A CAJM  article on Acute Bacterial Meningitis in Childhood

Kendall, A.C.

Central African Journal of Medicine

English

Kendall,  A.C.

National Research Database of Zimbabwe

Acute Bacterial Meningitis In Childhood

IDS OpenDocs

iy iP M M r  i©  w jyM i n?D mumi^  hd «
iPMTOiag ajfifiictiim© urns ©mtomiii ®if 
» I F A T O » ?P © IF S T O i a W M i n i
HKf MMMIimiL @®mm®ms
Am MttDXDJlh 3MlI!®mi|p afl 33fl HM&h£$@ ‘
Ek KL @C31M1^ 6!niliil51r[!M!D§i W&MGQ/MM,
Acute Bacterial Meningitis 
in Childhood
BY
A. C. KENDALL, m .b ., f .r .c .p ., d .c h .
Visiting Professor of Paediatrics, University of Rhodesia.
A  review of cases of acute bacterial meningitis 
occurring in children up to and including the age 
of twelve years admitted to Harari Hospital during 
the years 1967 - 1969 inclusive, was carried out. 
After excluding those cases in which meningitis 
was secondary to suppuration in the accessory 
nasal sinuses, brain abscess, meningomyelocoele, 
compound fractures of the skull and one case of 
terminal infection in a child with chronic renal 
failure, there remained 200 cases for analysis. As 
will be seen from Table I, there were 13 meningo­
coccal infections, nine streptococcal, two staphylo­
coccal and one case from which N. catarrhalis 
was isolated. The remaining cases, 175, comprised 
67 pneumococcal, 44 H. influenzal and 64 in which 
no definite bacterial pathogen was isolated (pyo­
genic no organisms). The yearly admission rate 
of these three groups taken together was fairly 
constant, 57 were admitted in 1967, 56 in 1968, 
and 62 in 1969, but comparing the .figures for 
1967 and 1969, it will be seen that while admissions 
for pneumococcal meningitis fell by just over 
one half, admissions of cases of H. Influenzal 
meningitis more than doubled. The figures for 
cases of pyogenic meningitis showed a small yearly 
increase.
Table I shows the striking differences in age 
incidence as between the various groups of cases. 
Meningococcal meningitis was seen throughout 
the whole, period of childhood while streptococcal 
meningitis occurred only in the first two months 
of life. Both pneumococcal meningitis and 
pyogenic meningitis while' having their greatest 
incidence in the early months of life were not 
infrequent after this period, while meningitis due 
to H. influenzae was not seen before-the age of 
three months, its peak incidence was at the age 
of six months and only three cases occurred after 
the age of 12 months. Again taking the three 
main groups as a whole, there was a marked
ACUTE BACTERIAL MENINGITIS T he Central AfricanJ ournal of MedicineMay, 1971.
TABLE 1
*\h? i to ■?h? 4/12 7/12 B/12 9fl2 B
11
12 1 Yr 2 3 4 5 6 7 & 9 10 11 12 TO TA L
A D M IS SIO N S
PNEUMOCOCCAL
D E A TH S
2 8 5 8 3 3 2 6 3 2 1 2 11 3 2 1 - 3 - - - 1 1 67
1 6 5 1 2 2 1 1 - 2 1 2 4 2 - 1 •■31 '
A D M IS S IO N S
H. INFLUENZAE
D E A T H S .
- - - 2 2 5 11 10 2 3 6 - 2 1 '4 4  .
- - - 2 1 1 1 1 1 1 4 - 1 13
A D M IS S IO N S  .
PYOGENIC
D E A TH S
8 8 3 - 3 3 5 4 3 1 3 - 4 4 2 - 1 1 3 3 3 1 ■ 1 - 64
4 4 1 - 2 1 2 4 3 1 1 - 1 2 - - 1 - 1 - 2 - 1 - 31
A D M IS S IO N S
MENINGOCOCCAL
D E A T H S
1 1 - - - 1 - - 1 1 1. 1 - - 1 - - - 2 2 13
1
A D M IS S IO N S
STREPTOCOCCAL
D E A T H S
7 - 2 9
- 2
OTHER ORGANISMS -3 -  (N . CATARRHALIS -1- )
(STAPHYLOCOCCI - 2-)
(-1- Death)
Table 1—Relates the types of meningitis to age and mortality.
the H: influenzae survivors and two cases in the 
TABLE 2 pyogenic group.
1987 1988 1989
PNEIJMOCOCCAI ■ ADMISSIONS 29 24 14
DEATHS 1 3 9 9 .
H- INFLIJEN7AE ADMISSIONS 10 , 10 24
■DEATHS 3 - 10
P Y O R F N I C  ADMISSIONS 18 22 24
DEATHS 8 13 10
MENINGOCOCCAL ADMISSIONS 2 6 5
DEATHS - - 1
Table 2—Relates the types of meningitis to the year of 
admission and mortality.
variation in the numbers of admissions as re­
lated to the month of the year (Table III). The 
average monthly admission rate was exceeded 
during the period March to July inclusive and 
there was a single isolated peak during the month 
of September. Of the total of 200 cases 79 died. 
The death rate was lowest in the meningococcal 
group, marginally higher in the pyogenic than 
in the pneumococcal cases, and significantly lower 
in the H. influenzal- group than in both the pneu­
mococcal and pyogenic groups. The relationship 
of age to the outcome was shown in that during 
the first three months of life of 15 cases of pneu: 
mococcal meningitis, 13 died and in the pyogenic 
group 16 of 19 died. An attempt was made to 
assess the quality of survival. As recorded in the 
case notes, residual cerebral damage was noted in 
14 survivors of pneumococcal meningitis, in 15 of
D isc u s s io n
The present series may be compared with pre­
vious series, Mathies & Wehrle (1968) and Glyn 
Jones (1968). Meningococcal meningitis occurs 
at any age at times sporadically but at other times 
in epidemic outbreaks of explosive violence. In 
our series it behaved sporadically. Streptococcal 
meningitis is predominantly a disease of early 
infancy and in this series was confined to the 
first two months of life. The greatest contrast 
with previous series is in relation to pneumococcal 
meningitis, H. influenzal meningitis and the pyo­
genic group. Pneumococcal meningitis is sub­
stantially more frequent in the present series than 
in series reported from elsewhere, but during the 
period under review the absolute yearly figure fell 
TABLE 3
Table 3—Relates the admission of cases of meningitis of 
the three main groups to the month of the year.
99
M ay, 1971. ACUTE BACTERIAL MENINGITIS T he Central AfricanJournal, of Medicine
TA B L E  4
PRESENr SERIES MATH1E AND  WEHRLE
PNEUM O CO C CAL 3 8 % 13%
H. INFLUENZAE 2 5 % 6 7%
PYOGENIC ( n o  o r g a n is m ) 3 7% 2 0 %
Table 4—Compares the present series with the series of 
Mathies and Wehrle.
from 29 in 1967 to 14 in 1969, or expressed as a 
percentage of the three main groups from 51 per 
cent, to 23 per cent. During the same period the 
yearly admissions for H. influenzal meningitis 
increased from 10 to 24, or expressed as a per­
centage, from 18 per cent, to 30 per cent. This 
trend is towards the frequency distribution seen 
in the developed countries as recorded by Mathies 
et al. (Table IV). In respect of pyogenic menin­
gitis the incidence in our series is almost double 
the figures quoted by Mathies—37 per cent, as 
against 20 per cent. The incidence of pneumococ­
cal meningitis is likely to be a reflection of the 
prevalence of pneumococcal infections in the 
general community and it would be interesting 
to compare the pneumococcal types recovered 
from cases of meningitis with those recovered 
from cases of acute lobar pneumonia. Even so 
the fall in admissions for primary lobar pneumonia 
at all ages at Harari Hospital during this period 
from 443 cases in 1967 to 325 cases in 1969 indica­
ting a reduced incidence of pneumococcal infec­
tions in the general population, seems too small 
to be solely responsible for the declining incidence 
of pneumococcal meningitis. There is also to be 
taken into consideration the increase in cases of 
, H. influenzal meningitis and the high incidence 
of pyogenic meningitis. All these changes might 
be explained if during this period penicillin were 
being used on an increasing scale and local en­
quiries seem to indicate that this is the case. The 
pneumococcus is more susceptible to the action 
of penicillin than is H. influenzae. The increasing 
use of penicillin would therefore be expected to 
cause a fall in pneumococcal infections in the I 
population generally. It is also likely that at least 
in some cases penicillin when given to a child 
with a primary respiratory infection would pre­
vent the development of a pneumococcal menin­
gitis but not meningitis due to the less susceptible 
H . influenzae. Thus a falling incidence of pneu- ' 
mococcal meningitis and an increasing incidence 
of H. influenzal meningitis would be explained.
There was a quite sharp difference between the 
age. incidence of meningitis due to H. influenzae 
and the other two main groups, pneumococcal and 
pyogenic.. No . case of H. influenzal meningitis
occurred under the age of three months, its maxi­
mum incidence was at six months and only three 
cases of 44 occurred after the age of 12 months. 
Such an age distribution suggests very strongly 
that an immunoglobulin of the IgG class is re­
sponsible for resistance to this organism and that 
as a consequence of maternal transplacental dona­
tion, the newly born child is well protected until 
the level of passively acquired antibody has fallen. 
Once an active immunity has been acquired re­
sistance is high and prolonged. In contrast the 
infant in the first few months of life shows a 
marked susceptibility to pneumococcal meningitis 
and although susceptibility to this infection 
diminishes after the age of one year, cases of men­
ingitis due to this organism are seen throughout 
the whole period of childhood. The early suscep­
tibility to infection is correlated with the fact that 
immunoglobulins active against the pneumococcus 
are contained within the IgM group which is not 
transferred from the maternal to the foetal circu­
lation: Burrell (1969). The persisting suscepti­
bility to infection is capable of two explanations. 
Actively produced antibody to the pneumococcus 
is not very long lasting and also since the pneumo­
coccus is of many antigenically separate types, ex­
posure to one type does not prevent infection with 
an organism of a different type in contrast to the 
situation with H. influenzal meningitis in which 
infections are due to one type only, namely type B.
The rate of monthly admissions for meningitis 
in the three main groups showed an interesting 
pattern. From March to July admissions were 
above the monthly average, they, fell to a low 
level in August and this was followed by an 
isolated peak in September. The preponderance 
of cases in the period March to July can probably 
be explained by climatic conditions, but the peak 
in September occurs at a time when the weather 
is not favourable for the promotion and dissemin­
ation of respiratory infections. One possible 
explanation is that September is a month during 
which there is a lull in seasonal agricultural work 
and that it is the time of year when visits to friends 
and relatives are customary. This would allow 
upper respiratory infections to become dissemin­
ated more widely beyond the immediate family 
circle.
Taking the three main groups together, there 
was an overall mortality of 43 per cent. (75 
deaths in 175 cases). The death rate was lowest 
in H. influenzal infections, 30 per cent., in the 
pyogenic group death occurred in 48 per cent, 
of admissions and in the case of pneumococcal 
infections in 46 per cent. The age distribution of 
the cases of H. influenzal meningitis does not 
allow an analysis of the relationship of age to
1 0 0
outcome. However, in both pneumococcal men­
ingitis and the pyogenic group the mortality was 
over 50 per cent, in children under the age of 
one year, and around 30 per cent, in those aged, 
one year and older. The effect which age had 
upon the outcome was most marked in pneumo­
coccal meningitis, of 15 children under the age of 
three months, 12 died.
The death rates in acute bacterial meningitis 
do not in themselves give a complete picture of 
the effects of the disease since many of'the sur­
vivors were known to have residual cerebral 
damage and this was noted to be present in 14 of 
the survivors of pneumococcal meningitis, 15 of 
the H. influenzal group and five in the pyogenic 
group. These figures are undoubtedly less than 
would have been found had it been possible to 
carry out a reassessment at a later date, but out 
of a total of 175 admissions no less than 109 
either died or were left with a significant degree 
of brain damage. Thus the cure rate for these 
three groups taken as a whole is not in excess 
of 38 per cent, and is probably much lower. In 
the light of these figures what can be done to im­
prove on the results of treatment? There is no 
doubt that early and effective treatment is the 
first essential. The suspicion of the possibility of 
meningitis in any child will indicate the necessity 
for a lumbar puncture. In situations where this 
cannot be carried out or the cerebrospinal fluid 
adequately examined and cultured, the child 
should be immediately transferred. It is further 
recommended that before being transferred an 
intramuscular injection of 1,000,000 units of peni­
cillin should be given. Such a dose of penicillin 
may make the organism more difficult to isolate 
but it will also save lives and reduce the chances 
of disability in the survivors. The standard treat­
ment for bacterial meningitis of all types is triple 
therapy, chloramphenicol 100/mgm per kilo per 
day, penicillin 500,000 units 6 hourly and sulpha- 
dimidine 200 mgms per kilo per day. Although 
recently amDicillin has been advocated in the 
treatment of H. influenzal meningitis no significant 
difference in mortality and morbidity has been 
shown when this drug is used in preference to 
chloramphenicol (Gellis & Kagan, 1970). It 
is recommended that where possible these agents 
should be given intravenously at least for the first 
12 hours and that in the case of pneumococcal in­
fections the dose of penicillin should be increased 
to 1,000,000. units 2 hourly.
Since natural resistance to both pneumococci 
and H. influenzae is largely mediated by humoral 
mechanisms would treatment be improved if 
specific antibodies could be provided? Prior to 
the advent of sulphonamides treatment of lobar
Vol. 17. No. 5. M ay, 1971.
pneumonia with specific antiserum where facilities 
for typing the pneumococcus were available was 
highly effective: Mudd, S. (1970). Prepared 
type specific sera are no longer available, but a 
trial is being conducted at present in which in ad­
dition to antibiotic therapy fresh frozen plasma 
is being given intravenously in a dose of 10 ml. 
per kilo. If one is fortunate the infused plasma 
will contain antibodies and in any event such 
treatment is not likely to do harm since the 
chances of transmitting homologous serum 
jaundice using a single donor is minimal.
Treatment of acute bacterial meningitis in 
childhood includes many other measures promin­
ent amongst which are the prevention and prompt 
treatment of convulsions and attention to fluid 
balance.
S u m m a r y
Cases of acute bacterial meningitis in childhood 
admitted to Harari Hospital from 1967 to 1969 
are reviewed. Attention is drawn to the changing 
pattern of the disease, the seasonal variations, the 
age -incidence and the prognosis. Recommenda­
tions are made as to treatment.
REFERENCES
1. Burnet, Sir Macfarland. (-1967). Self and Not-Self. 
Melbourne University Press. Cambridge University 
Press.
2. Gellis, S. S. & Kagan, B. M. (1970). ed. Current 
Paediatric Therapy—4. Philadelphia: Saunders.
3. G lyn J ones, R. (1967). S. Afr. med. J 41, 75.
4. M acLeod, C. M. in Infectious agents and Host re­
actions. M udd, S. ed. (1970). Philadelphia; Saunders. 
p.165. ;
A. Perstans and W. Bancrofti 
A Filarial Survey 
in a Game Reserve 
in the Zambezi Valley
BY
C. J. ROBERTS
Government Medical Officer, Umvukwes;
A. McKBAG
House Physician, Harare Hospital;
AND
M. GBL'FAND, c .b .e „ m .d ., f .r .c .p . 
Department of Medicine, University of Rhodesia.
Since it appears that employees of the Game 
Department working in the Zambezi Valley have 
a special liability to develop filariasis, we under­
took a survey of employees at the game camps, 
Mana Pools and Marangora, to find out the 
incidence of filariasis in these people.
T he Central African
Journal of Medicine
101
This work is licensed under a 
Creative Commons
Attribution -  Noncommercial - NoDerivs 3.0 License.
To view a copy of the license please see: 
http://creativecommons.org/licenses/by-nc-nd/3.0/
This is a dow nload  from  th e  BLDS Digital Library on O penD ocs
http://opendocs.ids.ac.uk/opendocs/
Institute o f 
Development Studies


https://opendocs.ids.ac.uk/opendocs/bitstream/20.500.12413/5456/1/Kendall%2c%20AC%20%20CAJm%20vol.17%2c%20no.5..pdf

Acute Bacterial Meningitis In Childhood

Abstract

Similar works

Full text

Available Versions

National Research Database of Zimbabwe

IDS OpenDocs