Cerebrospinal Fluid Bacterial Culture Research Articles

Comparison of Childhood Aseptic Meningitis with Bacterial Meningitis in a Tertiary Childrens Hospital of Taiwan

Objective: The initial clinical appearances of aseptic and bacterial meningitis in children are similar, but the treatment and outcome are quite different. To clarify the clinical presentation and laboratory results, we retrospectively reviewed our patients. Methods: The charts of hospitalized children under age 18 with discharge diagnosis of aseptic meningitis and bacterial meningitis during 2007~2014 were reviewed. Patients with aseptic meningitis were recruited as pleocytosis and negative bacterial growth in cerebrospinal fluid (CSF), while those with bacterial meningitis were recruited only who had positive CSF bacterial culture results. Traumatic tapping, contaminated cultures, or having received previous intravenous antibiotic therapy were excluded. Viral pathogens in CSF of aseptic meningitis were identified by CSF culture or polymerase chain reaction. Results: A total of 141 patients were enrolled as aseptic meningitis and 56 patients as bacterial meningitis. Aseptic meningitis occurred more in older than one-month-old children. Fever, headache, vomiting, and neck stiffness were significantly more in aseptic meningitis children, while convulsion, consciousness change, fontanelle bulging, and desaturation were significantly more in bacterial group. Significant laboratory differences were lymphocyte dominant in CSF, lower CSF protein level, higher CSF glucose level, and lower blood CRP level in aseptic meningitis group. Aseptic patients had shorter hospital duration (5.0 ± 2.0 days vs. 20.0 ± 8.0 days, p<0.001). All aseptic meningitis patients survived and were discharged without significant neurologic sequel. Among bacterial meningitis patients, 54.5% recovered completely, 10.9% died, and 34.5% had sequel. The outcome of aseptic meningitis group was significantly better than bacterial group. Conclusion: Aseptic meningitis occurred more in toddLers and older children, and had more meningeal symptoms/signs. More than half bacterial meningitis occurred in neonates and revealed more dreadful systemic presentations. Laboratory results can be helpful for differentiation of aseptic meningitis from bacterial meningitis. Careful monitoring clinical conditions and laboratory results are mandatory.

Neurocysticercosis in a 23-year-old Chinese man

Patient: Male, 23Final Diagnosis: NeurocysticerosisSymptoms: Diplopia • fever • headache • insomnia • neck stiffness • vomitingMedication: AlbendazoleClinical Procedure: —Specialty: NeurologyObjective:Challenging differential diagnosisBackground:Neurocysticercosis is a brain infection caused by the larval stage of the tapeworm Taenia (T.) solium. It is the most important parasitic disease of the human central nervous system and represents the most common cause of acquired epilepsy in developing countries.Case Report:Here, we report the case of a 23-year-old Chinese man who presented to the emergency department with a 7-day history of helmet headache radiating to the nuchal region and associated with vomiting, confusion, and fever. Cerebrospinal fluid (CSF) was clear, with increased pressure, lymphocytic pleocytosis, decreased glucose, and increased protein levels. Bacterial antigen detection test on CSF was negative, as were CSF bacterial and fungal cultures. Despite broad-spectrum antibiotic and antiviral therapy, the patient still complained of insomnia, diplopia, headache, neck stiffness, and pain in the sacral region. A second LP was performed and CSF had the same characteristics as the first LP. A brain and spinal cord MRI revealed widespread arachnoiditis and small septated cysts with CSF-like signal in the cisterna magna, within the fourth ventricle, and at the level of L3–L4. Cysticercus-specific immunoglobin G antibodies were detected by ELISA in the CSF. The patient received albendazole (15 mg/kg/day) and dexamethasone (5 mg/day) for 4 weeks, with progressive resolution of neurological symptoms.Conclusions:This case shows that, even if rare, neurocysticercosis may be responsible for meningeal symptoms and should be included in the differential diagnosis, especially in patients from endemic countries.

Study on isolates of acute meningitis in a tertiary care centre in Assam

Background: Meningitis is an inflammatory affection of the membranes surrounding the brain and spinal cord, which occurs as either a primary disease or secondarily to disease in some other part of the body. The epidemiological trend of acute meningitis varies with time and geography. Objective: To isolate the various agents of acute meningitis in all age group patients and to know the antimicrobial susceptibility pattern of bacterial isolates. Materials and Mathods: In this prospective study, a total of 316 cerebrospinal fluid (CSF) specimens were collected from patients showing signs and symptoms of acute meningitis and processed by standard microbiological methods in a tertiary care hospital in Guwahati, Assam over a period of one year, from August 2009 to July 2010. Results: Out of 316 CSF samples, bacterial and fungal culture positivity rate was found to be 16.13%. The most common bacterial isolate was Staphylococcus aureus , 29.41%. Isolation rate of Cryptococcus neoformans was 8%. All the Gram positive isolates were 100% sensitive to linezolid and vancomycin, whereas Gram negative isolates were 92% sensitive to polymyxin B. Conclusion: This study gives an idea about the changing trend of acute meningitis along with the changing in vitro antimicrobial susceptibility pattern of the bacterial isolates, which can help the clinicians to formulate the initial empiric therapy for patients of acute meningitis.

Infección por parechovirus 3 en un neonato con fiebre y sospecha de sepsis

The human parechovirus (HPeV) are viruses of the recently described Picornaviridae family and are causing several infections in young children. The pathology associated with these viruses is beginning to emerge. The HPeV type 3, has been described particularly in association with sepsis-like febrile syndromes, meningitis and encephalitis in very young infants and neonates. We report the case of a 14-day-old girl with a fever and clinical sepsis that required hospitalization and in which HPeV-3 was identified in the cerebrospinal fluid. The blood, urine and cerebrospinal fluid bacterial cultures were negative, and the patient improved.This case illustrates the usefulness of investigating parechovirus infection in neonates with fever or suspected sepsis.

Evolving trends of neonatal and childhood bacterial meningitis in northern Taiwan

The epidemiology of bacterial meningitis varies in different areas, age groups, and times. To know the trend of neonatal and childhood bacterial meningitis in northern Taiwan, we performed this 29-year-long assessment. Eligible patients were aged 18 years or younger, hospitalized in Mackay Memorial Hospital between 1984 and 2012, and proven by positive cerebrospinal fluid bacterial cultures. Analysis included the patient numbers and pathogens in different age groups, periods, complications, and outcomes. Males were predominant in all the age groups through the years. Almost half of the patients were in the neonatal period. Patient numbers went up in the early study period and declined after 1993-1997. Group B Streptococcus and Escherichia coli were the most common pathogens in neonates, whereas in childhood were Streptococcus pneumoniae and Haemophilus influenzae type b (Hib). Patient numbers of Group B Streptococcus, S. pneumoniae, and Hib meningitis declined in the late study period, but E. coli meningitis increased. The mortality rate decreased but sequela rate increased. Among the four most common pathogens, S. pneumoniae had the worst outcome and had highest mortality rate. All Hib meningitis patients survived, but their sequela rate was the highest. This study provides an epidemiological data on trends of neonatal and childhood bacterial meningitis in northern Taiwan during the past 29 years, including male and neonatal predominance, decrease of total patient number in recent years, change of major pathogens, and declined mortality but raised morbidity.

Application of detection of cerebrospinal fluid calcitonin in patients after surgery for craniocerebral trauma

Objective To investigate the value of detection of cerebrospinal fluid calcitonin in the early diagnosis of postoperative intracranial infection in patients undergoing surgery for traumatic brain injury and the value of guidence of antibiotic uses.Methods 40 patients positive cerebrospinal fluid bacterial culture were recruited as a study group,while 40 negative with bacterial culture were enrolled as a control group.The PCT level in cerebrospinal fluid and distribution of serum PCT level were analyzed in both groups.The PCT levels in cerebrospinal fluid in gramnegative and-positive bacteria,PCT in cerebrospinal fluid before and after treatment,serum PCT,and CSF cultures were compared.Results PCT levels in the cerebrospinal fluid and serum were significantly higher in the study group than in the control group (P＜ 0.05); one week after antibiotic therapy,PCT level in cerebrospinal fluid was significantly higher than serum PCT level and positive cerebrospinal fluid bacterial culture in the patients whose temperature returned to normal in the study group (P＜0.05).Conclusions Detection of cerebrospinal fluid PCT is faster and more accurate and convenient.It is of greater clinical significance in the early diagnosis of intracranial infection secondary to surgery for traumatic brain injury.PCT value in cerebrospinal fluid higher than serum PCT value and cerebrospinal fluid bacterial culture can be used as an indicator for predicting of postoperative intracranial infection in patients with traumatic brain injury and guiding uses of antibiotics. Key words: Cerebrospinal fluid calcitonin; Surgery for craniocerebral trauma; Clinical application; Bacterial infection; Antibiotics

Granulomatosis with polyangiitis masquerading as giant cell arteritis

A 65-year-old man presented with headache, weight loss, occasional scalp tenderness, and visual loss in his left eye, which worsened over a number of weeks to bare light perception. There was a left relative afferent papillary defect with a swollen disc and a small amount of associated hemorrhage. Erythrocyte sedimentation rate (ESR) was 16 mm/1st h, C-reactive protein (CRP) was 3.3 mg/l (normal \7). Temporal artery biopsy demonstrated no evidence of arteritis. On initiation of corticosteroids, his vision improved dramatically and the corticosteroids were subsequently weaned to zero over a period of 6–8 weeks. Three months later, he re-presented with left-sided ptosis and worsening headache. There had been weight loss (7 kg within the prior 6 months). Examination revealed a complete left-sided ptosis, with normal eye movements. Visual acuity was measured at 6/5 on the right and 6/9 on the left. Slit-lamp examination was unremarkable. Laboratory investigations revealed mild eosinophilia (0.78, range 0.04–0.4 9 10/l), an ESR of 9 mm/1st h, and a CRP of 13 mg/l. Serum complement levels were reduced: C3 \0.04 g/l (range 0.75–1.88), C4 \0.01 g/l (range 0.14–0.61). Dipstick urine testing was negative for blood and protein. Urinalysis was negative for casts and red cells. Serum anti-nuclear antibody, extractable nuclear antigen, anti-neutrophil cytoplasmic antibody (ANCA), PR3 and MPO antibodies were negative. Chest radiograph was normal. Dedicated gadolinium-enhanced magnetic resonance imaging (MRI) of the orbits and brain revealed dural enhancement and thickening over the left and right temporal lobes (Fig. 1), with normal orbits. Cerebrospinal fluid (CSF) examination demonstrated an absence of cells with normal glucose and protein concentrations. CSF bacterial and TB cultures and CSF ANCA were negative. The patient was commenced on high-dose corticosteroids (1 mg/kg/day), with resolution of his headache over the following days. The CRP level and eosinophilia normalized quickly. The ptosis improved significantly but not completely. Biopsy of the fronto-temporal dura mater demonstrated thickened dura (Fig. 2a), with multifocal infiltration by cellular aggregates comprised of an admixture of mature lymphocytes, plasma cells, and multinucleate giant cells (Fig. 2c). Foci of necrosis were present (Fig. 2b), and characterized by accumulation of polymorphonuclear A. McCarthy T. Lynch K. O’Rourke (&) Dublin Neurological Institute at the Mater Misericordiae University Hospital, 57 Eccles St, Dublin 7, Ireland e-mail: killian.orourke@gmail.com

Fever and Bulging Fontanelle Mimicking Meningitis in an Infant Diagnosed With Benign Intracranial Hypertension

A previously healthy 7-month-old male presented to the emergency department with fever and a bulging anterior fontanelle. A computed tomographic scan of the head suggested mild communicating hydrocephalus. Lumbar puncture was performed, which revealed a normal cerebrospinal fluid (CSF) cell count and glucose concentration, but a markedly elevated opening pressure. DNA polymerase chain reaction for herpes simplex virus performed on CSF was negative; CSF bacterial cultures were without growth. DNA polymerase chain reaction for human herpes virus 6 was strongly positive in serum. Fever and bulging fontanelle resolved within 24 hours. A presumptive diagnosis of transient intracranial hypertension of infancy was made, a form of benign idiopathic intracranial hypertension that mimics the presentation of serious intracranial pathology.

FatalExserohilumMeningitis and Central Nervous System Vasculitis After Cervical Epidural Methylprednisolone Injection

Fatal<i>Exserohilum</i>Meningitis and Central Nervous System Vasculitis After Cervical Epidural Methylprednisolone Injection

Rhodococcus erythropolisEncephalitis in Patient Receiving Rituximab

<i>Rhodococcus erythropolis</i>Encephalitis in Patient Receiving Rituximab

Intrauterine Herpes Simplex Virus Infection in a Monochorionic Twin Gestation.

Herpes simplex virus (HSV) of the newborn affects 1 in 3200 [1] live births in the United States, and can be acquired by the intrauterine or intrapartum route, or postnatally. Intrauterine or congenital infection represents the rarest form (5% of cases) [2] and frequently has devastating consequences such as congenital brain malformation and severe neurocognitive impairment leading to fetal or neonatal death [3]. Here we present two cases of fatal intrauterine HSV infection in monochorionic twin infants. CASE A 21-year-old secundigravida mother with twin gestation of 26-4/7 weeks presented with spontaneous rupture of membranes of clear amniotic fluid 11 hours prior to delivery. She had negative prenatal laboratory studies for hepatitis B, syphilis, human immunodeficiency virus (HIV), and an unknown group B streptococcus status. Her sexually transmitted infection history included chlamydia trachomatis infection treated during early pregnancy and no history of HSV in herself or her sexual partner. A structural survey 1 week prior to delivery revealed severe hydrops and hydranencephaly in the first twin, and moderate hydrocephalus in the second twin. The mother was afebrile, well-appearing, and reported no history of recent illness or genital lesions before or during either of her pregnancies. Both mother and father refused HSV serologic testing. The first twin boy was delivered via cesarean section with Apgar scores of 1, 2, and 3, at 1, 5, and 10 minutes, respectively. The infant was apneic, unresponsive to resuscitation efforts, and died shortly after birth. On autopsy, gestation was shown to be monochorionic–monoamniotic, and the placenta had evidence of acute chorioamnionitis; however, it was not tested for the presence of HSV. The intracranial cavity was composed of hemorrhagic fluid and fragments of parenchymal tissue with extensive necrosis and chronic inflammation, consistent with meningoencephalitis, and the liver was calcified and necrotic. Viral immunostaining revealed the presence of HSV in the adrenal gland and brain parenchyma, and no virus was detected in the liver. No viral cultures were performed on autopsy tissue due to formalin fixation, and surface cultures for HSV were not performed. The second twin boy had Apgar scores of 5, 7, and 8 at 1, 5, and 10 minutes, respectively. He was immediately intubated for respiratory distress, received inotropes and intravenous fluids for hypotension, and was given ampicillin and gentamicin for presumed sepsis. At 5 hours of life, vesicular skin lesions on the neck were noted on physical examination (PE). PE was otherwise unremarkable. HSV studies were sent from the skin lesion (neck), mucosal surfaces (eyes, mouth, rectum), and cerebrospinal fluid (CSF), and empiric acyclovir 20 mg/kg every 8 hours was started. Initial white blood cell (WBC) count, platelet count, liver function, and serum electrolytes were normal. The CSF revealed 111 WBC/mm 3 with a lymphocytic predominance, 7600 red blood cells/mm 3 , protein 1245 mg/dL, and glucose 21 mg/dL. Blood and CSF bacterial cultures were sterile. Toxoplasma immunoglobulin M antibody, cytomegalovirus (CMV), and parvovirus B-19 polymerase chain reaction (PCR) yielded negative results. PCR was positive for HSV type 2 (HSV-2) and negative for HSV type l from all five tested sites.

Predictors of Ventricular Shunt Infection Among Children Presenting to a Pediatric Emergency Department

Among a population of children with a ventricular shunt presenting to a pediatric emergency department (ED), and in whom cerebrospinal fluid (CSF) was obtained, we sought to (1) determine the rate of positive CSF bacterial culture and (2) identify clinical predictors of ventricular shunt infection. We performed a retrospective cohort study of children 3 months to 21 years of age evaluated in a single pediatric tertiary ED from 1995 to 2008. All included children had CSF obtained within 24 hours of presentation to the ED. A shunt infection was defined by growth of bacteria in the CSF of a child who underwent shunt removal within 7 days of presentation. Nine hundred seventy-nine children met the inclusion criteria; 130 patients (13%) had growth of bacteria in CSF, of which 58 (5.9% of total) had a shunt infection. The median time since last shunt revision or replacement was shorter for patients with a shunt infection compared with children without shunt infection (44 vs 209 days, P = 0.001). After adjustment for patient age, the following factors were associated with shunt infection: shunt revision within the prior 90 days (adjusted odds ratio [aOR], 2.4; 95% CI, 1.3-4.4), presence of fever (aOR, 8.4; 95% CI, 4.3-16.3), and white blood cell count greater than 15,000/μL (aOR, 3.2; 95% CI, 1.5-6.6). Among children with a ventricular shunt who had CSF obtained in the ED, the presence of recent shunt revision, fever, and leukocytosis was associated with ventricular shunt infection.

Diagnostic Dilemma of a Young Man With Fever and Headaches

A 23-year-old man was admitted to the hospital in the fall because of fever and headache. He had been well until 5 days earlier when he developed headaches associated with photophobia, neck pain, nausea, and vomiting. He had no significant medical history and took no medications. He lived with his parents in Seattle, Washington, and took classes at a local college. He had immigrated from China in 2007. The patient was alert and interactive. The temperature was 40.0°C, blood pressure was 161/92 mm Hg, pulse was 91 beats/min, and oxygen saturation was 100% on room air. His general examination revealed anicteric sclerae and no skin rash. Pain was noted with passive neck flexion. On neurologic examination, the patient was oriented with fluent speech and no dysarthria. Visual fields and extraocular movements were full. The remaining cranial nerve functions were intact. Muscle bulk and strength were normal. Sensation was preserved with no extinction detected. The tendon reflexes were equal at 2+, and plantar responses were flexor. There was no dysmetria on finger-to-nose testing. The gait was normal. Laboratory studies including a basic metabolic panel, liver function tests, coagulation studies, and urinalysis were notable only for a low sodium of 135 mEq/L (ref 136-145 mEq/L) and an elevated white blood cell count of 13 000/μL (ref 4.30-10.00 thousand/μL). Blood cultures were obtained. Chest radiograph revealed clear lungs and pleural spaces. Computed tomography (CT) of the head showed no abnormalities. The results of cerebrospinal fluid (CSF) analysis are shown in Table 1. Table 1. Cerebrospinal Fluid Analysis Dexamethasone, vancomycin, ceftriaxone, and acyclovir were started for possible bacterial or viral meningitis but discontinued once the blood cultures, CSF Gram stain and bacterial cultures, and viral polymerase chain reaction (PCR) tests were negative. Contrast-enhanced magnetic resonance imaging (MRI) of the brain was normal. The patient was discharged home after 3 days with a diagnosis of viral meningitis. Five days after initial discharge, the patient returned to the hospital with lethargy and confusion. His mother reported that he was less responsive, intermittently mumbling in response to questions, and requiring assistance with basic daily functions. The patient was drowsy and disoriented. The temperature was 38.2°C, blood pressure 119/90 mm Hg, and pulse 116 beats/minute. On examination, he exhibited neck stiffness, incoherent speech, and impaired comprehension. Serum sodium was 121 mEq/L and white blood cell count was 15 500/μL. Head CT showed mild dilatation of the third and lateral ventricles compared to the study 5 days before. Contrast-enhanced brain MRI demonstrated abnormal enhancement of the prepontine and interpeduncular cisterns (see Figure 1). Human immunodeficiency virus (HIV) test was negative. Repeat CSF analysis is shown in Table 1. Figure 1. Magnetic resonance scans of the brain. A, T1 fat-saturation postcontrast axial magnetic resonance image on initial presentation shows normal contrast enhancement. B, T1 postcontrast axial image 5 days later shows mild enhancement of the interpeduncular ... Antibiotics and antiviral medications were restarted. On hospital day 2, the patient had a witnessed convulsive seizure. Repeat head CT showed worsening hydrocephalus. An external ventricular drain was placed, and the patient was given a loading dose of phenytoin. The patient’s mother reported that the patient may have been exposed to an uncle with active pulmonary tuberculosis, leading to the initiation of antituberculous medications, including rifampin, isoniazid, pyrazinamide, and ethambutol. Three days after readmission, a presumptive mold grew in the CSF bacterial cultures. A rash was also noted on the patient’s right flank, consisting of plaques and papules with a central pearly pink color. A skin punch biopsy and additional laboratory studies were obtained, including antinuclear antibody (negative), rheumatoid factor (<13 IU/mL; negative), aspergillus galactomannan assay (0.114; negative), and Quantiferon-TB Gold (indeterminate). Upon further questioning, the patient’s mother reported the patient had spent 8 months in California 1½ years before. Liposomal amphotericin B was started. Six days after readmission, the results of 2 diagnostic tests were received.

Do Delays in Performing Lumbar Puncture After Administration of Antibiotics Alter the Results of CSF Cultures?

Michael B, Menezes BF, Cunniffe J, et al.: Effect ofdelayed lumbar punctures on the diagnosis of acutebacterialmeningitis in adults. Emerg Med J 2010,27:433–438.Rating: †Of importance.Keywords Lumbar puncture · Acute bacterial meningitis ·Antibiotics · Cerebrospinal fluid culturesIntroduction: Bacterial meningitis is associated withsignificant morbidity and mortality despite the availabilityof antibiotics active against all common community-acquired pathogens. One of the major determinants of anadverse outcome is a delay in antibiotic administration,prompting the publication of national guidelines in theUnited States [1] and Britain [2] advocating the rapidadministration of empiric antibiotics shortly after presenta-tion. However, the need to institute treatment quickly mustbe balanced against the risk of performing a lumbarpuncture in a patient with a contraindication to thisprocedure. When lumbar puncture is delayed in patientswho first undergo neuroimaging, antibiotics may potentiallysterilize the cerebrospinal fluid (CSF), decreasing thelikelihood of making a microbiologic diagnosis.Aims: To determine whether national guidelines on themanagement of bacterial meningitis are being followed, andwhether delays in performing lumbar puncture after adminis-tration of antibiotics alters the results of CSF cultures.Methods: Patients ≥15 years of age hospitalized at a districtgeneral hospital in Northwest England with a dischargediagnosis of meningitis between January 2004 and Decem-ber 2006 were identified. Patients who did not have lumbarpuncture performed or whose CSF had less than 5 whiteblood cells (WBCs)/μL were excluded. Chart and electronicinformation system review were performed to identifybaseline clinical and microbiologic data. Contraindicationsto an immediate lumbar puncture were determined accordingto the British Infection Society meningitis guidelines [2].Patients were stratified by Meningitest criteria as to theprobability of bacterial or viral meningitis [ 3]. Patients with apositive CSF bacterial culture or CSF viral polymerase chainreaction (PCR) were considered to have confirmed bacterialor viral meningitis, respectively. Patients without a microbi-ologic diagnosis were classified as likely bacterial meningitisif the peripheral WBC was greater than 15,000 cells/ μLandthe CSF had all of the following characteristics: WBC greaterthan 1,700 cells/μL, proportion of neutrophils greater than80%, protein greater than 2.3 g/L, and CSF/serum glucoseratio less than 0.35. Patients who had negative microbio-logic evaluation and did not meet the above criteria forprobable bacterial meningitis were classified as likely viralmeningitis.Results: A total of 92 patients met inclusion criteria for thestudy. Bacterial meningitis was diagnosed in 24 (26.1%)cases, with confirmatory cultures in 16 (66.7%) cases.Neisseria meningitidis was cultured in 75% of the confirmedcases, followed by Streptococcus pneumoniae (18.8%) andListeria monocytogenes (6.3%). Eight (33.3%) cases lackedmicrobiologic confirmation but met Meningitest criteria forlikely bacterial meningitis. The remaining 68 (73.9%) caseswere classified as viral meningitis, with a single virologicallyconfirmed case of herpes simplex virus type 2 meningitis.

A case of meningitis due to Achromobacter xylosoxidans denitrificans 60 years after a cranial trauma

SummaryBackgroundAchromobacter xylosoxidans (AX) is a non-fermentative aerobic Gram-negative bacillus. It is an opportunistic pathogen and the causative agent of various infections. We report an original case of late posttraumatic meningitis due to AX denitrificans.Case ReportAn 83-year-old man was hospitalized for acute headache, nausea and vomiting. The emergency brain computer tomography (CT) scan did not reveal any anomaly. In his medical history, there was an auditory injury due to a cranial trauma incurred in a skiing accident 60 years earlier. Cytobiochemical analysis of the cerebrospinal fluid (CSF) revealed increased levels of neutrophils and proteins. The CSF bacterial culture was positive: the Gram stain showed a Gram-negative bacillus, oxidase + and catalase +, and the biochemical pattern using the API 20 NE strip revealed AX dentrificans. Late posttraumatic meningitis on a possible osteomeningeal breach was diagnosed even though the breach was not confirmed because the patient declined a second brain CT scan. The patient was successfully treated with meropenem.ConclusionsThis report demonstrates the importance of searching for unusual or atypical organisms when the clinician encounters meningitis in a particular context, as well as the importance of adequate follow-up of craniofacial traumas.

Rapid diagnosis of bacterial meningitis in children with fluorescence quantitative polymerase chain reaction amplification in the bacterial 16S rRNA gene

Polymerase chain reaction (PCR) techniques have been increasingly used to detect microbial DNA in cerebrospinal fluid (CSF) for the diagnosis of bacterial meningitis. In order to determine the rapidity, sensitivity and specificity of 16S rRNA-based fluorescence quantitative polymerase chain reaction (FQ-PCR), 16S rRNA-based FQ-PCR, CSF bacterial culture and CSF routine analysis were compared in the diagnosis of bacterial meningitis in children. Twenty children who were clinically suspected of bacterial meningitis were included in this study. A total of 2.0 ml of CSF was collected from every child and was subjected to 16S rRNA-based FQ-PCR, CSF culture and CSF routine analysis. Bacterial DNA copies and the cycle threshold (CT) value of the 16S rRNA-based FQ-PCR was recorded, and the results were compared with CSF culture and CSF routine analysis. Seven children were found to be positive with a rate of 35% (7/20) when detected with 16S rRNA-based FQ-PCR and four children displayed a positive rate of 20% (4/20) with the CSF culture method. These two groups displayed a significant difference, with a p-value of 0.002. The method of 16S rRNA-based FQ-PCR demonstrated a high specificity when compared to the standard microbes. A negative correlation was noted between the CT value and the bacteria DNA copies, and the CT value was indicative of the seriousness of bacterial meningitis. 16S rRNA-based FQ-PCR was proved to be a more rapid, sensitive and specific method compared with CSF culture and it should have promising usage in the diagnosis of bacterial meningitis.

Rapid Diagnosis of Bacterial Meningitis Using a Microarray

Microarrays, or biochips, are a new technology that can allow rapid detection of bacterial genetic materials. To explore their practical applications, we compared use of a microarray for the diagnosis of bacterial meningitis with the traditional blood and cerebrospinal fluid (CSF) culture methods. Samples from 50 patients with suspected bacterial meningitis were analyzed by microarray and by traditional blood and CSF cultures. Among all samples, 11 were positive by microarray analysis, seven were positive by CSF bacterial culture and six were positive by blood culture. CSF pleocytosis was found in 26 patients. Of these, eight were positive by microarray analysis, seven were positive by CSF culture and five were positive by blood culture. The percentage of positive results from microarray analysis was 22%, compared to 14% by CSF culture and 12% by blood culture. The CSF bacterial culture method had the highest positive predictive value and specificity (both 100%). The sensitivity of microarray analysis was higher (30.8%) than that of CSF and blood cultures (26.9% and 19.2%). All three methods had a similar negative predictive value in the range of 52.3-55.8%. Of the 11 microarray positive samples, four were identified successfully in CSF culture (36.4%) and three samples were identified in blood culture (27.2%). One of the microarray positive samples was diagnosed as a polymicrobial infection (9%), and the rest were monomicrobial infections. The microarray method provides a more accurate and rapid diagnostic tool for bacterial meningitis compared to traditional culture methods. Clinical application of this new technique may reduce the potential risk of delay in treatment.

Amyloid-ß related angiopathy: a case report

A 68-year-old man with a history of progressive headache, intermittent periods of disorientation and slight personality change for several weeks presented with an acute onset of aphasic speech disturbances and a latent hemiparesis on the right side. His medical history was remarkable for hypertension, atrial fibrillation and clipping of an aneurysm of the anterior communicating artery three years previously. Upon admission, the speech disturbances and the hemiparesis appeared to be regressive. Magnetic resonance imaging demonstrated hyperintense subcortical signal-changes of the left frontal lobe in the T2-weighted images. Recent ischemia or hemorrhage could be excluded. The cerebral MR-angiogram was normal. Lumbar puncture revealed elevated protein content and a slight pleocytosis. The results of cerebrospinal fluid bacterial cultures, virology and cytology were negative. In the following days the patient's condition deteriorated dramatically. He developed frontal seizures, signs of frontal disinhibition and a clouding of consciousness to coma grade I. Correspondingly, magnetic resonance imaging controls displayed a progression of the fronto-parietal signal changes and new lesions bilaterally in the occipital lobe. Despite normal findings in a conventional angiography, the clinical diagnosis of granulomatous angiitis was made. An open brain biopsy verified this diagnosis showing a severe granulomatous meningo-encephalitis and vasculitis with extensive deposit of amyloid ß4. An immunosuppressive treatment with corticosteroids followed by cyclophosphamide was initiated. The patient responded well to the therapy and improved over the following weeks to the extent that only mild cognitive disabilities remained present.

Variations in rates of nosocomial infection among Canadian neonatal intensive care units may be practice-related

BackgroundNosocomial infection (NI), particularly with positive blood or cerebrospinal fluid bacterial cultures, is a major cause of morbidity in neonatal intensive care units (NICUs). Rates of NI appear to vary substantially between NICUs. The aim of this study was to determine risk factors for NI, as well as the risk-adjusted variations in NI rates among Canadian NICUs.MethodsFrom January 1996 to October 1997, data on demographics, intervention, illness severity and NI rates were submitted from 17 Canadian NICUs. Infants admitted at <4 days of age were included. NI was defined as a positive blood or cerebrospinal fluid culture after > 48 hrs in hospital.Results765 (23.5%) of 3253 infants <1500 g and 328 (2.5%) of 13228 infants ≥1500 g developed at least one episode of NI. Over 95% of episodes were due to nosocomial bacteremia. Major morbidity was more common amongst those with NI versus those without. Mortality was more strongly associated with NI versus those without for infants ≥1500 g, but not for infants <1500 g. Multiple logistic regression analysis showed that for infants <1500 g, risk factors for NI included gestation <29 weeks, outborn status, increased acuity on day 1, mechanical ventilation and parenteral nutrition. When NICUs were compared for babies <1500 g, the odds ratios for NI ranged from 0.2 (95% confidence interval [CI] 0.1 to 0.4) to 8.6 (95% CI 4.1 to 18.2) when compared to a reference site. This trend persisted after adjustment for risk factors, and was also found in larger babies.ConclusionRates of nosocomial infection in Canadian NICUs vary considerably, even after adjustment for known risk factors. The implication is that this variation is due to differences in clinical practices and therefore may be amenable to interventions that alter practice.

Serum procalcitonin monitoring for differential diagnosis of ventriculitis in adult intensive care patients.

The objective of our study was to assess the value of serum procalcitonin (PCT) monitoring in the differential diagnosis of ventriculitis in adult intensive care (ICU) patients. We analyzed 15 consecutive patients with ventriculitis in which a ventricular catheter had been inserted and contrasted these data with the observations in 10 patients with community-acquired bacterial meningitis. Cerebrospinal fluid (CSF) and blood samples were collected daily to assess serum PCT, C-reactive protein (CRP) and CSF leukocyte count. PCT levels were normal or slightly elevated in patients with ventriculitis with either positive or negative CSF bacterial culture but elevated in patients with bacterial meningitis. A PCT cut-off value of 1.0 ng/ml or more showed a specificity of 77% and a sensitivity of 68% for ventriculitis with positive CSF bacterial culture. Serum PCT levels reflected more accurately the time phases of disease during therapy. We conclude that the monitoring of serum PCT alone is not helpful for the differential diagnosis of ventriculitis, in contrast to that of bacterial meningitis. The value of PCT as an additional marker with which to assess the efficacy of therapy in ventriculitis is suggested, but requires further assessment.