Auckenthaler, Raymond

Barenkamp, Stephen J.

Granoff, Dan M.

Hirschel, Bernard J.

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THE JOURNAL OF INFECTIOUS DISEASES. VOL. 149, NO.4. APRIL 1984© 1984 by The University of Chicago. All rights reserved. 0022-1899/84/4904-0035$01.00Recurrent Meningitis in an Adult Due to Nontypable Haemophilus influenzaeCase history. The patient, who had been born in1940, had smoked one pack of cigarettes daily sinceadolescence. In 1972 she was involved in a car accident,a few days after which she presented to an emergencyroom complaining of headaches. Roentgenograms werenormal. Approximately six months later she started tosuffer from a runny nose. Attempts by several physiciansto cure this presumed "rhinitis" were unsuccessful. Shewas admitted under our care in April 1982after a 24-hrperiod of fever and headache. Lumbar puncture revealedcloudy CSF with 2,600 leukocytes/rum' and 90% PMNs;cultures yielded Haemophilus influenzae. Treatment wasstarted with penicillin and changed to ampicillin afterculture results became known, and the patient made anuneventful recovery.The patient declined subsequent neurosurgical consul-tation and remained well until March 1983, when shedeveloped symptoms of an upper-respiratory-tract infec-tion, and fever and violent headaches led to hospitaliza-tion. Again, CSF was purulent, and cultures revealedH influenzae. Recovery with ampicillin was excellent.Two days after the second episode of meningitis, uni-lateral rhinorrhea became profuse, exceeding 1 ml/min,the fluid having the chemical composition of CSF. Sevendays later, rhinorrhea ceased. The patient underwentneurosurgical exploration 17 days after the second ad-mission, but the neurosurgeons were unable to visualizea fistula. Serum immunoglobulin and complement levelswere normal.Both microorganisms isolated from CSF were identi-fied as H influenzae by standard methods [1]. Neitherproduced iridescent colonies on fresh Levinthal agar orformed precipitin bands by CIE with monospecific anti-sera to H influenzae types a-f (Burroughs Wellcome,Cornwallis, NC). The outer-membrane proteins of theisolates were subjected to SDS-PAGE. The electro-phoretic patterns were clearly different, indicating thatthe organisms were of different strains; however, bothwere of the same Kilian biotype II.Unique features. We were unable to find anotherThis work was supported in part by Public Health Servicegrant AI 17572 from the National Institute of Allergy and In-fectious Diseases of the National Institutes of Health.Please address requests for reprints to Dr Bernard J.Hirschel, Division des Maladies Infectieuses, Department deMedecine, Hopital Cantonal Universitaire, 1211-Geneva' 4,Switzerland.656case in the literature of an adult with two episodes ofHaemophilus-related meningitis caused by encapsulatedor nonencapsulated (nontypable) organisms; however, asimilar case has been noted in a 15-year-old boy with aventriculo-peritoneal shunt and suspected cribiformplate abnormality who had two episodes of meningitis ina lO-week period [1]. Evidence for the existence of anintermittent fistula was strong, despite the negativeresults of the neurosurgical exploration. Since naso-pharyngeal carriage of H influenzae by humans is fre-quent, especially in smokers, and the strains are diverse,different nonencapsulated strains may well have mi-grated through the suspected fistula of our patient onseparate occasions and entered the CNS from thenasopharynx.Conclusions. In the context of a clinically diagnosedcerebrospinal-nasal fistula, humoral immunity is prob-ably ineffective in preventing recurrent episodes ofmeningitis, even if the antibody response to the firstinfection is capable of conferring protection againstbacteremia caused by the heterologous strain associatedwith the second episode. However, recent evidenceindicates that protection resulting from anti-outermembrane-protein antibody may be strain specific forboth type b [2] and for nontypable organisms. There-fore, lack of a protective antibody response against theheterologous strain causing the second infection mayalso have been a factor in the recurrence.BERNARD J. HIRSCHEL, RAYMOND AUCKENTHALER,STEPHEN J. BARENKAMP, DAN M. GRANOFFDivision des Maladies Infectieuses, Department deMedecine, Hopital Cantonal Universitaire, Geneva,Switzerland; and Edward Mallinckrodt Departmentof Pediatrics, Washington University School ofMedicine, and Division of Infectious Diseases,St Louis Children's Hospital, St Louis, MissouriReferences1. Barenkamp SJ, Munson RS Jr, Granoff OM. Outer mem-brane protein and biotype analysis of pathogenic non-typeable Haemophilus influenzae. Infect Immun 1982;36:535-402. Shenep JL, Munson RS Jr, Barenkamp SJ, Granoff OM.Further studies of the role of noncapsular antibody inprotection against. experimental Haemophilus influenzaetype b bacteremia. Infect Immun 1983;42:257-63

Recurrent Meningitis in an Adult Due to Nontypable Haemophilus influenzae

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