Signs Of Meningitis Research Articles

Widespread circulation of echovirus 6 causing aseptic meningitis in paediatric patients in the area of Modena, Italy, in 2011

<p><em>Introduction</em>: Between May and November 2011, enterovirus RNA was detected in the cerebrospinal fluids (CSFs) of 72 children with signs of aseptic meningitis admitted to paediatric departments of different Hospitals of the prefecture of Modena, Emilia Romagna region, Italy. Enterovirus RNA was detected in 34 CSFs by commercial reverse transcriptase-polymerase chain reaction (RT-PCR). Twenty-one samples, resulted human enterovirus B by species-specific RT-nested PCR, were submitted to sequencing of the 3’ terminus of the VP1 gene. <br /><em>Materials and Methods:</em> Upon sequencing and interrogation of the National Center for Biotechnology Information database, all 21 viruses were characterized as echovirus 6 (E6), and posses a 100% nucleotide identity each other.<br /><em>Results</em>: This study reports the molecular detection and typing of E6 isolated from clinical specimens from paediatric patients with aseptic meningitis in the wide area of Modena, Italy, in 2011.</p>

Definition and management of varicella zoster virus-associated meningoradiculitis: a case report.

BackgroundThe varicella zoster virus affects the central or peripheral nervous systems upon reactivation, especially when cell-mediated immunity is impaired. Among varicella zoster virus-related neurological syndromes, meningoradiculitis is an ill-defined condition for which clear management guidelines are still lacking. Zoster paresis is usually considered to be a varicella zoster virus-peripheral nervous system complication and treated with oral antiviral therapy. Yet in the literature, the few reported cases of herpes zoster with mild cerebral spinal fluid inflammation were all considered meningoradiculitis and treated using intravenous antiviral drugs, despite absence of systemic signs of meningitis. Nevertheless, these two clinical pictures are very similar.Case presentationWe report the case of an alcohol-dependent elderly Caucasian man presenting with left lower limb zoster paresis and mild cerebral spinal fluid inflammation, with favorable outcome upon IV antiviral treatment. We discuss interpretation of liquor inflammation in the absence of clinical meningitis and implications for the antiviral treatment route.ConclusionFrom this case report we suggest that varicella zoster virus-associated meningoradiculitis should necessarily include meningitis symptoms with the peripheral neurological deficits and cerebral spinal fluid inflammation, requiring intravenous antiviral treatment. In the absence of (cell-mediated) immunosuppression, isolated zoster paresis does not necessitate spinal tap or intravenous antiviral therapy.

Bacterial agents causing meningitis during 2013–2014 in Turkey: A multi-center hospital-based prospective surveillance study

ABSTRACTThis is an observational epidemiological study to describe causes of bacterial meningitis among persons between 1 month and 18 y of age who are hospitalized with suspected bacterial meningitis in 7 Turkish regions. covering 32% of the entire population of Turkey. We present here the results from 2013 and 2014. A clinical case with meningitis was defined according to followings: any sign of meningitis including fever, vomiting, headache, and meningeal irritation in children above one year of age and fever without any documented source, impaired consciousness, prostration and seizures in those < 1 y of age. Single tube multiplex PCR assay was performed for the simultaneous identification of bacterial agents. The specific gene targets were ctrA, bex, and ply for N. meningitidis, Hib, and S. pneumoniae, respectively. PCR positive samples were recorded as laboratory-confirmed acute bacterial meningitis. A total of 665 children were hospitalized for suspected acute meningitis. The annual incidences of acute laboratory-confirmed bacterial meningitis were 0.3 cases / 100,000 population in 2013 and 0.9 cases/100,000 in 2014. Of the 94 diagnosed cases of bacterial meningitis by PCR, 85 (90.4%) were meningococcal and 9 (9.6%) were pneumococcal. Hib was not detected in any of the patients. Among meningococcal meningitis, cases of serogroup Y, A, B and W-135 were 2.4% (n = 2), 3.5% (n = 3), 32.9% (n = 28), and 42.4% (n = 36). No serogroup C was detected among meningococcal cases. Successful vaccination policies for protection from bacterial meningitis are dependent on accurate determination of the etiology of bacterial meningitis. Additionally, the epidemiology of meningococcal disease is dynamic and close monitoring of serogroup distribution is comprehensively needed to assess the benefit of adding meningococcal vaccines to the routine immunization program.

A Single Mutation in the VP1 of Enterovirus 71 Is Responsible for Increased Virulence and Neurotropism in Adult Interferon-Deficient Mice.

Hand, foot, and mouth disease (HFMD) has spread throughout the Asia-Pacific region, affecting millions of young children, who develop symptoms ranging from painful blisters around their mouths and hands to neurological complications. Many members of the genus Enterovirus (family Picornaviridae) cause HFMD. Enterovirus 71 (EV71) is one of the primary causative agents and has been linked to severe disease. Vaccine efficacy and pathogenesis studies for EV71 have been limited because there is a lack of suitable animal models. Previously, we generated a mouse-adapted EV71 (mEV71) capable of infecting 12-week-old interferon receptor-deficient AG129 mice and used the model to evaluate the efficacy of candidate HFMD vaccines. Here, we present data investigating the genetic correlates of EV71 adaptation and characterize the virus's tissue tropism in mice. Using reverse genetics, a VP1 mutation (K244E) was shown to be necessary for mEV71 virulence in adult mice. Another VP1 mutation (H37R) was required for mEV71 recovery on rhabdomyosarcoma (RD) cells. Viral loads determined by real-time reverse transcription (RT)-PCR confirmed the presence of mEV71 in the sera and multiple organs of mice. Histological analysis revealed signs of meningitis and encephalitis, characteristic of severe human disease. The further description of this model has provided insight into EV71 pathogenesis and demonstrates the importance of the VP1 region in facilitating mEV71 adaptation. EV71 is a reemerging pathogen, and little is known about the genetic determinants involved in its pathogenesis. The absence of animal models has contributed to this lack of knowledge. The data presented here improve upon the existing animal models by characterizing a mouse-adapted strain of EV71. We determined that a VP1 mutation (K244E) was needed for EV71 virulence in adult AG129 mice. While this mutation was found previously for EV71 adaptation in 5-day-old BALB/c mice, neurotropic disease did not develop. Using interferon-deficient mice, we raised the age of susceptibility beyond 6 weeks and provided clear evidence that our model mimics severe human infections. The model can be exploited to identify determinants of EV71 virulence and to reveal molecular mechanisms that control the virus-host interaction, especially those associated with neurotropic disease. Furthermore, these data provide useful information regarding the importance of VP1, specifically position 244, in host adaptation and tissue dissemination.

The History and Current Relevance of the Eponymous Signs of Meningitis.

During the past several decades, researchers have shown that the eponymous signs of meningitis have reduced sensitivity and specificity compared with when they were originally described. This may be because of the changing epidemiology of meningitis and its treatment or it may be because of variations in performance of the maneuvers. For example, in the original descriptions, the Kernig sign (resistance of leg extension) is best elicited with the patient sitting and the Brudzinski nape of the neck sign involves holding down the patient's chest as the neck is flexed. These and other lesser-known signs of meningitis by Amoss, Bikeles and Edelmann all relate to the mechanics of stretching inflamed meninges, and this review will allow the clinician to understand how the history related to these maneuvers is still germane to clinical practice today.

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Ventriculoperitoneal shunt malfunction caused by proximal catheter fat obstruction

Ventriculoperitoneal (VP) shunt placement is the mainstay of treatment for hydrocephalus, yet shunts remain vulnerable to a variety of complications. Although fat droplet migration into the subarachnoid space and cerebrospinal fluid pathways following craniotomy has been observed, a VP shunt obstruction with fat droplets has never been reported to our knowledge. We present the first reported case of VP shunt catheter obstruction by migratory fat droplets in a 55-year-old woman who underwent suboccipital craniotomy for removal of a metastatic tumor of the left medullocerebellar region, without fat harvesting. A VP shunt was inserted 1month later due to communicating hydrocephalus. The patient presented with gait disturbance, intermittent confusion, and pseudomeningocele 21days after shunt insertion. MRI revealed retrograde fat deposition in the ventricular system and VP shunt catheter, apparently following migration of fat droplets from the fatty soft tissue of the craniotomy site. Spinal tap revealed signs of aseptic meningitis. Steroid treatment for aseptic “lipoid” meningitis provided symptom relief. MRI 2months later revealed partial fat resorption and resolution of the pseudomeningocele. VP shunt malfunction caused by fat obstruction of the ventricular catheter should be acknowledged as a possible complication in VP shunts after craniotomy, even in the absence of fat harvesting.

Decompressive Laminectomy Complicated by Postoperative Mycoplasma hominis Epidural Abscess and Meningitis in a Young Woman: A Case Report.

A twenty-eight-year-old woman underwent decompressive laminectomy and placement of an interlaminar stabilizer due to L4/L5 disc herniation. Thirteen days later she developed a fever unresponsive to meropenem and vancomycin, along with signs of meningitis. A Mycoplasma hominis epidural abscess was identified. She had no preoperative risk factors for extragenital M. hominis infection, but had had a urinary catheter inserted intraoperatively. M. hominis postoperative surgical site infection is a rarely identified complication of spinal surgery. Seeding from the genitourinary tract is the most likely source.

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Meningitis Signs and Symptoms.

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Central Nervous System Histoplasmosis in Acquired Immunodeficiency Syndrome

BackgroundInvolvement of the central nervous system (CNS) by Histoplasma capsulatum in AIDS is uncommon and not easily recognized. Materials and MethodsCNS histoplasmosis cases from our institution were identified by a retrospective chart review from 2004-2014. A thorough literature search was performed for additional cases and their characteristics were compared. Clinical findings, treatment and outcomes are discussed. ResultsA total of 5 cases from our institution were identified. They had a clinical presentation that included classic signs of meningitis, often with evidence of disseminated involvement, and was typically severe with important neurological impairment. These cases were treated with antifungal agents, including a lipid amphotericin B formulation and azole drugs, but eventually 3 experienced nonresolution of their disease likely because of lack of adherence to therapy and died from their infection. The clinical presentation, treatment and outcome of these cases did not significantly differ from cases found in the review of the literature. ConclusionsClinicians practicing in endemic areas should be aware of this rare but serious form of histoplasmosis. The recognition of 5 cases of CNS histoplasmosis in AIDS patients from a single institution suggests that histoplasmosis should be included in the differential diagnosis of the CNS complications of AIDS.

A Rare Complication of Trimethoprim-Sulfamethoxazole: Drug Induced Aseptic Meningitis.

Drug induced aseptic meningitis is a rare but challenging diagnosis, most commonly reported with nonsteroidal anti-inflammatory drugs and antibiotics. Trimethoprim/sulfamethoxazole is a sulfonamide that is widely used in clinical practice for the treatment and prophylaxis of various infections. Drug induced aseptic meningitis, when seen with trimethoprim/sulfamethoxazole, occurs predominantly in patients with some degree of immune compromise and is less commonly seen in immune competent individuals. The patient often exhibits the classic symptoms of meningitis. Early diagnosis is important, since the cessation of the antibiotic leads to rapid clinical improvement. Trimethoprim/sulfamethoxazole induced aseptic meningitis has been underreported to FDA/MED-WATCH program. Here we report two cases of trimethoprim/sulfamethoxazole: an immune competent individual and immune compromised individual, both of which presented with signs of meningitis and a negative infectious workup. Trimethoprim/sulfamethoxazole is an uncommon and mysterious adverse reaction to a commonly used antibiotic. It should be considered in the differential diagnosis of patients presenting with acute signs and symptoms of meningitis especially after infectious causes have been ruled out.

Pattern, Clinical Characteristics, and Outcome of Meningitis among HIV-Infected Adults Admitted in a Tertiary Hospital in North Western Tanzania: A Cross-Sectional Study.

Background. Limited information exists on the etiologies, clinical characteristics, and outcomes of meningitis among HIV-infected patients in Africa. We conducted a study to determine the etiology, clinical characteristics, and outcomes of meningitis among HIV-infected adults. Methods. A prospective cross-sectional hospital based study was conducted among HIV-infected patients aged ≥18 years admitted to the medical wards with symptoms and signs of meningitis. Sociodemographic and clinical information were collected using a standardized data collection tool. Lumbar puncture was performed to all patients; cerebrospinal fluid samples were sent for analysis. Results. Among 60 HIV-infected adults clinically diagnosed to have meningitis, 55 had CSF profiles consistent with meningitis. Of these, 14 (25.5%) had a laboratory-confirmed etiology while 41 (74.5%) had no isolate identified. Cryptococcus neoformans was the commonest cause of meningitis occurring in 11 (18.3%) of patients followed by Mycobacterium tuberculosis (6.7%). The in-hospital mortality was 20/55 (36.4%). Independent predictors of mortality were low baseline CD4 count and turbid CSF appearance. Conclusion. Cryptococcal meningitis is the most prevalent laboratory-confirmed etiological agent among adult HIV-infected patients with suspected meningitis admitted to medical wards in Western Tanzania. Mortality rate in this population remains unacceptably high. Improving diagnostic capacity and early treatment may help to decrease the mortality rate.

Sandfly virus seroconversion associated with neurologic presentation.

Objective:To describe the clinical presentation and unique neurologic manifestations of sandfly viruses (SFVs) in the Jerusalem area.Methods:We identified all patients with acute seroconversion to SFV at the Hadassah-Hebrew University Medical Centers during the years 2008–2013 and retrospectively collected and analyzed the clinical and imaging data.Results:Nine patients (ranging from 1.5 to 85 years old) were identified. Presentation included acute neurologic disease, mostly with fever, change in consciousness and behavior, seizures, headache, meningitis, limb paresis, or myelitis. Eight patients had clinical signs of meningitis, meningoencephalitis, or encephalitis alone. Four patients had myelitis. MRI identified pathologic symmetrical changes in the basal ganglia, thalami, and other deep structures in 5 patients, and additional myelitis of the spine was noted on imaging in 3 patients. Seven patients had long-term follow-up: 4 completely recovered and 3 had remaining neurologic sequelae, among them 1 with permanent severe brain damage.Conclusion:Neurologic involvement associated with acute SFV infections is considered to be benign. However, in this series, all 9 patients presented with significant neurologic pathology associated with a unique finding of myelitis and symmetrical basal ganglia, thalami, or white matter involvement. Thus, acute SFV infection should be included in the differential diagnosis in febrile onset of neurologic manifestations and neuroradiologic changes.

Enterovirus meningitis in Tunisia (Monastir, Mahdia, 2011–2013): identification of virus variants cocirculating in France

Acute enterovirus (EV) meningitis is a frequent cause of hospitalisation, and over 100 EV serotypes may be involved. A total of 215 patients of all ages with meningitis signs were investigated in 2 Tunisian hospitals. Their cerebrospinal fluid (CSF) was analysed retrospectively for EVs with a TaqMan real-time RT-qPCR. The virus strains were typed, and their evolutionary relationships were determined by Bayesian phylogenetic methods. An EV genome was detected in 21/215 patients (9.8%). The CSF viral loads ranged from 3.27 to 5.63 log10 genome copies/mL. The strains were identified in 13/21 patients and assigned to EV-B types. Viruses identified in Tunisian patients were genetically related to variants detected in France. The viral loads were similar in Tunisian and French patients for most EV types. The phylogenetic data and viral loads determined in Tunisian and French patients suggest that close EV variants were involved in aseptic meningitis in the 2 countries over a same period.

Interaction of fibrinogen and muramidase-released protein promotes the development of Streptococcus suis meningitis

Muramidase-released protein (MRP) is as an important virulence marker of Streptococcus suis (S. suis) serotype 2. Our previous works have shown that MRP can bind human fibrinogen (hFg); however, the function of this interaction in S. suis meningitis is not known. In this study, we found that the deletion of mrp significantly impairs the hFg-mediated adherence and traversal ability of S. suis across human cerebral microvascular endothelial cells (hCMEC/D3). Measurement of the permeability to Lucifer yellow in vitro and Evans blue extravasation in vivo show that the MRP-hFg interaction significantly increases the permeability of the blood–brain barrier (BBB). In the mouse meningitis model, wild type S. suis caused higher bacterial loads in the brain and more severe histopathological signs of meningitis than the mrp mutant at day 3 post-infection. Western blot analysis and immunofluorescence observations reveal that the MRP-hFg interaction can destroy the cell adherens junction protein p120-catenin of hCMEC/D3. These results indicate that the MRP-hFg interaction is important in the development of S. suis meningitis.

Méningococcémie sans méningite : à propos de deux observations

IntroductionMeningococcemia without meningitis is an often under recognized clinical form of invasive Neisseria meningitidis infection. Case reportsWe report two unusual cases of invasive meningococcal disease who presented with meningococcemia without distinct signs of meningitis or severe sepsis manifestation. In both cases, confirmation of the diagnosis is provided by meningococcal PCR performed on blood or skin lesion biopsy. ConclusionClinical recognition of this entity is crucial for early antibiotic treatment and to avoid delayed diagnosis and potentially dangerous complications.

Predictors of non-traumatic coma in a pediatric cohort from a South Indian tertiary care center: Results of a multivariate analysis

Objective: To study the etiology and clinical profile of non-traumatic coma in children at tertiary care center and to determine the predictors of outcome. Methods: One hundred and four consecutive children between 2 mo-12 yr were studied. The clinical signs at admission; vital signs, Glasgow coma scale, respiratory pattern, papillary reflex, extra-ocular movements, fundus picture and motor deficits were recorded. Etiology of coma was determined by clinical history, examination and relevant investigations. Their progress was monitored clinically, biochemically and with multi-system monitors. Outcome was recorded as survived or died. Results: Etiology of coma in 65% cases was intracranial infections; other causes were metabolic (20%). Sixty-seven percent recovered completely, 16% had residual neurodeficits, 16% died. Survival was better in children with intracranial infections (13%) as compared to metabolic coma (33%). On multivariate logistic regression, bradycardia, hypoten- sion, abnormal respiratory pattern (especially, ataxic type), duration of coma more than 48 h, Glasgow coma scale < 7 at ad- mission, unequal and non-reactive pupils, papilledema, abnormal extra-ocular movements, motor deficits, signs of meningitis correlated with mortality. Requirement of ventilatory support and abnormal computerized tomography findings correlated with mortality. Conclusions: Intracranial infections were the most common cause of non-traumatic coma in children; the most common cause of death being metabolic coma. Simple clinical signs and relevant investigations served as prognostic indicators of outcome.

A Case of Antimicrobial Non-compliance in an Immunocompromised Patient Resulting in Invasive Pneumococcal Disease

A 46-year-old male patient initially presented to the ED with purulent otitis media and was discharged with empirically prescribed oral and otic ciprofloxacin. Cultures of the otic discharge grew drug-resistant S. pneumoniae that was sensitive only to vancomycin, rifampin, and levofloxacin. Upon reviewing the culture and sensitivities, the physician attempted to contact the patient multiple times to change therapy to levofloxacin. The patient9s phone line had been disconnected. Twelve days later, the patient presented with cardinal signs of meningitis and admittance to the Intensive Care Unit was required. The patient had not been compliant with the prescribed antimicrobial regimen. Imaging studies and microbiologic cultures revealed that the untreated otitis media had resulted in otomastoiditis, meningitis and bacteremia. Past medical history included recurrent ear infections, intrahepatic shunt placement, hepatic portal hypertension, and alcoholism. The patient had multiple chronic disease processes that suppressed immune function, predisposing him to invasive disease including end-stage liver disease (chronic Hepatitis C and alcoholic cirrhosis), and uncontrolled diabetes mellitus. The patient required extensive antimicrobial therapy to treat the infection and recovered without neurological sequelae. ABBREVIATIONS:Streptococcus pneumoniae - S. pneumoniae, Emergency Department - ED, Diabetes Mellitus - DM, Complete Blood Count - CBC, Comprehensive Metabolic Panel - CMP, Hepatitis C Virus - HCV, Cerebrospinal fluid - CSF, Blood Urea Nitrogen - BUN, White Blood Cell - WBC, Red Blood Cell - RBC

CONTRIBUTION OF IMAGING EXAMINATIONS IN DIAGNOSIS OF INTRACRANIAL COMPLICATIONS IN CHILDREN OTOMASTOIDITIS

Introduction. Otitis media (OM) is one of the most common infections in child pathology, most often with self-limited evolution (1,2). In 2-6% of cases (2) developed, intracranial complications with unfavorable, fatal outcome in 8-26.3% of them (2,3). Presence of neurological signs in the evolution of suppurative otitis require early imaging examinations (2-8). Material and methods. We presents the case of a 10 year old girl with suppurative otitis complicated, transferred to the Clinical Emergency Hospital for Children „M.S. Curie“, Bucharest to ENT department after 2 weeks of disease progression. The child presents at hospital: fever, purulent otorrhea, neurological signs represented by headache, seizures, stiff neck. Contrast-enhanced computed tomographic (CT) were performed in emergency. Result. CT scanning, extended to the neck show the presence of a lytic process in the temporal bone, solution of continuity between mastoid antrum and meninges with epidural abscess form over sigmoid sinus, thrombophlebitis and thrombus of sigmoid sinus, which is propagate to the lateral sinus and the jugular vein ;signs of meningitis, cerebellar cerebritis, brain temporal abscess and subdural empyema. Conclusions. Complications in middle ear infections are rare, but the appearance of neurological signs in clinical examination must be completed by CT of head with contrast, which can specify local architecture, presence of local or distant complications, help in the application to a fast and appropriate therapy.