisch, und oft sind erste Symptome bei einer Grippe oder einem gastrointestinalen Infekt sehr ähnlich. Bereits bei geringem Verdacht sollte eine Liquorpunktion erfolgen, wobei diese die erste Gabe von Ceftriaxon i.v. nicht verzögern darf. In der empirischen Therapie müssen Meningokokken, Pneumokokken und je nach Risikoprofil auch Listerien sowie mögliche resistente Keime abgedeckt werden.

ASSESSMENT OF THE DIAGNOSTIC AND PROGNOSTIC ROLE OF CEREBEROSPINAL FLUID INTERLEUKIN-8 LEVEL IN ADULT PATIENTS WITH MENINGITIS

Meningitis necessitates immediate diagnosis and therapy. It is important to distingu- ish bacterial from aseptic meningitis, as this help to avoid complications and unnece- ssary antibiotic use. This work assessed the diagnostic and prognostic role of cerebro-spinal fluid interleukin-8 (IL-8) level in adult patients with meningitis. Ninety adult patients with meningitis were studied. They were divided into 3 groups: bacterial, tuberculous and aseptic meningitis. Full clinical examination and laboratory workup of meningitis were done. Cerebrospinal fluid (CSF) IL-8 levels were assessed. Patients were followed up till discharge or death. CSF IL-8 level was significantly higher in bacterial and tuberculous meningitis in comparison to aseptic meningitis. At cut off value 121.77 pg/ml, the area under ROC curve was 0.774 with efficacy 69% for differentiating viral from non-viral meningitis. The test efficacy is low in differentiating tuberculous from bactedal meningitis. There is no correlation of CSF IL-8 levels and disease severity or prognosis.

[Clinical features of childhood purulent meningitis caused by Escherichia coli and Streptococcus pneumoniae: a comparative analysis]

OBJECTIVE

To investigate the differences in clinical features of childhood purulent meningitis (PM) caused by Escherichia coli and Streptococcus pneumoniae, and to provide help for the selection of antibiotics for PM children with unknown etiology.

METHODS

A retrospective analysis was performed for the clinical data of children with PM caused by Escherichia coli (12 children) or Streptococcus pneumoniae (15 children).

RESULTS

Compared with the Streptococcus pneumoniae infection group, the Escherichia coli infection group had a significantly higher proportion of children with an age of onset of <3 months and a significantly higher incidence rate of convulsion, but significantly lower incidence rates of severe fever (>39°C) and disturbance of consciousness and a significantly lower proportion of children with an increased leukocyte count at diagnosis (>12×10(9)/L). The results of routine cerebrospinal fluid test and biochemical examinations showed no significant differences between the two groups. Escherichia coli and Streptococcus pneumoniae were resistant to cephalosporins and had a sensitivity to chloramphenicol more than 90%. Escherichia coli was fully sensitive to meropenem and Streptococcus pneumoniae was fully sensitive to vancomycin.

CONCLUSIONS

PM caused by Escherichia coli and Streptococcus pneumoniae has different clinical features. As for PM children with severe fever, disturbance of consciousness, and an increased leukocyte count, the probability of Streptococcus pneumoniae infection should be considered. For PM children with an age of onset of <3 months, medium- and low-grade fever, frequent convulsions, and a leukocyte count of <12×10(9)/L, the probability of Escherichia coli infection should be considered.

Listeria monocytogenes meningitis in the elderly: epidemiological, clinical and therapeutic findings

Listeria monocytogenes is a Gram-positive bacillus and facultative intracellular bacterium whose transmission occurs mainly through the consumption of contaminated food, L. monocytogenes invades the host cells using various protein and can escape to the human T-cell immune system by cell-to-cell spreading. If the infection is not controlled at the stage in which the bacterium is in the liver, for instance, due to a severe immunodepression, a secondary bacteraemia can be developed and L. monocytogenes reaches the preferred sites transgressing the blood-brain barrier or the placental barrier. Individuals with T-cell dysfunction, such as pregnant women, the elderly, and those receiving immunosuppressive therapy are at the highest risk of contracting the disease. Average life expectancy throughout developed countries has rapidly increased during the latter half of the 20th century and geriatric infectious diseases have become an increasingly important issue. L. monocytogenes meningitis in young previously healthy adults has been reported only in anecdotal observations. Differently, L. monocytogenes is the third most common cause of bacterial meningitis in the elderly population, after Streptococcus pneumoniae and Neisseria meningitidis. Patients with L. monocytogenes meningitis presented with signs and symptoms that were similar to those of the general population with community-acquired bacterial meningitis, but reported a longer prodromal phase. According to literature data, the prevalence of the classic triad of fever, neck stiffness, and altered mental status is 43%, and almost all patients present with at least 2 of the 4 classic symptoms of headache, fever, neck stiffness, and altered mental status. On the basis of our published data, in patients aged over 50 years, diagnosing L. monocytogenes meningitis was more challenging than pneumococcal meningitis, as demonstrated by the lower percentage of cases receiving a correct diagnosis within 48 hours from the onset of symptoms. No significant difference was observed in respect to the presenting symptoms, but progression to respiratory failure was not as rapid as pneumococcal meningitis.

[Fatal pneumococcal meningitis due to serotype 19 A: A preventable case?]

Invasive pneumococcal disease (IPD) remains as an important cause of morbidity in the world and in our country, while in Chile the incidence has decreased after the incorporation of the 10 valent pneumococcal conjugate vaccine, in the routine infant inmunization schedule (EPI). One of the expected effects of the program after vaccination with 10-valent pneumococcal vaccine is the likely replacement serotype phenomenon that means the presence of ENI caused by serotypes not included in the vaccine. In this context, we present the case of a child with pneumococcal meningitis caused by serotype 19 A of fatal course. The occurrence of ENI in a later stage of pneumococcal vaccine incorporation in Chile reinforces the importance of active surveillance, in order to know in detail the impact of vaccination, distribution of circulating serotypes and their correlation with the different clinical disease and their severity.

Comparison of the clinical presentations of Naegleria fowleri primary amoebic meningoencephalitis with pneumococcal meningitis: a case-control study

BACKGROUND

Primary amoebic meningoencephalitis (PAM) is a rare but fatal infection caused by Naegleria fowleri. The infection is acquired by deep nasal irrigation with infected water. Patients present with signs and symptoms similar to pneumococcal meningitis, leading to delayed diagnosis and treatment and hence high mortality.

METHODS

We conducted a case-control study comparing culture proven cases of PAM with pneumococcal meningitis presenting to our center between April 2008 and September 2014. Only patients with blood and/or cerebrospinal fluid cultures positive for Streptococcus pneumoniae during the same time period were included for comparison.

RESULTS

There were 19 cases of PAM and pneumococcal meningitis, each. When comparing PAM with pneumococcal meningitis, patients with PAM were more likely to be male (89.5 vs. 36.8 %), younger (mean age: 30 vs. 59 years), present with seizures (42.1 vs. 5.3 %). Both groups of patients presented with similar vital signs and there were no remarkable differences on physical examinations, Glasgow Coma Scale scores, laboratory and radiological investigations and cerebrospinal fluid parameters. PAM was also more likely to present if the city's average maximum temperature was higher in the previous week (mean: 34.6 vs. 30 °C). There was history of fresh water contact in only one patient. On multivariate analysis, PAM was more likely if patients presented when the city's average maximum temperature was high, being young males.

CONCLUSION

PAM and pneumococcal meningitis remain virtually indistinguishable; however, these predictive features should be validated in a prospective study and may lead to a viable algorithm for early management of these patients.

Surgically Cured, Relapsed Pneumococcal Meningitis Due to Bone Defects, Non-invasively Identified by Three-dimensional Multi-detector Computed Tomography

A 43-year-old Japanese man presented with a history of bacterial meningitis (BM). He was admitted to our department with a one-day history of headache and was diagnosed with relapse of BM based on the cerebrospinal fluid findings. The conventional imaging studies showed serial findings suggesting left otitis media, a temporal cephalocele, and meningitis. Three-dimensional multi-detector computed tomography (3D-MDCT) showed left petrous bone defects caused by the otitis media, and curative surgical treatment was performed. Skull bone structural abnormalities should be considered a cause of relapsed BM. 3D-MDCT was useful for revealing the causal minimal bone abnormality and performing pre-surgical mapping.

Enhanced Diagnosis of Pneumococcal Bacteremia Using Antigen- and Molecular-Based Tools on Blood Specimens in Mali and Thailand: A Prospective Surveillance Study

Prior antibiotic use, contamination, limited blood volume, and processing delays reduce yield of blood cultures for detection of Streptococcus pneumoniae. We performed immunochromatographic testing (ICT) on broth from incubated blood culture bottles and real-time lytA polymerase chain reaction (PCR) on broth and whole blood and compared findings to blood culture in patients with suspected bacteremia. We selected 383 patients in Mali and 586 patients in Thailand based on their blood culture results: 75 and 31 were positive for pneumococcus, 100 and 162 were positive for other pathogens, and 208 and 403 were blood culture negative, respectively. ICT and PCR of blood culture broth were at least 87% sensitive and 97% specific compared with blood culture; whole blood PCR was 75–88% sensitive and 96–100% specific. Pneumococcal yields in children < 5 years of age increased from 2.9% to 10.7% in Mali with > 99% of additional cases detected by whole blood PCR, and from 0.07% to 5.1% in Thailand with two-thirds of additional cases identified by ICT. Compared with blood culture, ICT and lytA PCR on cultured broth were highly sensitive and specific but their ability to improve pneumococcal identification varied by site. Further studies of these tools are needed before widespread implementation.

A pediatric case of acute meningitis due to Streptococcus pneumoniae serotype 33D

Streptococcus pneumoniae is a leading cause of bacterial meningitis in children. It is also responsible for bacteremia, sepsis, pneumonia, sinusitis and acute otitis media in young children worldwide. The serotypes included in the 7-valent conjugated pneumococcal vaccine (PCV7)-1, 5, 6A, 6B, 14, 19F, 23F-are those most commonly responsible for invasive pneumococcal disease (IPD) globally. Unvaccinated children are at greater risk for meningitis. The rate of non-vaccine serotypes as causes of invasive disease has increased. Although the incidence rate of IPD is highest in children aged <2 years, the rare, non-vaccine serotypes of S. pneumoniae may be responsible for acute meningitis in older, unvaccinated children. In this report, we present a pediatric case of meningitis due to S. pneumoniae serotype 33D, which has not been previously identified as a cause of IPD in those countries where PCV7 is routinely administered, including Turkey.

Epidemiology and diagnostic testing for meningitis in adults as the meningococcal epidemic declined at Middlemore Hospital

AIMS

To describe changes in epidemiology and diagnostic techniques for adult meningitis at Middlemore Hospital following the decline of the meningococcal epidemic.

METHODS

Retrospective audit of cases of meningitis from 2000 to 2009.

RESULTS

Microbiologically-confirmed diagnosis (MCD) was established in 296 of 743 episodes (40%), most commonly enterovirus (123/296, 42%), Neisseria meningitidis (43/296, 15%) and Streptococcus pneumoniae (34/296, 11%). N. meningitidis meningitis declined and herpes viruses increased over time, without significant change in overall meningitis case numbers. By 2009, S. pneumoniae constituted a greater proportion of cases than N. meningitidis. Cerebrospinal fluid (CSF) polymerase chain reaction (PCR) and pneumococcal immunochromatographic testing (PICT) increased over time as did the proportion of cases with MCD. CSF Gram stain was positive in 45% (53/118) and CSF culture made MCD in 37% (44/118) of confirmed bacterial episodes (CBE). PCR provided MCD in 59% (26/54) of CBE and 99% (168/170) of viral episodes. CSF PICT was tested in 76% (26/34) of S. pneumoniae meningitis (positive in 92% (24/26).

CONCLUSIONS

As the epidemic waned, local incidence of meningococcal meningitis decreased without significant decreasing meningitis overall. Empiric treatment for meningitis in New Zealand adults should routinely include pneumococcal cover. Increased PCR testing increases MCD in meningitis.

Severe Sepsis due to Otogenic Pneumococcal Meningitis with Pneumocephalus without Meningeal Symptoms

The absence of meningeal signs and symptoms is rare in patients with bacterial meningitis and may lead to a delay in diagnosis and treatment. Furthermore, the onset of bacterial meningitis associated with pneumocephalus is a rare complication of ear infections. We herein report a rare case of otogenic meningitis complicated by pneumocephalus that was initially missed due to the absence of typical meningeal signs and symptoms and later diagnosed correctly based on a thorough review of the patient's systems.

Sphenoid Sinusitis Complicated by Pneumococcal Meningitis and an Infectious Aneurysm in the Intracavernous Carotid Artery

A 61-year-old Japanese woman presented with a headache and appetite loss lasting for nine days and was admitted to our hospital, where she was diagnosed with pneumococcal meningitis associated with acute sphenoid sinusitis. While the administration of meropenem and dexamethasone ameliorated the meningitis, right third and sixth nerve palsy suddenly developed 10 days after admission. CT angiography subsequently demonstrated an aneurysm in the cavernous portion of the right internal carotid artery. This is the first reported case of sphenoid sinusitis simultaneously complicated by both pneumococcal meningitis and an infectious aneurysm in the intracavernous carotid artery.

[Acute bacterial meningitis as an occupational disease]

Streptococcus suis is a zoonotic pathogen with worldwide distribution, responsible for more than 700 human cases globally reported. This infection affects mostly men, exposed to pig or pork, which leads to its usual classification as an occupational disease. We report a case of acute bacterial meningitis in a 44 years old male. According to his past medical history, the patient had chronic alcoholism and worked in a restaurant as a piglet roaster. Microbiological examination of blood and CSF revealed S. suis. After 14 days of ceftriaxone the patient fully recovered. The authors review the clinical reports previously described in Portugal. In all of them was possible to identify risk exposition to pork. We alert to this microorganism's importance in Portugal where it is probably underdiagnosed.

[Pneumococcal meningitis in a pregnant woman]

Bacterial meningitis is a life-threatening disease. The incidence of meningitis is about 2.6-6 cases per 100.000 adults per year in developed countries. The most common causative microorganisms are Sreptococcus pneumoniae and Neisseria meningitidis. A 33-year-old multigravida, at 24 week of gestation was admitted to the hospital because of ear pain, haedache, fever and confusion. Lumbal puncture was performed and cerebrospinal fluid analysis showed signs of bacterial meningitis. Latex agglutination test was positive for S. pneumoniae, Gram-positive diplococci have seen under microscope and later cultivation verified S. pneumoniae as the causative agent. After ceftriaxon, dexamethasone administration and treatment in intensive care unit, left side mastoidectomy was performed since cranial computed tomography showed acut exacerbation of chronic mastoiditis on the left side. After extubation, mobilisation and 14 days antibiotic treatment the patient, who had residual hearing loss on the left side, was discharged from the hospital. During the treatment the foetal parameters were normal. The patient at 39 week of gestation gave birth to a healthy infant. Forty-eight case reports have been published in this topic around the world until April, 2012. The most common causative agents were S. pneumoniae and Listeria monocytogenes. Because of the little amount of data, it is hard to appreciate the actual incidence and prognosis of this life-threatening illness both for mother and infant. As far as we know this is the first published case report of meningitis during pregnancy in Hungary. By this article we would like to draw attention to the importance of teamwork, of prevention of brain abscess formation and of the removal of the infection's focus.

[Real-time pcr procedure for determination of Streptococcus pneumoniae serotypes]

AIM

Development and application of real-time PCR (RT-PCR) procedure for determination of Streptococcus pneumoniae serotypes.

MATERIALS AND METHODS

S. pneumoniae cps-locus wzx, wzy, wzz, wcwV and galU genes were chosen as PCR targets to select serotype-specific oligonucleotide primers and fluorescent labeled probes. 89 samples of cerebrospinal fluid (CSF) obtained in 2007 - 2010 from patients with pneumococcal meningitis diagnosis undergoing therapy in the Infectious Clinical Hospital No. 2, Moscow, were studied with the aim of testing the possibility of practical use of RT-PCR.

RESULTS

Primers and probes were selected for the determination of 16 vaccine and/or frequently encountered serotypes distributed among 4 reaction mixtures also including a pair of primers and a probe for cpsA gene detection that is present in all the capsule pneumococci (internal control). The procedure was tested on a collection of 108 pneumococci strains gathered in Research Institute of Antimicrobial Therapy and serotyped earlier by specific PCR with electrophoretic detection and serologically by using Pneumotest-Latex kit. The sensitivity and specificity of the RT-PCR was 100%. RT-PCR procedure allowed to determine pneumococcus serotype in 79% of CSF clinical samples containing S. pneumoniae DNA. Serotype 3 and 23F were detected most frequently (13%, each).

CONCLUSION

RT-PCR application does not assume causative agent seeding stage, significantly reduces analysis execution time and increases sensitivity of the study. The developed procedure will allow to begin addressing the important problem--clarification of spectra and frequency of occurrence of pneumococci serotypes circulating on the territory of Russia.

[Pneumococcal meningitis in children]

OBJECTIVE

Presented are the authors' own experiences with invasive pneumococcal diseases in a group of pediatric inpatients with pneumococcal meningitis treated in the Department of Infectious Diseases, University Hospital and Charles University Faculty of Medicine in Hradec Králové over the last 10 years.

MATERIAL AND METHODS

A group of patients aged 0-18 years and hospitalized in the above facility in 2002-2011 was retrospectively assessed. The patients' basic clinical characteristics and treatment outcomes are shown below.

RESULTS

Over the study period, 27 children with pneumococcal meningitis were treated; of those, 15 were boys and 12 were girls. The patients' ages ranged from 2 days to 17 years; seventeen children (63 %) were younger than 2 years. On admission, 11 children (40 %) had the infection in the middle ear or paranasal sinuses; intracranial complications were noted in 10 cases. Cerebrospinal fluid culture was positive for Streptococcus pneumoniae in 21 cases. In 6 patients, pneumococcal DNA was determined in the cerebrospinal fluid by PCR. None of the studied patients died. Eight children (29 %) were left with permanent damage; of those, seven had hearing impairment.

CONCLUSION

Even today, pneumococcal meningitis in children remains a serious condition posing a risk of dangerous consequence or even death. To the maximum extent possible, prevention should include vaccination, especially in infants and children with the predisposing factors.

Impact of the revised penicillin susceptibility breakpoints for Streptococcus pneumoniae on antimicrobial resistance rates of meningeal and non-meningeal pneumococcal strains

BACKGROUND AND OBJECTIVES

In January 2008, the Clinical Laboratory Standard Institute (CLSI) revised the Streptococcus pneumoniae breakpoints for penicillin to define the susceptibility of meningeal and non-meningeal isolates. We studied the impact of these changes. In addition, the pneumococcal resistance rate to other antimicrobial agents was reviewed.

DESIGN AND SETTING

Laboratory data on peumococcal isolates collected retrospectively from hospitalized children in tertiary care hospital in Riyadh, Saudi Arabia from January 2006 to March 2012.

PATIENTS AND METHODS

Only sterile samples were included from cerebrospinal fluids, blood, sterile body fluids and surgical tissue. Other samples such as sputum and non sterile samples were excluded. We included samples from children 14 years old or younger. The minimum inhibitory concentration (MIC) for penicillin, cefuroxime, ceftriaxone and meropenem were determined by using the E-test, while susceptibility to erythromycin, cotrimoxazole and vancomycin were measured using the disc diffusion methods following the guideline of CLSI.

RESULTS

Specimens were analyzed in two different periods: from January 2006 to December 2007 and from January 2008 to March 2012. During the two periods there were 208 samples of which 203 were blood samples. Full penicillin resistance was detected in 6.6% in the first period. There was decrease in penicillin nonmeningeal resistance to 1.5% and an increase in resistance in penicillin meningeal 68.2% in the second period (P=.0001). There was an increase in rate of resistance among S pneumoniae isolates over the two periods to parenteral cefuroxime, erythromycin and cotrimoxazole by 34.6%, 35.5% and 51.9%, respectively. Total meropenem resistance found 4.3% and no vancomycin resistance was detected.

CONCLUSIONS

The current study supports the use of the revised CLSI susceptibility breakpoints that promote using penicillin to treat nonmeningeal pneumococcal disease, and might slow the development of resistance to broader-spectrum antibiotics.

The Austrian syndrome: a case report and review of the literature

A 61-year-old man presented with fever and altered mental status. He was intubated for respiratory distress and was found to have multilobar pneumonia for which antibiotic therapy was instituted. However, his mental status continued to deteriorate despite appropriate antibiotic therapy for his pneumonia. The results from lumar puncture revealed meningitis and endocarditis was evident on a trans-esophageal echocardiogram. His blood and respiratory cultures grew Streptococcus pneumoniae. The patient was diagnosed with Austrian syndrome. After appropriate changes to his antibiotic regimen and an aortic valve replacement, he recovered and was discharged.

The enhanced pneumococcal LAMP assay: a clinical tool for the diagnosis of meningitis due to Streptococcus pneumoniae

BACKGROUND

Streptococcus pneumoniae is a leading cause of invasive bacterial disease in developed and developing countries. We studied the loop-mediated isothermal amplification (LAMP) technique to assess its suitability for detecting S. pneumoniae nucleic acid in cerebrospinal fluid (CSF).

METHODOLOGY/PRINCIPAL FINDINGS

We established an improved LAMP assay targeting the lytA gene (Streptococcus pneumoniae [Sp] LAMP). The analytical specificity of the primers was validated by using 32 reference strains (10 Streptococcus and seven non-Streptococcus species) plus 25 clinical alpha-hemolytic streptococcal strains, including four S. pneumoniae strains and 21 other strains (3 S. oralis, 17 S. mitis, and one Streptococcus species) harboring virulence factor-encoding genes (lytA or ply). Within 30 minutes, the assay could detect as few as 10 copies of both purified DNA and spiked CSF specimens with greater sensitivity than conventional polymerase chain reaction (PCR). The linear determination range for this assay is 10 to 1,000,000 microorganisms per reaction mixture using real-time turbidimetry. We evaluated the clinical sensitivity and specificity of the Sp LAMP assay using 106 randomly selected CSF specimens from children with suspected meningitis in Korea, China and Vietnam. For comparison, CSF specimens were also tested against conventional PCR and culture tests. The detection rate of the LAMP method was substantially higher than the rates of PCR and culture tests. In this small sample, relative to the LAMP assay, the clinical sensitivity of PCR and culture tests was 54.5% and 33.3%, respectively, while clinical specificity of the two tests was 100%.

CONCLUSIONS/SIGNIFICANCE

Compared to PCR, Sp LAMP detected S. pneumoniae with higher analytical and clinical sensitivity. This specific and sensitive LAMP method offers significant advantages for screening patients on a population basis and for diagnosis in clinical settings.

[Meningitis can resemble subarachnoid haemorrhage]

A 70 year-old man was admitted under the diagnosis of subarachnoid haemorrhage and presented with a history of ear pain, followed by acute onset of severe headache, nausea, vomiting, impaired consciousness, and fever. However, a computed tomography (CT) showed an acute mastoiditis and pneumocephalus, and a lumbar puncture confirmed the diagnosis meningitis. The increased middle ear pressure relative to the intracranial pressure had caused air and bacteria to penetrate intracerebrally. This case illustrates the importance of a rapid diagnostic workup in acute onset headache including a careful anamnesis, CT and lumbar puncture.

Serial PCR genetic load determination in the surgical management of pneumococcal intracranial sepsis

PURPOSE

Aspirated intracranial fluid, in the surgical management of intracranial sepsis, may not culture an organism due to the previous administration of antibiotics. We have sought to utilise polymerase chain reaction (PCR) to determine the cause of culture-negative sepsis and in monitoring response to therapy.

METHODS

This was a retrospective review of five cases of Streptococcus pneumoniae intracranial sepsis. Samples were analysed using real-time quantitative PCR targeting the pneumococcal lytA gene and the number of genome copies per microlitre of sample determined.

RESULTS

Streptococcus pneumoniae sepsis was diagnosed by PCR in five culture-negative cases comprising: ventriculitis (×3), subdural empyema and meningitis. Serial serum inflammatory markers (CRP and WBC) and number of genome copies were graphically plotted over the duration of inpatient stay for cases requiring surgical drainage of recurrent collections or external ventricular drainage. A correlation was demonstrated between change in bacterial genomic load and serum inflammatory markers, reflecting similar changes in clinical state.

CONCLUSIONS

This is the first report of the use of serial quantitative PCR in monitoring the course of intracranial sepsis secondary to S. pneumoniae. Further work is required to determine the precise relationship between serum inflammatory markers, clinical state and bacterial load: do changes in one precede the other? Furthermore, a threshold value for number of genome copies in cerebrospinal fluid/aspirate samples has yet to be defined.

[An infant with meningitis caused by resistant pneumococcus: infection despite vaccination]

BACKGROUND

Following the introduction of a heptavalent pneumococcal conjugate vaccine (PCV7) in the Netherlands in 2006, the incidence of invasive pneumococcal disease (IPD) declined significantly. Since then a shift towards non-vaccine serotype IPD has been noted.

CASE DESCRIPTION

We present the case of multidrug resistant non-vaccine serotype 19A pneumococcal meningitis in a 5-month-old boy. He was admitted to our Paediatric Intensive Care Unit (PICU) with seizures and septic shock. A barbiturate-induced coma was eventually required to control the seizures; shock was combated with intravenous fluids and inotropes. He received a 6-week course of ceftriaxone and vancomycin. At follow-up, one year after discharge, he had unilateral deafness and minor developmental delay.

CONCLUSION

Worldwide, pneumococcal serotype 19A is now the most common cause of IPD in children, with an increasing incidence of multidrug resistant strains. This trend has not yet been observed in the Netherlands. This case demonstrates that even following the introduction of PCV7 pneumococcal meningitis can still occur. Prompt recognition of the symptoms is still essential.

An adult case of pneumocephalus and pneumococcal meningitis associated with the sphenoid sinusitis

A 60-year-old man was admitted to our hospital after being found at his home in a comatose state. Cerebrospinal fluid and blood cultures were positive for Streptococcus pneumoniae. Brain magnetic resonance imaging (MRI) revealed sinusitis in the sphenoid sinus. Computed tomography demonstrated the presence of multiple air pockets in the basilar cistern, and we diagnosed pneumococcal meningitis complicated with pneumocephalus. Multiple cerebral infarctions were found on brain MRI after admission. In this case, pneumocephalus was secondary to pneumococcal meningitis due to sinusitis on admission, and multiple cerebral infarctions after admission. We demonstrated that early diagnosis is required for the successful treatment of pneumococcal meningitis.

Detection of acute childhood meningitis by PCR, culture and agglutination tests in Tabriz, Iran

Meningitis is one of the hazardous and life threatening infections and is associated with mortality and morbidity. The aim of this study was to determine etiological agents of childhood bacterial meningitis. The culture, Gram staining, agglutination and PCR assays were used to examine CSF specimens from 277 patients with presumed bacterial meningitis for the occurrence of 4 most common infectious agents consist of N. meningitis, H. influnsae, S. pneumoniae and S. agalactiae between 2008 and 2009 at different wards of the Children Hospital of Tabriz. The mean age of patients was 35 ± 2 (Mean ± SEM) month, (minimum 11 days maximum 14 years), of all cases 59.6% male and 40.4% female. Overall the diagnosis was confirmed with a CSF culture in 11/277 (3.97%), by agglutination test in 14/277 (5.05%). The isolated bacteria included S. pneumoniae 5 cases, H. influnsae 2 cases, N. meningitis 3 cases and P. aeroginusae 1 case. A positive PCR assay allowed us to diagnose bacterial meningitis in 19 patients (6.8%). In the present study, we found PCR to be a useful and sensitive method for the detection of bacterial DNA in the CSF samples from suspected meningitis patients. Furthermore, to maximize management of meningitis cases, a combination of culture and PCR is necessary.

Potential serotype coverage of three pneumococcal conjugate vaccines against invasive pneumococcal infection in Italian children

BACKGROUND AND AIM OF THE WORK

Since the introduction of the 7-valent vaccine, invasive pneumococcal disease have greatly decreased; however, changes in the distribution of pneumococcal serotypes have recently highlighted the need for vaccines with wider coverage. The aim of the work was to assess the potential serotype coverage of three pneumococcal conjugate vaccines (7-, 10- and 13-valent) against bacteremic pneumococcal pneumonia and meningitis/sepsis in Italian children.

PATIENTS AND METHODS

We determined pneumococcal serotypes in immunocompetent patients who had been admitted to hospital with suspicion of invasive bacterial disease and had confirmed bacteremic pneumococcal pneumonia or meningitis/sepsis determined by molecular detection of Streptococcus pneumoniae in a normally sterile site. Positive samples were serotyped using Realtime-PCR.

RESULTS

Between April 2008 and March 2011, a total of 144 patients (age median 4.1 years; Interquartile range 1.8-5.6) with pneumococcal meningitis/sepsis (n=43) or pneumonia (n=101) from 83 participating centers located in 19 of 20 Italian regions were serotyped. The 10 most prevalent serotypes were 1 (29.9%), 3 (16.0%), 19A (13.2%), 7F (8.3%), 5 (4.2%), 14 (4.2%), 6A (3.5%), 6B (3.5%), 18C (3.5%), 19F (3.5%). Overall, serotype coverage for PCV-7, -10 and -13 were respectively 19.4%, 61.8% and 94.4% with no statistical difference between pneumonia and meningitis/sepsis. Potential coverage was similar for children 0-2 or 2-5 years of age. Cultures resulted positive in 35/99 (35.4%) samples simultaneously obtained for both culture and RT-PCR.

CONCLUSION

These findings indicate that increasing the potential serotype coverage by introducing PCV13 in the vaccination schedule for infancy could provide substantial added benefit for protection from pneumococcal pneumonia or meningitis/sepsis in Italy in children below 2 years as well in older children. The importance of molecular methods for diagnosis and serotyping of invasive pneumococcal disease was confirmed.