pyogenic meningitis, monitor clinical course and assess complications. Methods: The study was conducted in Paediatric department of Rawalpindi General Hospital, Rawalpindi, over a period of 1 year. Thirty patients were enrolled in the study. History, complete examination, routine investigations, blood culture and cerebrospinal fluid (CSF) routine examination and culture were performed. Cranial ultrasound and CT scan of brain were performed in selected patients. Treatment was given for ten days, and after discharge patients were followed upto 6 months. Data was entered and analyzed using computer programme SPSS version 10.0. Results: Mean age of patients was 40 + 39.2 months. Eighteen (60%) were male and 12 (40%) were females. The most common clinical presentation was fever (100 %) with mean duration 3.4 + 0.7 days. Cerebrospinal fluid culture was positive in 12 (40%) patients. The most common organism isolated was Streptococcus pneumoniae in 7 (23.3%).On follow up 6 (20%) patients had hearing loss. Thirteen (43.3%) patients fully recovered after therapy, 15 (50.0%) recovered with complications while 2 (6.6%) patients expired. Conclusion: The clinical features like loss of consciousness, signs of meningeal irritation (SOMI) and signs of raised intracranial pressure (ICP) are significantly associated with morbidity and mortality. The positive CSF culture, cranial ultrasound and CT scan findings are also associated with morbidity and mortality

Rai Muhammad Asghar, Zeeshan Ghani , Muddassir Sharif

English

Journal of Rawalpindi Medical College

Journal of Rawalpindi Medical College (JRMC); 2008;12(2):88-91  88 Causative Organisms, Clinical Course and Complications of Pyogenic Meningitis in Children   Rai Muhammad Asghar, Zeeshan Ghani , Muddassir Sharif  Department of Paediatrics Benazir Bhutto Hospital and Rawalpindi Medical College Rawalpindi   Abstract  Background To identify causative organisms of pyogenic meningitis, monitor clinical course and assess complications. Methods: The study was conducted in Paediatric department of Rawalpindi General Hospital, Rawalpindi, over a period of 1 year. Thirty patients were enrolled in the study. History, complete examination, routine investigations, blood culture and cerebrospinal fluid (CSF) routine examination and culture were performed. Cranial ultrasound and CT scan of brain were performed in selected patients. Treatment was given for ten days, and after discharge patients were followed upto 6 months. Data was entered and analyzed using computer programme SPSS version 10.0. Results: Mean age of patients was 40 + 39.2 months. Eighteen (60%) were male and 12 (40%) were females. The most common clinical presentation was fever (100 %) with mean duration 3.4 + 0.7 days. Cerebrospinal fluid culture was positive in 12 (40%) patients. The most common organism isolated was Streptococcus pneumoniae in 7 (23.3%).On follow up 6 (20%) patients had hearing loss. Thirteen (43.3%) patients fully recovered after therapy, 15 (50.0%) recovered with complications while 2 (6.6%) patients expired.  Conclusion: The clinical features like loss of consciousness, signs of meningeal irritation (SOMI) and signs of raised intracranial pressure (ICP) are significantly associated with morbidity and mortality. The positive CSF culture, cranial ultrasound and CT scan findings are also associated with morbidity and mortality.  Introduction  Meningitis is inflammation of the membranes surrounding the brain and spinal cord. It is a life threatening clinical syndrome. Pyogenic meningitis occurs at all ages, but it is commonest in infancy1. During neonatal period the main pathogens include group B streptococcus, Escherichia coli, Streptococcus pneumoniae and less commonly Haemophilus influenzae and Listeria monocytogens. After neonatal period Haemophilus influenzae, Streptococcus pneumoniae2 and Neisseria meningitides3 predominate, the latter being more common with increasing age4. Alterations in host defence due to anatomic defects or immune deficits increase the risk of meningitis from less common pathogens such as Pseudomonas aeruginosa, Staphylococcus aureus, coagulase-negative staphylococci, salmonella and Listeria monocytogens. A major risk factor for meningitis is the lack of immunity to specific pathogens associated with young age. Additional risks include recent colonization with pathogenic bacteria, close contact, over crowding, poverty and male gender. The mode of transmission is person to person contact through respiratory tract secretions or droplets. Altered immunoglobulin production in response to encapsulated pathogens is another risk factor. CSF leak across a mucocutaneous barrier, lumbosacral dermal sinus and meningomyelocele are associated with an increased risk of meningitis. Pyogenic meningitis accounts for 3 percent of total admissions. The incidence of pyogenic meningitis is higher in developing countries5. It is associated with a high rate of acute complications, mortality and risk of chronic morbidity6.This serious disease has 8-20 percent mortality, 50 percent neurobehavioral morbidity while relapse rate is 3-4 percent. Neurodevelopmental sequelae may occur in 10-20 percent of the cases. The onset of acute meningitis has two predominant patterns. There may be sudden onset with rapid progression leading to shock, purpura, disseminated intravascular coagulation (DIC), reduced levels of consciousness and death. The other presentation is presence of nonspecific signs and symptoms followed by signs of meningeal irritation, raised intracranial pressure and seizures. Diagnosis is confirmed by cerebrospinal fluid examination7. Antibiotics along with supportive therapy are the mainstay of treatment. Mortality can be reduced by an early recognition and prompt treatment. Journal of Rawalpindi Medical College (JRMC); 2008;12(2):88-91  89 The most common neurological sequelae include hearing loss, mental retardation, delayed milestones, speech problem, visual impairment and motor deficit8. The poor prognostic indicators include age at onset of illness less than 6 months, occurrence of seizures more than 4 days into therapy, acute complications like coma and focal neurological signs, low CSF glucose and more than 106 CFU bacteria/ml in the CSF 9. With the above guide lines from the current literature, a study was planned to identify the causative organisms, observe clinical course and follow up of patients aged two months to twelve years with meningitis. The objective of this study was to identify causative organisms and complications of pyogenic meningitis.  Patients and Methods  This was a descriptive study conducted in Paediatric department of Benazir Bhutto  Hospital(BBH), Rawalpindi from October 2005 to September 2006.Thirty patients, from two months to twelve years of age with pyogenic meningitis were enrolled. Neurosurgical conditions (myelomen-ingocele, neural crest defects etc), known cerebral palsy and cyanotic congenital heart disease and known deafness prior to admission were excluded .  After taking informed consent, detailed history was taken followed by complete examination. Routine investigations including complete blood count and ESR, urine routine examination, urea and creatinine, serum electrolytes, chest X-ray, serum calcium and blood sugar random were carried out. Blood culture and cerebrospinal fluid examination and culture were performed. Cranial ultrasound and CT scan of brain were performed in patients with raised intracranial pressure, papilledema and focal neurological deficits to exclude hydrocephalus, brain abscess and infarction. All the patients were given intravenous ceftriaxone (100 mg/kg/day) for ten days. After discharge, patients were followed upto 6 months. During follow up, they were assessed for vision and hearing loss and development of hydrocephalus. Neurological sequale including motor deficits, nerve palsies and seizures were documented and developmental assessment for developmental delay was performed. All the data was entered into a specially designed proforma. Data was entered and analyzed using computer programme SPSS version 10.0.  Results  Of the thirty patients enrolled in study. eighteen (60%) were male and 12 (40%) were females. Mean age was 40 + 39.2 months. Majority of patients (53.33 %) were aged 2 months to 2 years (Table 1).  Table 1: Baseline Characteristics  (n=30)  No. (%age) Sex     Male     Female  18 (60.0%) 12 (40.0%) Age (months)     Mean + SD     Median     Range  40.0 + 39.2 24 4 – 132  Table 2: Duration of Symptoms prior to hospitalisation (n=30) Symptoms Mean +SD Median  Range Fever (days)  3.4 + 0.7  3.0  2 – 5 Fits      1.9 + 0.8  2.0  1 – 4 Headache      1.9 + 0.7  2.0  1 – 3 Vomiting 2.3 + 1.2 2.0  1 – 5  Table 3: Clinical features  (n=30)  No. (%age) Irritability 18 (60.0%) Lethargy 20 (66.6%) Bulging anterior fontanel 8 (26.7%) GCS     7     8     9  6 (20.0%) 5 (16.7%) 9 (30.0%) Signs of meningeal irritation 9 (30.0%) Signs of raised ICP Nerve palsy    3 (10.0%) 9 (30.0%) The most common clinical presentation was fever (100 %) with mean duration 3.4 + 0.7 days. Journal of Rawalpindi Medical College (JRMC); 2008;12(2):88-91  90 Seizures were present in 19 (63.3%) with mean duration 1.9 + 0.8 days, vomiting in 20 (66.6%) with mean duration 2.3 + 1.2 days while loss of conscious level and lethargy was present in 20 (66.6%) patients. Nineteen (63.3%) patients had signs of raised intracranial pressure like papilledema, hypertension and bradycardia.   Table 4: Investigations  (n=30)  No. (%age) Blood CP     TLC (high)     TLC high with neutropenia     ESR (high)  9 (30.0) 21 (70.0) 2 (6.7) CSF cultures     Negative     S. pneumoniae    Neisseria meningitidis    H. influenzae  18 (60.0) 7 (23.3) 3 (10.0) 2 (6.7) CT scan     Suggestive of meningitis     Cerebral infarction     Subdural effusion  16 (53.3) 4  (13.3) 4 (13.3)  Neck stiffness, Kernig and Brudzinski signs were present in 9 (30.0%) patients. Four (13.3%) patients had stroke and subdural effusion. One  case of subdural effusion was symptomatic (Table 2 and 3).CSF culture was positive in 12 (40%) patients. The most common organism isolated was Streptococcus pneumoniae in 7 (23.3%), followed by Neisseria meningitides in 3 (10.0%) and Haemophilus influenzae type B in 2 (6.6%) (Table 4).However blood cultures were negative.   Table 5: Complications  (n=30)  No. (%age) Developmental delay 6 (20.0%) Epilepsy 4 (13.3%) Mental retardation 5 (16.7%) Spasticity 5 (16.7%) Hearing problem 6 (20.0%) Visual problem 5 (16.7%) Speech problem 6 (20.0%) Behavioural disorder 4 (13.3%) Table 6: Comparison of Recovered Patients (n=30)  Complete recovery  (n=13) Recovered with complications (n=15)  p-value CSF cultures     Negative     S. pneumoniae    Neisseria meningitis    H. influenzae  13 (100.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%)  5 (33.3%) 6 (40.0%) 2 (13.2%) 2 (13.2%)  0.001 Cranial U/S and CT      Suggestive of meningitis     Cerebral infarction     Subdural effusion  9 (69.2%)  0 (0.0%) 1 (7.7%)  5 (33.3%)  4 (26.7%) 3 (20.0%)  0.05  During follow up, 6 (20%) patients had hearing loss, speech problem and developmental delay. Five (16.66%) patients had visual impairment, motor deficit and mental retardation. Four (13.33%) patients developed epilepsy and behavioural problems (Table 5).  Regarding outcome, 13 (43.3%) patients fully recovered after therapy, 15 (50.0%) recovered with complications while 2 (6.6%) patients expired. The two groups, one with  complete recovery (n=13) and the other one with recovery with complications (n=15) were compared for  clinical features and the investigations done. The duration of the clinical symptoms like fever, seizures and vomiting were compared and found non-significant. The conscious level, signs of meningeal irritation and signs of intracranial pressure showed a significant association (Table 6). Comparing the investigations like CSF cultures and CT scan we found a significant association among the fully recovered and the complications groups (Table 6).   Discussion  Pyogenic meningitis is a life threatening clinical syndrome having high morbidity and mortality11. Pyogenic meningitis occurs at all ages, but it is commonest in infancy. In a study from India10, 78 % cases of meningitis were found in children aged less than 1 year. In our study, 53.33 % (n=16) were aged between 2 months and 2 years.  Pyogenic meningitis is more common in males than females. In one study in India10, more cases of Journal of Rawalpindi Medical College (JRMC); 2008;12(2):88-91  91 pyogenic meningitis were found in males than females. In another study in Nigeria14, 70% were male and 30 % were females. In our study, similar results were obtained, 60 % (n=18) were male and 40 % (n=12) were females. The most common clinical presentation of pyogenic meningitis is fever10, seizures, loss of conscious level, vomiting and lethargy. In our study, all patients presented with fever while vomiting, loss of conscious level and lethargy were observed in 20 (66.6%). Seizures and signs of raised intracranial pressure were present in 19 (63.3%). Similar results were found in studies carried out in India10 and Nigeria14. CSF culture is positive in 40 to 60 % of patients with pyogenic meningitis10. The most common organism between age 2 months and 12 years is Streptococcus pneumoniae, followed by Neisseria meningitidis and Haemophilus Influenzae. In our study, 12 (40%) patients had positive CSF culture. Streptococcus pneumoniae was isolated from 7 (23.3%) patients, Neisseria meningitidis from 3 (10.0%) and Haemophilus influenzae from 2 (6.6%) patients. These results were similar to a study carried out in India10 and one in Pakistan12. The same results were found in another study carried out in Nigeria14. Blood cultures were negative in our study; however blood cultures can be positive in 80-90 % of cases15. Nineteen (63.3%) patients had signs of raised intracranial pressure which include papilledema, hypertension and bradycardia. Neck stiffness, Kernig and/or Brudzinski sign were present in 9 (30.0%) patients. Signs of meningeal irritation are not present before 18 months of age15. Cranial nerve palsy and bulging fontanelle were found in 9 (30 %) and 8 (26.7%) patients respectively. Four (13.33 %) patients had stroke and subdural effusion.16  Appropriate recognition, prompt antibiotic therapy, and supportive care have reduced the mortality to less than 10 %. In our study, 2 (6.66%) patients expired. Similar results were also shown by other studies. In one study12 in Pakistan, mortality was 10%. All patients enrolled in our study were followed up for 6 months. The chronic sequelae included hearing loss, mental retardation, speech problem, developmental delay, visual impairment, spasticity, epilepsy and behavioural disorder. In our study, the most common chronic sequelae were hearing loss which is comparable to other studies10, 13, . Speech problem and developmental delay were seen in 6 (20%) patients. Visual impairment, spasticity and mental retardation were present in 5 (16.6%) patients and epilepsy and behavioral disorder were observed in 4 (13.3%) patients. These results are similar to studies carried out in India11 and Pakistan2.  References  1. Campbell AGM, Mclintosh N, editors. Forfar and Arneil's. In: Textbook of Paediatrics. 5th edition New York Churchill Livingstone; 1998. 2. Khichi Q A, Siddique N, Warraich I. Pyogenic meningitis aetiological agents and outcome. JPPA 2004; 28: 412. 3. Huang HR, Chen HL, Chu SM. Clinical spectrum of meningococcal infection in infants younger than six months of age. Chang Gung Med J 2006; 29(1): 107-13   4. Muhe L, Klugman KP. Pneumococcal and Haemophilus meningitis in children. Trop Med Int Health 1999; 4(6): 421-27. 5. Amir A, Zaheer M, Yunus M. A clinico-epidemiological study of pyogenic meningitis in children. Indian J Matern Child Health 1999; 4(4): 114-17. 6. Qazi SA, Khan MA, Mughal N, Ahmed M Dexamethasone and bacterial meningitis in Pakistan. Arch Dis Child 1998; 75: 482-88. 7. Saha SK, Darmstadt GL, Yamanaka N, Billal DS, Nasreen T, Islam M et al. Rapid diagnosis of pneumococcal meningitis implications for treatment and measuring disease burden. Pediatr. Infect Dis J 2005; 24(12): 1093-98. 8. Grimwood K, Andreson P: Twelve year outcome following bacterial meningitis: Further evidence for persisting effects. Arch Dis Child 2000; 83: 111-16. 9. Lucena R, Fonseca N, Nunes L, Cardoso A, Goes J, Correia MC et al. Intra-hospital lethality among infants with pyogenic meningitis. Pediatr Neurol 2005; 32(3): 180-83. 10. Nandita C, Meenakshi M, Sheila B, Swatee B, Ashish B, Anand P et al. Diagnosis and outcome of acute bacterial meningitis in early childhood. Indian Pediatrics 2002; 39: 914-21 11. Ciji N, George S, Letha S, Sushama Bai. A clinical study of chronic morbidity in children following pyogenic meningitis. Indian Pediatrics 2002; 39: 663-67. 12. Khichi G Q, Channar M S, Mannan M A. Mortality variables in pyogenic meningitis in paediatric age group. JCPSP 2003; 13: 10. 13. Laeeq A, Ali L, Ahmed M. Assessment of hearing loss after childhood meningitis. Pak Ped J 2002; 26(3): 125-31 14. Ogunlesi TA, Okeniyi JAO, Oyelami OA. Pyogenic meningitis in Ilesa, Nigeria. Indian Pediatrics 2005; 42:1019-23  15. Behrman RE, Robert M. Kliegman HB,. JensonH, editors. Nelson: Textbook of Paediatrics.17th edition, Philadelphia, Pennsylvania  Saunders; 2004. 16. Vinchon M, Joriot S, Jissendi-Tchofo P, Dhellemmes P. Post meningitis subdural fluid collection in infants: changing pattern and indications for surgery. J Neuro Surg  2006; 104(Suppl 6): S383-87.  

Causative Organisms, Clinical Course and Complications of Pyogenic Meningitis in Children

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Causative Organisms, Clinical Course and Complications of Pyogenic Meningitis in Children

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