Clinical and laboratory predictors in patients with acute meningitis in the Gaza Strip: a case series

Abstract

BackgroundMeningitis is an infection of the membranes (meninges) surrounding the brain and spinal cord. It is a dangerous condition with potentially serious consequences if misdiagnosed or left untreated. Our study aimed to summarise the clinical and laboratory predictors in patients with acute meningitis at one hospital in the Gaza Strip. MethodsWe did a retrospective case series study of a series of randomly selected patients with meningitis who were admitted to Nasser Hospital (Gaza Strip, occupied Palestinian territory), with a target of 100 participants assessed using the ICD-10 code for meningitis. We extracted the relevant data using a pre-piloted and standardised data collection form and collected data on demographics and clinical and laboratory variables from patient medical records. Approval was obtained from the Palestinian Ministry of Health. FindingsWe included 100 randomly selected records of patients who had been admitted to Nasser Hospital during 2016–18. 67 were male and 33 were female. Young (<20 years) patients were the most common age group affected (48 patients), followed by those aged 20–29 years (36 patients) whereas the least commonly affected were adults aged 40–49 years (three patients). There were 39 meningitis cases in the spring, 34 in the summer, 11 in the autumn, and 16 in winter. 76 patients presented with a fever of 38–40 degrees C° and 18 patients were afebrile. The most common presentation was headache and vomiting (39 patients) followed by vomiting and neck rigidity (34 patients). 34 patients had a positive Kernig's sign, 26 had a positive Brudzinski's sign, and only one participant was admitted with petechiae. We did not identify any data on testing for papilledema. We also examined cerebrospinal fluid analysis findings. The white blood cell count was less than 4000 per μL in 93 patients and 4000–10 000 per μL in five patients. Only two patients had more than 10 000 per μL white blood cells. The neutrophil count was less than 1500 per μL in 87 patients, 1500–7500 per μL in 11 patients, and only two patients had a neutrophil count of more than 7500 per μL. The platelet count was less than 150 000 per μL in nine patients, whereas 84 patients had platelet counts between 150 000 and 450 000 per μL. The Gram stain was positive in 45 patients, negative in 50 patients, and not documented in five patients. The cerebrospinal fluid culture was positive for two patients, negative for 93 patients, and not documented for five patients. InterpretationOur study showed that most acute meningitis cases occurred during the summer and spring. Any patient presenting with fever during these seasons should be suspected of meningitis. The Gram stain was informative in approximately half of patients and could guide decision making and antibiotic choice. However, classic meningeal signs (Kernig's and Brudzinski's signs) were absent in more than 50% of patients with acute meningitis. Therefore, the absence of these signs in adult patients cannot rule out meningitis. Notably, more than 93 patients with acute meningitis had a total white blood cell count in the cerebrospinal fluid of less than 4000 per μL. So, patients presenting with febrile illness ought to be suspected of meningitis in the light of a lower white blood cell count in the cerebrospinal fluid, which was more common in our case series. A limitation of this study is that using ICD-codes for ascertainment might miss some cases. FundingNone.