Bacterial meningitis in children whose cerebrospinal fluid contains polymorphonuclear leukocytes without pleocytosis

A retrospective study was performed of 424 children who received diagnostic lumbar puncture for analysis of cerebrospinal fluid during evaluation of an acute illness. In 106 children, the CSF contained polymorphonuclear leukocytes without pleocytosis. Of these 106 patients, 90 percent had a CSF differential cell count with 20 percent or less PMN's and 88 percent had glucose and protein concentrations within the range of normal limits. All patients had a Gram-stained smear of CSF that revealed no organisms. In no instance was a CSF culture positive for a bacterial pathogen. In most instances, cerebrospinal fluid that contains total white cell count and glucose/protein concentrations within limits of normal, Gram-stained smear which reveals no organisms, and a differential cell count with less than 20 percent PMN's is not indicative of risk for bacterial meningitis. If the clinical situation warrants, the majority of children with this profile do not require hospitalization and initiation of empiric antibiotic therapy pending CSF culture results.     

Prediction of bacterial meningitis in children with meningeal signs: reduction of lumbar punctures

Physicians often have to perform a lumbar puncture to ascertain the diagnosis in patients with meningeal signs, because of the serious consequences of missing bacterial meningitis The aim of this study was to derive and validate a clinical rule to predict bacterial meningitis in children with meningeal signs, to guide decisions on the performance of lumbar punctures. Information was collected from records of patients (aged 1 mo to 15 y) consulting the emergency department of the Sophia Children's Hospital between 1988 and 1998 with meningeal signs. Bacterial meningitis was defined as cerebrospinal fluid (CSF) leucocyte count >5 cells μl^?1 with a positive bacterial culture of CSF or blood. The diagnostic value of predictors was judged using multivariate logistic modelling and area under the receiver operating characteristic curves (ROC area). In the derivation set (286 patients, years 1988–1995) the duration of the main complaint, vomiting, meningeal irritation, cyanosis, petechiae and disturbed consciousness were independent clinical predictors of bacterial meningitis. The ROC area of this model was 0.92. The only independent predictor from subsequent laboratory tests was the serum C‐reactive protein concentration, increasing the ROC area to 0.95. Without missing a single case, this final model identified 99 patients (35%) without bacterial meningitis. Validation on 74 consecutive patients in 3 subsequent years (1996–1998) yielded similar results. Conclusion: This prediction rule identifies about 35% of the patients with meningeal signs in whom a lumbar puncture can be withheld without missing a single case of bacterial meningitis. For the individual patient this prediction rule is valuable in deciding whether or not to perform a lumbar puncture.     

C-reactive protein is useful in distinguishing Gram stain-negative bacterial meningitis from viral meningitis in children.

OBJECTIVE: To clarify to what extent Gram stain-negative bacterial meningitis can be distinguished from viral meningitis by assessment of cerebrospinal fluid (CSF) and blood indices and serum C-reactive protein (CRP) in children over 3 months of age. DESIGN: Common CSF indices, blood leukocyte counts, and serum CRP values were compared between patients with bacterial meningitis who had a positive CSF bacterial culture but a negative Gram stain and patients with viral meningitis. POPULATION: Three hundred twenty-five consecutive patients with CSF culture-proven bacterial meningitis, for whom Gram stain was negative in 55 cases, and 182 children with proven or presumed viral meningitis. RESULTS: Significant differences between patients with bacterial and viral meningitis were found in all indices with large overlap in all except serum CRP. In patients with bacterial meningitis, the mean CSF glucose concentration, protein concentration, leukocyte count, blood leukocyte count, and serum CRP were 2.9 mmol/L (52 mg/dL), 1.88 g/L, 4540 x 10(6)/L, 18.0 x 10(9)/L, and 115 mg/L; and in those with viral meningitis, mean values were 3.3 mmol/L (59 mg/dL), 0.52 g/L, 240 x 10(6)/L, 10.6 x 10(9)/L, and <20 mg/L, respectively. Of the tests investigated in this study, only serum CRP was capable of distinguishing Gram stain-negative bacterial meningitis from viral meningitis on admission with high sensitivity (96%), high specificity (93%), and high negative predictive value (99%). CONCLUSION: Exclusion of bacterial meningitis with only the conventional tests is difficult. Combined with careful physical examination and CSF analyses, serum CRP measurement affords substantial aid.     

Predictors of bacterial meningitis in the era after Haemophilus influenzae.

OBJECTIVE: To determine if, in the era after Haemophilus influenzae type b, the cerebrospinal fluid (CSF) white blood cell (WBC) count can be safely used to stratify children suspected of having bacterial meningitis into low- and high-risk groups. DESIGN: Retrospective analysis of CSF samples. SETTING: Tertiary care pediatric center in Toronto, Ontario, between January 1, 1992, and October 1, 1996. PATIENTS: All CSF samples collected on children aged 2 months to 17 years were included. The final database consisted of 1617 atraumatic samples from children without prior neurologic or immunologic disease who underwent a lumbar puncture to assess the possibility of community-acquired bacterial meningitis. MAIN OUTCOME MEASURES: The predictive values of CSF WBC count, differential, protein, and glucose. RESULTS: There were 44 cases of bacterial meningitis. Five had 3 CSF WBCs per microliter or less, and 6 had 4 to 30 CSF WBCs per microliter. The negative predictive value of CSF specimens with 30 WBCs per microliter or less for bacterial meningitis was 99.3%. Cerebrospinal fluid samples with greater than 30 WBCs per microliter had a likelihood ratio for bacterial meningitis of 10.3 (95% confidence interval, 8.0-13.1) and a positive predictive value of 22.3%. Other significant predictors of bacterial meningitis included age, CSF glucose, protein, gram stain, CSF-serum glucose ratio, and peripheral blood band count. CONCLUSIONS: Given the occurrence of bacterial meningitis in children in the absence of CSF pleocytosis, other factors should be considered when managing children with suspected bacterial meningitis. Children older than 6 months with 30 CSF WBCs per microliter or less are at low risk for bacterial meningitis. If clinically stable and without other laboratory markers of bacterial meningitis, hospital admission and empiric antibiotic therapy may be unwarranted.     

Value of cerebrospinal fluid leukocyte aggregation in distinguishing the causes of meningitis in children

BACKGROUND: Current laboratory tests often cannot distinguish between bacterial and aseptic meningitis rapidly and accurately. The ability to make a prompt diagnosis has important implications for the management and outcome of children with meningitis. The observation that leukocytes aggregate in the cerebrospinal fluid (CSF) has been previously reported, and it has been advocated as a reliable method to distinguish the causes of meningitis in children. OBJECTIVE: To investigate the utility of CSF leukocyte aggregation as a screening test to distinguish between bacterial and aseptic meningitis. METHODS: We compared the clinical and laboratory indices of 109 prospectively enrolled patients with meningitis (67 bacterial, 23 viral, 19 undefined etiology) and evaluated the validity of the CSF leukocyte aggregation test. The predefined leukocyte aggregation scores (LAS) were compared among the types of meningitis, and correlations with other markers of inflammation were calculated. RESULTS: The median LAS was significantly higher (P < 0.001) in the bacterial (32.1%; range, 0 to 84.1%) than in the viral (0%; range, 0 to 16.6%) or undefined (0%; range, 0 to 20.7%) groups. The optimal sensitivity of the leukocyte aggregation test, 98.5 to 92.5%, was demonstrated with LAS values of 0 to 3%. The corresponding specificity was 64.3 to 88.1%. The peripheral white blood cell (WBC) count, serum C-reactive protein, CSF WBC count, blood culture, CSF Gram stain and CSF culture were inferior to the LAS as screening tests when compared individually. The LAS was as effective as CSF protein, TNF-alpha, IL-1-beta, IL-6 and IL-8 to predict bacterial meningitis. In a logistic regression model that included routine laboratory tests, the best predictor of bacterial meningitis was the LAS (odds ratio, 1.6 to 3.7). Significant correlations were demonstrated between the LAS and CSF protein, CSF WBC count, IL-1-beta, IL-6 and IL-8. Duration of symptoms before diagnosis, pretreatment with antibiotics, HIV-1 infection status and CSF red blood cell count did not significantly alter the LAS. CONCLUSIONS: There is no single test to diagnose the etiology of meningitis in children promptly and accurately. The finding of leukocyte aggregation in CSF might be of value as a sensitive adjunctive screening tool for the timely diagnosis of bacterial meningitis, recognizing that it has low specificity and potential practical limitations.     

Significance of polymorphonuclear leukocytes in CSF of bacteremic children

A retrospective study was performed of 32 bacteremic children not receiving preadmission antibiotic therapy who had a diagnostic lumbar puncture for analysis of cerebrospinal fluid at the time of initial evaluation for an acute illness. In each instance, the CSF contained polymorphonuclear leukocytes without pleocytosis. Of these 32 bacteremic patients, 88% had a CSF differential cell count with 20% or fewer polymorphonuclear cells, and greater than 90% had glucose and protein concentration within the range of normal limits. All patients had a Gram-stained smear of CSF which revealed no organisms. In no instance was a CSF culture positive for a bacterial pathogen. In the bacteremic child not pretreated with antibiotics, cerebrospinal fluid which contains total white blood cell, glucose, and protein concentrations within limits of normal, a differential cell count with 20% or fewer polymorphonuclear leukocytes, and Gram-stained smear which reveals no organisms is not indicative of risk for bacterial meningitis.     

Meningitis and interferon-alpha in the cereprospinal fluid. What diagnostic and therapeutic approach? A case report]

BACKGROUND: In meningitis without germs, the existence of an inflammatory syndrome leads toward a bacterial etiology while the detection of interferon-alpha (IFN-alpha) in the cerebrospinal fluid (CSF) argues for a viral meningitis. The coexistence of the inflammatory syndrome and the presence of IFN-alpha in the CSF makes this differentiation difficult. The reported case yields the picture and begs the question on the diagnostic approach and the required therapeutic attitude. CASE REPORT: A six-week-old infant, exclusively breast-fed, was hospitalized for fever. The examination showed an important inflammatory syndrome and meningeal attempt with a cellularity at 94/mm3 with 53% polymorphonuclear neutrophils, contrasting with normal proteinorrhachia and glycorrhachia. The IFN-alpha in the CSF was present at 4 UI/mL while the bacteriological culture and the viral search by PCR were negative. The clinical and biological worsening within the first 36 hours, in spite of the parenteral dispensation of a triple antibiotic therapy (amoxicillin, ceftriaxone, netilmicin), then a favorable clinical and biological response after adjunction of vancomycin, led toward a pneumococcal meningitis with reduced sensitivity to beta-lactams. The maternal antibiotic therapy by amoxicillin and its presence in the maternal milk favored the hypothesis of a decapitated bacterial meningitis. CONCLUSION: In the presence of a meningitis without germs, the coexistence of a sizable inflammatory syndrome and the detection of IFN-alpha in the CSF must be considered as an unusual phenomenon and motivate the pursuit of antibiotic therapy until viral identification.     

The Diagnostic and Predictive Value of Cerebrospinal Fluid Lactate in Children with Meningitis

ABSTRACT. One hundred and thirty-three children with suspected meningitis aged from 11 days to 16 years were investigated with routine cerebrospinal fluid (CSF) laboratory methods: microscopy of a Gram-stained smear, bacterial culture, determination of leukocytes, lactate, and the CSF/blood glucose ratio. On the basis of bacterial cultures and clinical course, the children were classified into three groups: bacterial meningitis (n=18), aseptic meningitis (n=28), and a control group (n=87). The main intention was to study the relation between current diagnostic methods and lactate. CSF lactate levels and cell counts, related significantly (p<0.01) better to the presence of bacterial meningitis than CSF/blood glucose ratios. Lactate levels exceed 2.4 mmol/l in all children with bacterial meningitis, but in none of the control group. Of 28 children with aseptic meningitis 3 had lactate in the range 2.5-2.7 mmol/l, while the others had values of 2.4 mmol/l or less. We consider CSF lactate to be the best predictor in the clinical decision to institute antibiotic treatment of children with suspected bacterial meningitis.     

The diagnostic and predictive value of cerebrospinal fluid lactate in children with meningitis. Its relation to current diagnostic methods

One hundred and thirty-three children with suspected meningitis aged from 11 days to 16 years were investigated with routine cerebrospinal fluid (CSF) laboratory methods: microscopy of a Gram-stained smear, bacterial culture, determination of leukocytes, lactate, and the CSF/blood glucose ratio. On the basis of bacterial cultures and clinical course, the children were classified into three groups: bacterial meningitis (n = 18), aseptic meningitis (n = 28), and a control group (n = 87). The main intention was to study the relation between current diagnostic methods and lactate. CSF lactate levels and cell counts, related significantly (p less than 0.01) better to the presence of bacterial meningitis than CSF/blood glucose ratios. Lactate levels exceed 2.4 mmol/l in all children with bacterial meningitis, but in none of the control group. Of 28 children with aseptic meningitis 3 had lactate in the range 2.5-2.7 mmol/l, while the others had values of 2.4 mmol/l or less. We consider CSF lactate to be the best predictor in the clinical decision to institute antibiotic treatment of children with suspected bacterial meningitis.     

Seasonal outbreak of enteroviral meningitis during summer 2005: experience of a French pediatric unit]

OBJECTIVE: To describe the clinical and biological characteristics of children presenting with enteroviral (EV) meningitis in a French paediatric unit during summer 2005. METHODS: Retrospective study of children with EV meningitis from May to September 2005, diagnosed by PCR and/or viral culture in cerebrospinal fluid (CSF), serum or throat. RESULTS: We reported 99 cases of EV meningitis (96 confirmed and 3 probable). The sex ratio was 2/1, and the median age was 5 years. Peak incidence was reached during the second week of July. The predominant symptom was meningism. ENT (16%), digestive (10%), cutaneous (15%) or respiratory (4%) symptoms were rare. Blood leucocyte count found a predominance of neutrophils (73%), and lymphopenia in half of the children. The mean value of CRP was 25,5 mg/l. The median leukocyte count in CSF was 65 cells/mm(3), with a prevalence of neutrophils in 60% of cases. Pleiocytosis was absent in 20 children. CSF protein level was increased in 20% of cases. The rate of hospitalization was 57,5%. Intravenous antibiotic treatment, initiated among 18 patients, was stopped in 66,6% of the cases on reception of PCR result. The latter result was obtained in 2,3 days on average. CONCLUSION: The epidemic of 2005 EV meningitis was as widespread as that of summer 2000. Characteristics of these meningitis are strong proportion of CSF without pleiocytose and high prevalence of neutrophils in blood and CSF.     

Clinical decision rules to distinguish between bacterial and aseptic meningitis.

BACKGROUND: Clinical decision rules have been derived to distinguish between bacterial and aseptic meningitis in the emergency room to avoid unnecessary antibiotic treatments and hospitalisations. AIMS: To evaluate the reproducibility and to compare the diagnostic performance of five clinical decision rules. METHODS: All children hospitalised for bacterial meningitis between 1995 and 2004 or aseptic meningitis between 2000 and 2004 have been included in a retrospective cohort study. Sensitivity and specificity were calculated by applying each rule to the patients. The best rule was a priori defined as the one yielding 100% sensitivity for bacterial meningitis, the highest specificity, and the greatest simplicity for a bedside application. RESULTS: Among the 166 patients included, 20 had bacterial meningitis and 146 had aseptic meningitis. Although three rules achieved 100% sensitivity (95% CI 84-100), one had a significantly lower specificity (13%, 95% CI 8-19) than those of the other two rules (57%, 95% CI 48-65; and 66%, 95% CI 57-73), which were not statistically different. The ease of manual computation of the rule developed by Nigrovic et al (a simple list of five items: seizure, blood neutrophil count, cerebrospinal fluid (CSF) Gram stain, CSF protein, CSF neutrophil count) was higher than the one developed by Bonsu and Harper. CONCLUSION: On our population, the rule derived by Nigrovic et al had the best balance between accuracy and simplicity of manual computation and could help to avoid two thirds of unnecessary antibiotic treatments and hospitalisations.     

Signs of meningeal irritation at the emergency department: how often bacterial meningitis?

OBJECTIVE: Although signs of meningeal irritation are highly indicative of meningitis, they are not pathognomonic. In this study, we described the final diagnoses in children with signs of meningeal irritation, and we assessed the frequency of bacterial meningitis related to specific signs of meningeal irritation. METHODS: Information was collected from records of 326 patients (aged 1 month to 15 years) who visited the emergency department of the Sophia Children's Hospital between 1988 and 1998 with signs of meningeal irritation, assessed by either the general practitioner or the pediatrician. RESULTS: Bacterial meningitis was diagnosed in 99 patients (30%), viral or aseptic meningitis in 43 (13%). Other diagnoses were pneumonia (8%), other serious bacterial infections (2%), and upper respiratory tract infections or other self-limiting diseases (46 %). Presence of one of the signs of meningeal irritation assessed by the pediatrician was related to bacterial meningitis in 39%. Specific tests eliciting meningeal irritation, such as Brudzinski's and Kernig's signs, were not related to a higher frequency of bacterial meningitis than neck stiffness and the tripod phenomenon. In children < or =1 year, bacterial meningitis is more frequently related to presence of irritability and a bulging fontanel. CONCLUSION: Bacterial meningitis is present in 30% of children with signs of meningeal irritation. Presence of meningeal irritation as assessed by the pediatrician is related to bacterial meningitis in 39%. A better prediction of bacterial meningitis was not achieved by using more specific tests for signs of meningeal irritation.     

Absent or minimal cerebrospinal fluid abnormalities in Haemophilus influenzae meningitis

A case of Haemophilus influenzae type b (Hib) meningitis in which the diagnosis and treatment were delayed because of normal cerebrospinal fluid analysis is presented. A retrospective review was conducted at two children's hospitals to determine the frequency and clinical characteristics of patients with Hib meningitis whose spinal fluid had a normal total white blood cell count, normal chemistries, and negative Gram stain, but subsequent growth of Hib in culture. Of 379 cases of Hib meningitis, two had completely normal CSF, and two had CSF containing small numbers of polymorphonuclear cells as the sole abnormality. In three of the four cases, the duration of symptoms was less than 24 hours, and appropriate therapy was significantly delayed because of benign-appearing CSF. Normal CSF cell counts, chemistries, and Gram stain do not exclude the possibility of bacterial meningitis, and one should remain suspicious when a child has clinical findings suggesting meningitis.     

Test characteristics and interpretation of cerebrospinal fluid gram stain in children

BACKGROUND: Few data exist regarding the test characteristics of cerebrospinal fluid (CSF) Gram stain among children at risk for bacterial meningitis, especially the rate of false positive Gram stain. METHODS: We conducted a retrospective cohort study of children seen in the emergency department of Children's Hospital Boston who had CSF obtained between December 1992 and September 2005. Patients who had ventricular shunts, as well as those who received antibiotics before CSF was obtained were excluded. Test characteristics of CSF Gram stain were assessed using CSF culture as the criterion standard. Patients were considered to have bacterial meningitis if there was either: (1) growth of a pathogen, or (2) growth of a possible pathogen noted on the final CSF culture report and the patient was treated with a course of parenteral antibiotics for 7 days or more without other indication. RESULTS: A total of 17,569 eligible CSF specimens were collected among 16,036 patients during the 13-year study period. The median age of study subjects was 74 days. Seventy CSF specimens (0.4%) had organisms detected on Gram stain. The overall sensitivity of Gram stain to detect bacterial meningitis was 67% [42 of 63; 95% confidence interval (CI): 54-78] with a positive predictive value of 60% (42 of 70; 95% CI: 48-71). Most patients without bacterial meningitis have negative Gram stain [specificity 99.9% (17,478 of 17,506; 95% CI: 99.8-99.9)] with a negative predictive value of 99.9 (17,478 of 17,499; 95% CI: 99.8-99.9). CONCLUSIONS: CSF Gram stain is appropriately used by physicians in risk stratification for the diagnosis and empiric treatment of bacterial meningitis in children. Although a positive Gram stain result greatly increases the likelihood of bacterial meningitis; the result may be because of contamination or misinterpretation in 40% of cases and should not, by itself, result in a full treatment course for bacterial meningitis.     

Clinically inapparent meningitis complicating periorbital cellulitis

Two young children with periorbital (preseptal) cellulitis were found to have meningitis despite having no signs of meningeal irritation and normal cerebrospinal fluid (CSF) cell counts and chemistries. These cases are reported to remind physicians caring for acutely ill children that periorbital cellulitis can have life-threatening complications and that meningitis can occur in the absence of significant clinical signs and in the presence of an initially normal CSF.     

Lipopolysaccharide binding protein is a potential marker for invasive bacterial infections in children

BACKGROUND: The aim of this study was to test the hypothesis that elevated lipopolysaccharide binding protein (LBP) serum concentration is a useful marker in the early diagnosis of invasive bacterial infection in children. We measured LBP in serum and cerebrospinal fluid (CSF) of children with proven invasive infection caused by Haemophilus influenzae, Streptococcus pneumoniae and Neisseria meningitidis. PATIENTS AND METHODS: Samples were collected from 39 children (aged 2 months to 17 years) with bacterial sepsis (n = 19) or meningitis (n = 20). Bacterial infection was diagnosed when a blood or CSF culture was positive and clinical signs of invasive infection were present. The control group consisted of serum (n = 60) and CSF (n = 19) samples from children with neurologic disease, juvenile idiopathic arthritis or viral infection. In 10 patients with bacterial infection, follow-up samples (24 and 48 hours) were available. LBP values were measured by an immunochemiluminescence analyzer (IMMULITE; DPC Biermann, Bad Nauheim, Germany) and compared with tumor necrosis factor-alpha and interleukin-8 concentrations. RESULTS: The median LBP serum concentrations in patients with bacterial infection were markedly elevated compared with the control groups (45.0 [33.1-55.2] versus 8.3 [6.8-10.1] microg/mL [median and 5-95% confidence interval]; P < 0.0001). Follow-up serum values of LBP were persistently elevated despite adequate antibiotic treatment, whereas tumor necrosis factor-alpha and interleukin-8 concentrations decreased. In contrast, LBP concentrations in the CSF were below the detection limit of 0.5 microg/mL in 67% of patients with bacterial meningitis (median <0.5 microg/mL), whereas tumor necrosis factor-alpha and interleukin-8 levels were highly elevated. CONCLUSION: LBP serum concentration is elevated in serum of children with invasive bacterial infection and could be a promising diagnostic marker.     

Acute bacterial meningitis. Cerebrospinal fluid differential count

A retrospective analysis of 112 cases of pediatric bacterial meningitis over a 3-year period was performed to determine the rate of cerebrospinal fluid (CSF) lymphocytosis at initial evaluation. Of 14 neonates and 98 children older than 1 month of age not receiving preadmission antibiotic therapy, only one instance of CSF lymphocytosis occurred. This patient's CSF exhibited pleocytosis, hypoglycorrhachia, abnormally elevated protein content, and organisms visualized on gram stain smear. In children with bacterial meningitis not receiving antibiotic therapy at the time of evaluation, CSF differential cell count with relative lymphocytosis is rare.     

Strategies for diagnosis and treatment of children at risk for occult bacteremia: clinical effectiveness and cost-effectiveness

Decision analysis was used to evaluate the probable health benefits, complications, and costs of six management strategies for febrile children at risk for occult bacteremia. The strategy that combined blood culture with empiric oral antibiotic treatment for all patients was predicted to prevent the highest number of major infections and to have the lowest cost per major infection prevented. The strategy that combined a leukocyte count and blood culture for all patients, followed by empiric antibiotic treatment for those with leukocyte count greater than or equal to 10,000/mm3, had almost equal cost and clinical effectiveness and avoided many antibiotic complications. Culture of blood specimens from all patients and no empiric treatment constituted the third most clinically effective intervention but was the least cost-effective in this model. Giving a 2-day oral course of amoxicillin without testing had the lowest average cost per febrile patient but was the least clinically effective intervention. However, the low degree of effectiveness of empiric treatment alone was based on the assumption that oral amoxicillin therapy was only 20% effective in preventing major infections after bacteremia. At higher estimates of effectiveness, treatment alone became a more viable strategy. We conclude that approaches which combine blood culture with empiric antibiotic treatment are the most clinically effective and the most cost-effective strategies for children at risk for occult bacteremia.     

Successful treatment with linezolid of meningitis complicated with subdural empyema in a 6-month-old boy

Recent findings have focused on the possible role of linezolid as a suitable candidate for the treatment of central nervous system infections. The linezolid treatment for meningitis was sporadically reported in adults but there was no report in children. Here, we present a 6-month-old boy with meningitis and subdural empyema which was unresponsive to more conventional agents but successfully treated with linezolid therapy. A previously healthy 6-month-old boy was referred to our clinic for deteriorating general condition with fever, vomiting and seizures. He had fever and tense-bulging anterior fontanelle. Based on his first cerebrospinal fluid (CSF) results, empirical antibiotic therapy for bacterial meningitis consisting of vancomycin and ceftriaxone was started. However, CSF culture yielded no micro-organisms but blood culture showed coagulase-negative Staphylococci. On the 7th day, he still had high fever and the erythrocyte sedimentation rate (ESR) and serum CRP levels had risen by 105 mm/h and 36.2 mg/dl, respectively. On 10th day, computerized cranial tomography showed bilateral frontoparietal subdural empyema. Purulent material was evacuated by burr hole, and gram stains of the material showed polymorphonuclear leukocytes and no microorganisms. Clinical and CSF findings of our case were, unresponsiveness to vancomycin, ceftriaxone and consecutive meropenem treatment while we still observed subdural empyema during these treatments. For this reason we started linezolid 10 mg/kg twice daily. Clinical signs improved dramatically, with both completely normal neurological findings and normalization of CSF and radiological findings. To the of our best knowledge, linezolid treatment of meningitis in children has not been reported previously. Clinical and CSF findings of our case were improved completely with linezolid treatment. Also, control cranial computerized tomography showed the total recovery of subdural empyema. Here we present the youngest case with meningitis which was successfully treated with linezolid treatment.     

Prognostic value of cytobiochemical changes in children with pyogenic meningitis

Thirtyeight out of fifty cases of pyogenic meningitis were followed up for an average period of 383 days to find out if cytobiochemical changes in the cerebrospinal fluid could help the physician as a dependable parameter for long term prognosis. The study revealed a bad prognosis in the form of increasing sequalae and mortality when the initial CSF cell count was > 1000 cells/ cumm with high protein and low sugar or when the cerebrospinal fluid was purulent Subsequent CSF examination after 48–96 h revealing perisistence of polymorphonuclear leucocytosis despite antibiotic therapy was associated with untoward prognosis. The favourable progress was noted when the CSF cell count was less than 1000/cu mm with an early change from polymorphonuclear leucocytosis to predominent lymphocytosis.