Spontaneous Meningitis Research Articles

Experience with enterococcal meningitis/ventriculitis in children.

Enterococcal infections are increasingly common in hospitalized patients. Enterococcal meningitis/ventriculitis (EMV) is an extremely rare condition of enterococcal infections, occurring particularly in children. This study investigated the clinical and microbiological characteristics, predisposing factors, and prognosis in pediatric patients with EMV. Pediatric patients (<18 years) diagnosed with EMV were retrospectively evaluated over 10 years. The study included a total of 25 isolates from 24 patients, median age 23months (range: 1-136months). The most common symptoms included vomiting, fever, and headache, with hydrocephalus shunt and preterm birth being the two most common conditions. Commonly associated infections, with central nervous system (CNS) devices as a predisposing factor, were due to external ventricular drainage and ventriculoperitoneal shunts. Two patients with spontaneous meningitis were preterm infant. Of the isolates, 44% were Enterococcus faecalis, 44% E.faecium, and 12% E.gallinarum. Five (20%) isolates were vancomycin resistant. Twelve patients were resistant to anti-enterococcal antibiotics, including ampicillin, ciprofloxacin, imipenem, teicoplanin, gentamicin, and linezolid (40%, 20%, 8%, 8%, 4%, and 4%, respectively). Enterococcus faecium was more resistant to ampicillin, ciprofloxacin, teicoplanin, and vancomycin than E.faecalis. The median treatment duration was 17 days (interquartile range: 14-26 days).The mortality rate was 8.3% (2/24; both associated with vancomycin resistance). Neurosurgical conditions are the most common predisposing factors for EMV. Preterm birth is an important predisposing factor in children. Because EMV is nonspecific in clinical findings, it should be considered when there is an underlying CNS disorder and empirical treatment should begin in this direction.

Spontaneous and postsurgical/traumatic Klebsiella pneumoniae meningitis: two distinct clinico-microbiological entities

ObjectivesTo analyze and compare the characteristics and outcomes of spontaneous meningitis (SM) versus postsurgical/traumatic meningitis (PSTM) due to Klebsiella pneumoniae. MethodsA retrospective multicentric cohort study of all K. pneumoniae meningitis cases managed between January 2007 and May 2018 was carried out in seven university hospitals in the Paris area. The microbiological characteristics of 16 available K. pneumoniae isolates were further analyzed, and the genomes of seven of those isolated from SM were sequenced. ResultsAmong 35 cases, 10 were SM and 25 were PSTM. SM cases more severe than PSTM cases, with higher septic shock (p = 0.004) and in-hospital mortality rates (p = 0.004). In contrast, relapse occurred in five patients from the PSTM group versus no patients from the SM group. All K. pneumoniae strains recovered from SM but none of those recovered from PSTM displayed hypervirulent phenotypic (positive string test) and genotypic (genes corresponding to capsular serotypes K1 or K2; virulence genes rmpA and iutA) characteristics (p < 0.0001). PSTM tended to be more frequently polymicrobial (p = 0.08) and caused by an extended-spectrum β-lactamase producing strain (p = 0.08) than SM. ConclusionsSM and PSTM are two entities differing both from a clinical and a microbiological standpoint. SM appears to be a more serious infection, induced by hypervirulent K. pneumoniae strains.

Staphylococcus aureus meningitis in adults: A comparative cohort study of infections caused by meticillin-resistant and meticillin-susceptible strains

Staphylococcus aureus meningitis is an uncommon nosocomial infection usually associated with neurosurgical procedures, but spontaneous infections may occasionally appear. To compare the features of meningitis caused by meticillin-resistant (MRSA) and meticillin-susceptible (MSSA) S.aureus and examine the prognostic factors for mortality, including MRSA infection and combined antimicrobial therapy. Retrospective cohort study of 350 adults with S.aureus meningitis admitted to 11 hospitals in Spain (1981-2015). Logistic regression and propensity score matching were used to analyse prognostic factors. There were 118 patients (34%) with MRSA and 232 (66%) with MSSA. Postoperative infection (91% vs 73%) and nosocomial acquisition (93% vs 74%) were significantly more frequent in MRSA than in MSSA meningitis (P<0.001). Combined therapy was given to 118 (34%) patients. Overall 30-day mortality rate was 23%. On multivariate analysis, mortality was associated with severe sepsis or shock (odds ratio (OR) 9.9, 95% confidence interval (CI) 4.5-22.0, P<0.001), spontaneous meningitis (OR 4.2, 95% CI 1.9-9.1, P<0.001), McCabe-Jackson score rapidly or ultimately fatal (OR 2.8, 95% CI 1.4-5.4, P=0.002), MRSA infection (OR 2.6, 95% CI 1.3-5.3, P=0.006), and coma (OR 2.6, 95% CI 1.1-6.1, P<0.029). In postoperative cases, mortality was related to retention of cerebrospinal devices (OR 7.9, 95% CI 3.1-20.3, P<0.001). Clinical and epidemiological differences between MRSA and MSSA meningitis may be explained by the different pathogenesis of postoperative and spontaneous infection. In addition to the severity of meningitis and underlying diseases, MRSA infection was associated with increased mortality. Combined antimicrobial therapy was not associated with increased survival.

Methicillin-Resistant Staphylococcus aureus central nervous system infections – Analysis and outcome

Introduction. Methicillin-Resistant Staphylococcus aureus (MRSA)-associated infections are potentially devastating and fatal. It has two distinct pathogenic mechanisms: postoperative and spontaneous. In the study presented here, we review the epidemiology, clinical features, response to treatment, and outcome of MRSA central nervous system infections at our tertiary referral institute. Material and methods. In this analysis, we reviewed the medical records of all patients who were diagnosed with S. aureus meningitis between January 2010 and December 2012. Clinical information included predisposing factors, past medical history, comorbidities, mode of acquisition of infection, as well as therapeutic management, length of treatment, and clinical outcomes were analyzed. Results. A total of 34 cases of MRSA meningitis were diagnosed during the study period. There were 28 (82.4%) cases of postoperative meningitis and 6 (17.6%) cases of spontaneous meningitis. A majority (24/28) of the patients had one or the other predisposing conditions for the infection. Compared with patients with postoperative meningitis, patients with spontaneous meningitis had a significantly older (31.93 yrs vs 55.8 yrs; p = 0.021) and higher frequency of community-acquired infection (100% vs. 39%; p = 0.007). In patients with postoperative meningitis, the median postoperative day when the infection manifested clinically was day- 19 (range, 3–90 days). A total of 25/34 (74%) patients received definitive antibiotic (vancomycin and/or linezolid based) therapy. Nine patients were continued on empirical antimicrobial therapy (combination of ceftriaxone, amikacin, and metronidazole), as the organism was sensitive to those drugs. There were no in-hospital mortalities in our series, though 3/34 patients (8.8%) were discharged with Glasgow coma score (GCS)< 8 and 8/34 patients (23.5%) were discharged with GCS 9–12 from the hospital. Conclusion. In acute bacterial meningitis, there is a progressive shift from methicillin-sensitive strains to methicillin-resistant strains in recent years. Although most patients have a favorable response to vancomycin and linezolid, the beneficial effect of combined antimicrobial therapy or alternative antibiotics needs to be evaluated.

Spontaneous gram-negative bacillary meningitis in adult patients: characteristics and outcome

BackgroundSpontaneous meningitis caused by gram-negative bacilli in adult patients is uncommon and poorly characterized. Our objective is to describe and compare the characteristics and the outcome of adult patients with spontaneous gram-negative bacilli meningitis (GNBM) and spontaneous meningitis due to other pathogens.MethodsProspective single hospital-based observational cohort study conducted between 1982 and 2006 in a university tertiary hospital in Barcelona (Spain). The Main Outcome Measure: In-hospital mortality.ResultsGram-negative bacilli meningitis was diagnosed in 40 (7%) of 544 episodes of spontaneous acute bacterial meningitis. The most common pathogens were Escherichia coli and Pseudomonas species. On admission, characteristics associated with spontaneous gram-negative bacilli meningitis by multivariate modeling were advanced age, history of cancer, nosocomial acquisition of infection, urinary tract infection as distant focus of infection, absence of rash, hypotension, and a high cerebrospinal fluid white-cell count. Nine (23%) episodes were acquired in the hospital and they were most commonly caused by Pseudomonas. The in-hospital mortality rate was 53%. The mortality rate was higher among patients with Gram-negative bacillary meningitis than among those with other bacterial meningitis and their risk of death was twenty times higher than among patients infected with Neisseria meningitidis (odds ratio 20.47; 95% confidence interval 4.03-103.93; p<0.001).ConclusionsGram-negative bacilli cause 9% of spontaneous bacterial meningitis of known etiology in adults. Characteristics associated with GNBM include advanced age, history of cancer, nosocomial acquisition, and urinary tract infection as distant focus of infection. The mortality rate is higher among patients with gram-negative bacillary meningitis than among those with other bacterial meningitides.

Isolated Sinusitis of Lateral Recesses of Sphenoid Sinus

To the Editor: An 11-y-old boy presented with acute onset headache, eye pain and fever. There was no sinus tenderness, and symptoms did not resolve with oral antibiotics and antihistaminics. The CTscan of paranasal sinuses was done which revealed acute sinusitis with fluid only within lateral recesses of bilateral sphenoid sinuses (Fig. 1). This finding was also confirmed on MRI (Fig. 2). Rests of the sinuses, particularly bilateral frontal sinuses were clear (Fig. 3). No neurological complications were seen. The child was managed with intravenous antibiotics and endoscopic sphenoidotomy. Intraoperatively, hypertrophied inflamed polypoidal mucosa was seen involving the lateral recesses of sphenoid sinuses which were excised and curetted. On histopathological examination of the excised tissue, the lamina propria and epithelial layer showed extensive edema with infiltration of neutrophils and mononuclear cells, thrombophlebitis and necrotic foci suggestive of acute inflammatory pathology. Follow-up after one month showed near complete resolution with minimal soft tissue in right lateral recess (Fig. 4). Imaging finding of an isolated acute sinusitis of lateral recess of sphenoid sinus in a child is very uncommon and has not been described in the literature. The diagnosis is often delayed until there is a neurological complication. An important differential diagnoses with similar imaging findings that should be kept in mind while treating these cases is meningocele/meningoencephalocele of the lateral recesses, due to persistence of Sternberg’s canal. These patients usually present with spontaneous cerebrospinal fluid leaks and clinical meningitis. The anatomical location of Sternberg’s canal is medial to the superior orbital fissure Fig. 1 a Axial and b Coronal non-contrast CT scan of paranasal sinuses showing fluid within bilateral lateral recesses (arrow) of the sphenoid sinus (arrowhead) and clear bilateral ethmoid sinuses (asterisk)

Glial Heterotopia of Sphenoid in Association with a Patent Sternberg's Canal presenting with Meningitis

ABSTRACT Ectopic glial tissue, presenting at various sites of body is a rare embryonic developmental anomaly. Very few cases are reported in adults, most being incidentally detected, revealed only by histopathological findings. One of the rarest locations is the sphenoid sinus. We present here the case of a middle aged female, presenting with spontaneous cerebrospinal fluid (CSF) rhinorrhea and meningitis. With the radiological finding of a soft tissue density in sphenoid sinus with erosion of left temporal skull base, she underwent lateral craniotomy, with excision of the mass and middle cranial fossa floor repair. Histopathology revealed a heterotopic glial tissue. Peroperative finding of a well-defined defect in the lateral wall of an extensively pneumatized sphenoid showed typical features of a patent Sternberg's canal. This case could be a living proof for the existence of this rare developmental anomaly. A persisting Sternberg's canal should be considered as the source of spontaneous CSF leaks with or without lesions in sphenoid sinuses with extensive lateral pneumatization. Most of the cases may be treated with an extended endoscopic approach. Extreme lateral lesions like this would benefit most from a craniotomy approach for proper closure of skullbase defect. Three years after successful surgery, she remains symptom free.

Methicillin-Resistant Staphylococcus aureus Meningitis in Adults

Methicillin-resistant Staphylococcus aureus (MRSA) meningitis is an uncommon disease, and little is known about its epidemiology, clinical features, therapy, and outcome. We performed a multicenter retrospective study of MRSA meningitis in adults. Eighty-six adult patients were included and the following data were obtained: underlying diseases, clinical presentation, analytical and microbiologic data, response to therapy, and outcome.There were 56 men (65%) and the mean age was 51.5 years; 54 of them (63%) had severe comorbidities. There were 78 cases of postoperative meningitis and 8 of spontaneous meningitis. The infection was nosocomial in 93% (80/86) of the cases. Among the 78 patients with postoperative meningitis, the most common predisposing conditions were cerebrospinal fluid (CSF) devices (74%), neurosurgery (45%), CSF leakage (17%), and head trauma (12%). Most patients had fever (89%), altered mental status (68%), headache (40%), and meningeal signs (29%). The most common CSF findings were pleocytosis (90%), elevated protein level (77%), and hypoglycorrhachia (30%). CSF Gram stain and blood cultures were positive in 49% (32/65) and 36% (16/45) of cases, respectively. An associated MRSA infection and polymicrobial meningitis appeared in 33% (28/86) and 23% (20/86) of cases, respectively. Antimicrobial therapy was given to 84 patients. Most of them received vancomycin (92%) either as monotherapy (64%) or in combination with other antibiotics (28%), for a median of 18 days. Overall 30-day mortality was 31% (27/86). Multivariate study identified 2 independent factors associated with mortality: spontaneous meningitis (odds ratio [OR], 21.4; 95% confidence interval [CI], 2.3-195.4; p = 0.007), and coma (OR, 9.7; 95% CI, 2.2-42.3; p = 0.002).In conclusion, MRSA is a relatively uncommon but serious disease. Although most cases are nosocomial infections appearing in neurosurgical patients, spontaneous meningitis may present as a community-onset infection in patients with severe comorbidities requiring frequent contact with the health care system. Most patients have a favorable response to vancomycin, but the beneficial effect of combined and intraventricular therapy, or alternative drugs, remains unclear. MRSA meningitis is associated with a high mortality, and the presence of spontaneous infection and coma are the most important prognostic factors.

Clinical Aspects of Bacterial Meningitis in Cerebrospinal Fluid Culture Positive Patients in a Tertiary Care University Hospital

Background: There have been previous clinical research studies on clinical manifestations of meningitis in adults or children; however, few have focused on including both groups and none on the causative organism and its susceptibilities to antibiotics. Here we describe the distribution of causative organism and its antibiotic susceptibilities of meningitis from spinal fluid positive patients of a university hospital. Methods: Cases of spinal fluid culture results from admitted patients in Kyung Hee Medical Center from July 2004 to June 2009 were analyzed retrospectively by their medical records and laboratory results. Results: Ninety five cases of positive spinal fluid culture results were obtained and 25 cases fit the diagnostic criteria for bacterial meningitis. 5 cases were spontaneous meningitis and 20 were post cranial surgery meningitis. Among the 25 patients, fever was the most common clinical presentation (100%) and ventriculoperitoneal shunt was the most common causative procedure of post cranial surgery meningitis. Streptococcus pneumoniae for spontaneous meningitis and Acinetobacter species for post cranial surgery meningitis was identified as the most common causative organisms. Conclusion: Recurrent positive spinal fluid culture results of the same organism was found in expired patients due to post cranial surgery meningitis and also from the culture results of the wound and intra-cranial inserted instruments, suggesting post operative infection control is directly related to morbidity requiring adequate usage of antibiotics rather than empirical broad spectrum antibiotics. (Korean J Clin Microbiol 2011;14:1-6)

Meningitis bacteriana por bacilos gramnegativos en adultos

Gram-negative bacilli are causative agents of bacterial meningitis in the neonatal period but rarely cause meningitis in adults without risk factors. To report on meningitis due to gram-negative bacilli (MGNB) in adults diagnosed in a hospital over a 25-year period. We reviewed the medical records of all patients with an age > or = 14 years who had been diagnosed with MGNB between 1982 and 2006. Fifteen cases of MGNB are included (10.5% of the cases of bacterial meningitis with an identified aetiology), with a mean age of 48 years (14-79). Twelve (80%) were post-operative: recent neurosurgery (9 cases, 75%) and having a neurosurgical device (8 cases, 67%) were risk factors. Three (20%) were spontaneous: two were of a urinary origin and one had an undetermined origin. The aetiology was: Pseudomonas aeruginosa (3 cases), Escherichia coli (3 cases), Enterobacter aerogenes (2 cases), Pseudomonas fluorescens (1 case), Klebsiella pneumoniae (1 case), Morganella morganii (1 case), Acinetobacter anitratus (1 case), Acinetobacter iwoffii (1 case) and Flavobacterium brevis (1 case); in one patient with Gram positive staining for gram-negative bacilli, the culture was negative, and three of them (20%) were mixed infections (Staphylococcus spp.). Three patients (20%) died. In adults, gram-negative bacilli rarely cause spontaneous meningitis, but are a common causation of post-neurosurgical meningitis and in those with neurosurgical devices. The mortality rate of MGNB is high.

Oral infection of mice with Salmonella entericaserovar Typhimurium causes meningitis and infection of the brain

BackgroundSalmonella meningitis is a rare and serious infection of the central nervous system following acute Salmonella enterica sepsis. For this pathogen, no appropriate model has been reported in which to examine infection kinetics and natural dissemination to the brain.MethodsFive mouse lines including C57BL/6, Balb/c, 129S6-Slc11a1tm1Mcg, 129S1/SvImJ, B6.129-Inpp5dtm1Rkh were used in the murine typhoid model to examine the dissemination of systemic Salmonella enterica serovar Typhimurium following oral infection.ResultsWe report data on spontaneous meningitis and brain infection following oral infection of mice with Salmonella enterica serovar Typhimurium.ConclusionThis model may provide a system in which dissemination of bacteria through the central nervous system and the influence of host and bacterial genetics can be queried.

Mondini-Dysplasie

Mondini dysplasia is a rare malformation of the inner ear commonly associated with loss of hearing and vestibular function. Children with Mondini dysplasia are predisposed to developing a spontaneous cerebrospinal fluid (CSF) leak and recurrent meningitis. If there is no CSF leak but a unilateral hearing loss, the condition may go undiagnosed for years. We describe a 65-year-old man with unrecognized unilateral Mondini dysplasia who presented with CSF leak and meningoencephalitis after minor head trauma. Two operative interventions were undertaken to close the defect properly. Patients with Mondini dysplasia or their parents should be cautioned about the potential hazards of any head trauma.

Culture-proven bacterial meningitis in elderly patients in southern Taiwan: clinical characteristics and prognostic factors.

The epidemiologic landscape of causative pathogens and clinical characteristics of bacterial meningitis varies with several clinical factors including preceding/pre-existent medical and/or surgical conditions, modes of contraction, geographic distributions, status of vaccinations, the study time periods and differences among age groups. In order to delineate the epidemiology of bacterial meningitis in senior adults (ages > or =60 y/o) in southern Taiwan, we analyzed the clinical characteristics and therapeutic outcomes of 64 senior adults (42 men and 22 women, aged 60-80 years) with bacterial meningitis collected over a period of 13 years at our hospital. The prognostic factors between fatal and non-fatal groups of patients were compared. Twenty-seven of the 64 patients belonged to a nosocomial infection group, and the other 37 comprised a community-acquired infection group. Sixty percent (39/64) of the patients had a post-neurosurgical state as the most preceding event prior to infection. Liver disease (13) and diabetes mellitus (6) were the most common underlying conditions of the other 25 patients with spontaneous meningitis. Of these 64 patients, Klebsiella (K.) pneumoniae (18), Acinetobacter baumannii (5), Escherichia coli (5), and Enterobacter species (5) were the most commonly implicated Gram-negative pathogens. Staphylococcus (S.) aureus infection was increasing during the study period. The therapeutic results of this group of patients showed a mortality rate of 38% (24/64). The presence of septic shock was the most significant prognostic factor. In conclusion, for this study group, a post-neurosurgical state was the single most important preceding event for senior adults developing bacterial meningitis. Of the implicated pathogens, K. pneumoniae and S. aureus were the most common gram-negative and gram-positive pathogens, respectively. The therapeutic result of this specific group of patients showed a high mortality rate; however, the small case number and possible bias of case selection have limited the analytical conclusions of this study.

Bacterial Meningitis in Young Adults in Southern Taiwan: Clinical Characteristics and Therapeutic Outcomes

To delineate the epidemiologic trend, clinical characteristics and therapeutic outcomes of bacterial meningitis in young adults in Southern Taiwan. Over a period of 18 years, 329 cases of culture-proven adult bacterial meningitis were identified at our hospital. Among these 329 cases, 62 were identified as young adults (< or = 40 years) and their clinical features, laboratory data and therapeutic outcomes were reviewed. The prognostic factors between fatal and non-fatal groups were compared. The 62 young adults were 48 men and 14 women, aged 17-40 years. Thirty of the 62 patients belonged to nosocomial infection, and the other 32 belonged to community-acquired infection. A total of 74% (46/62) of the patients had a post-neurosurgical state as the underlying condition. Alcoholism (n = 8) was the most common underlying condition of the other 16 patients with spontaneous meningitis. Of these 62 patients, Klebsiella pneumoniae and Pseudomonas aeruginosa were the most common implicated gram-negative pathogens. During the late study period, there was an increase in coagulase-negative staphylococcus and Staphylococcus aureus infections. The therapeutic results of this group of patients are as follows: 13 patients died, 18 had full recovery and 31 had varying degrees of neurologic deficits. Impaired consciousness and thrombocytopenia were significant prognostic factors. A post-neurosurgical state is an important preceding event for young adults to develop bacterial meningitis. Of the implicated gram-negative pathogens, K. pneumoniae and P. aeruginosa are common; however, there has been an increase in staphylococcal infection in recent years. Therapeutic results of this specific group of patients showed that 20% (13/62) of the patients died, and 50% (31/61) of the patients in this study had neurologic deficits. However, the small case number and possible bias of case selection has limited the analytical conclusions of this study. Further large-scale studies are needed to delineate the clinical characteristics and therapeutic outcomes of bacterial meningitis in this specific group of patients.

Enterococcal meningitis: a clinical study of 39 cases and review of the literature.

To describe the clinical features and outcome of enterococcal meningitis, we retrospectively reviewed the charts of 39 cases seen at 2 tertiary hospitals during a 25 years and collected 101 additional, previously reported cases for review. Among these 140 cases, there were 82 cases (59%) of postoperative meningitis and 58 cases (41%) of spontaneous meningitis. Eighty-six patients (61%) were adults and 54 (39%) were children. Patients with spontaneous meningitis had a higher frequency of community-acquired infection (50% versus 18%; p < 0.01), severe underlying diseases (67% versus 22%; p < 0.01), and associated enterococcal infection (29% versus 8%; p < 0.01) than patients with postoperative meningitis. The clinical presentation was similar in both groups, but patients with spontaneous infection had a higher frequency of bacteremia (58% versus 12%; p < 0.01), and a lower frequency of mixed infection (9% versus 29%; p < 0.01). Spontaneous meningitis in children was associated with a significantly lower frequency of fever, altered mental status, headache, and meningeal signs (p < 0.01), probably explained by the high proportion of neonates in this age-group. Most infections were caused by Enterococcus faecalis, which accounted for 76% of the isolates identified at the species level. Fifteen of the 25 cases due to Enterococcus faecium were produced by vancomycin-resistant strains. Most patients were treated with ampicillin, penicillin, or vancomycin, with or without aminoglycosides, for a median period of 18 days (range, 1-85 d). Overall mortality was 21%. The mortality rate was higher in spontaneous than in postoperative meningitis (33% versus 12%; p < 0.01), but was similar in patients treated with beta-lactams (18%), glycopeptides (14%), or other antibiotics (25%), as well as in patients treated with monotherapy (16%) or combination therapy (22%). An adverse outcome correlated significantly with advanced age, the presence of severe underlying diseases, associated enterococcal infection, bacteremia, septic shock, and the absence of fever at presentation. Shunt removal was associated with a lower mortality. Multivariate analysis showed that the presence of severe underlying diseases was the only prognostic factor associated with mortality (odds ratio = 6.8, 95% confidence intervals = 2.7-17.5, p < 0.01).

Clinical study of 44 cases of Staphylococcus aureus meningitis.

In order to describe the clinical features and outcome of Staphylococcus aureus meningitis, the charts of 44 cases seen at one teaching hospital during a 20-year period were retrospectively reviewed. Staphylococcus aureus was the fifth most common cause of bacterial meningitis (10.2% of cases). There were 28 (63%) cases of postoperative meningitis and 16 (37%) of spontaneous meningitis. Patients with postoperative meningitis were younger than patients with spontaneous meningitis (mean age, 40.3 vs. 59.3 years; P=0.04) and had a lower frequency of community-acquired infection (32.1% vs. 93.8%; P<0.01), severe underlying diseases (28% vs. 87%; P<0.01) and associated staphylococcal infection (35% vs. 75%; P=0.01). The clinical presentation was similar in both groups, but patients with postoperative meningitis had a lower frequency of altered mental status (39% vs. 75%; P=0.02), meningeal signs (28% vs. 62%; P=0.02), petechial rash (0% vs. 18%; P=0.04), bacteremia (7% vs. 75%; P<0.01), and septic shock (0% vs. 44%; P<0.01). Most patients were treated with cloxacillin or vancomycin, with or without rifampicin, for a mean period of 22.5 days (range, 1-100 days). Overall mortality was 27%, and the mortality rate was higher for cases of spontaneous than postoperative meningitis (50% vs. 14%; P=0.01). Mortality correlated significantly with advanced age, spontaneous meningitis, altered mental status, and the presence of severe underlying diseases, bacteremia, and septic shock.

Spontaneous Escherichia coli Meningitis in an Adult

Spontaneous meningitis due to gram-negative bacilli (excluding Hemophilus influenzae) is an infrequent infection in adult patients. It usually occurs in patients with underlying immunosuppressive conditions. Most of the cases are due to Escherichia coli and represent a complication of bacteraemia. The infection has a high mortality rate which may be as high as 90%, especially if associated with septicaemia. We report the case of a 53-y-old man with spontaneous, community-acquired Escherichia coli meningitis who was admitted with an unusual presentation. Blood and urine cultures were negative.

意識障害をきたした鼻性髄膜炎例

Rhnnogenic meningitis is a rare complication with a relatively high morbidity rate. Recently, a case of rhinogenic spontaneous meningitis with unconsciousness was reported. The patient was a 22-year-old male who exhibited headaches, high fever and right eyelid swelling. Unconsciousness and meningeal signs developed the night of admission. Spinal fluid analysis showed a high cell count. He was diagnosed as having rhinogenic meningitis. Chemotherapy and spinal drainage were carefully conducted. Following an improvement of the intracranial complications, a right Caldwell-Luc operation, a right external frontoethmoidectomy and left endoscopic sinus surgery were carried out. However, no bony defects were recognized in any sinus. The intracranial complications were considered to be caused by a bacterial infection via the venous system. Nasal operation should be carried out according to the state of intracranial complications and the general condition of the patient.

Staphylococcus aureus Meningitis in a Patient With Acquired Immunodeficiency Syndrome

Meningitis due to Staphylococcus aureus is well described but uncommon. Most cases arise as a complication of neurosurgical interventions or head trauma, although some arise spontaneously. To our knowledge, no case of S. aureus meningitis has been previously reported in a person with the acquired immunodeficiency syndrome (AIDS). Herein we describe a case of S. aureus meningitis in a person with AIDS who had no history of a neurosurgical procedure, head trauma, or overwhelming bacteremia. Treatment of this infection was successful. S. aureus should be added to the list of potential pathogens that can cause spontaneous meningitis in people with AIDS.

Klebsiella pneumoniae meningitis: prognostic factors.

All 42 cases of Klebsiella pneumoniae meningitis diagnosed between 1981 and 1991 were evaluated. These accounted for 13% of patients with blood and/or cerebrospinal fluid culture-proven bacterial meningitis. There was an increased incidence of K. pneumoniae meningitis from the first 6 years of study (7%) to the last 5 years (16%). K. pneumoniae became increasingly important not only in community-acquired meningitis but also in nosocomial meningitis. 12/13 nosocomial cases were patients who had undergone neurosurgical procedures. The overall mortality rate was 43%. The mortality rate in patients with spontaneous meningitis was higher than that in patients with post-traumatic or postoperative meningitis. Factors that adversely affected mortality were age over 60, diabetes mellitus, and severe neurological deficits on admission. The use of third-generation cephalosporins did not reduce the mortality rate.