Predictors of long term neurological outcome in bacterial meningitis

Objective To study the long-term neurological and developmental outcome and the clinical and laboratory predictors of sequelae in children with acute bacterial meningitis (ABM). Methods Detailed clinical and demographic data was retrieved from the medical records of study children. Subsequently they were followed up for a minimum of 12 months after discharge for development, neurological and hearing assessment. All sequelae were identified and divided into minor or major. For analysis data was divided into 2 groups those with sequelae and without sequelae at follow-up. Statistical analysis was done using SPSS version 10.00 and Epi Info version 2000. Results 61 boys and 19 girls, a mean age of 31.4±41.9 months at the time of ABM, were included in the study. Of these 62.5% children were infants. Mean age at follow-up was 58.6 ± 47.2 months. Sequelae were observed in 32 (40%) children (8 (10%) minor and 24 (30%) major). Mean social quotient at follow-up was 92.8 ± 32.6. Developmentally 22 (37.9%) children were normal and 20 (34.5%) had global delay. Seizures (P=0.015), cranial nerve palsy (P=0.0065), abnormal deep tendon reflexes (P=0.002), Glasgow coma scale score (GCS) < 8 (P = 0.044) at admission, a CSF culture positive for bacteria and abnormal findings on ultrasonography or computed tomography of head at admission had significant association with sequelae at follow-up. All children (7/7) who had infarct on CT scan (P=0.001) and 12 (80%) of 15 patients who had hydrocephalus (OR-9.0, 95% Cl-2.03-45.6, P=0.001) diagnosed on CT scan developed severe sequelae. On multiple regressions GCS score <8, presence of cranial nerve palsy and abnormal deep tendon reflexes were independent predictors of sequelae. Conclusion Neurological and audiological sequelae and global developmental delay may be seen in about one third of survivors of bacterial meningitis. GCS score <8, presence of infarct or cranial nerve palsy, or hydrocephalous on CT/ultrasound at admission may help in identification of children most likely to need long term follow up and rehabilitation.     

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.     

Management of children with aseptic meningitis in the emergency department.

OBJECTIVE: To review the emergency department management of children with aseptic meningitis and compare the clinical features, laboratory findings, and short-term follow-up of those who were hospitalized or discharged to determine guidelines for discharge. DESIGN: Retrospective chart review study. SETTING: Emergency department of an inner-city teaching, level III, children's hospital during an outbreak of aseptic meningitis from, March through December 1993. METHODS: The medical records of children < or = 18 years of age diagnosed in the emergency department with aseptic meningitis after lumbar puncture were retrospectively reviewed and analyzed. Thirty-four parameters were recorded for each child including demographic (2), epidemiologic (5), clinical (2), laboratory (10), and short-term follow-up data (5). RESULTS: Of the 158 eligible patients, 99 (62.7%) were hospitalized, and 59 (37.3%) were discharged. Compared to the hospitalized group, children who were discharged were significantly older (5.7 years vs. 4.7 years, P < 0.05) and experienced a more benign course, with lower rates of headache (54.7 vs. 85.7%, P < 0.05), vomiting (38.2 vs. 69.7%, P < 0.05), and irritability (1.8 vs. 8.1%, P < 0.05). They also had significantly (P < 0.05) lower mean peripheral and cerebrospinal fluid leukocyte counts (13,233 vs. 11,498/mm3 and 293.91 vs. 105.29/mm3, respectively). Interestingly, 30 (50.8%) of children in the discharged group had over 50% polymorphonuclears in their cerebrospinal fluid (CSF) cell count. The hospitalization rate during the day was significantly (P < 0.05) lower than that for the evening and night shifts (51.5 vs. 66.7%, respectively). In the discharged group, symptoms of headache, fever, and vomiting resolved after an average of 3.05 days, 2.25 days, and 1.3 days, respectively. The average hospitalization time was 3.5 days. There were no significant complications in either group. More important, in neither group were there any misdiagnoses of bacterial meningitis as aseptic meningitis. During the study period, the ambulatory management of the 59 patients cost $51,625 less than the hospitalization of an equal number of children. CONCLUSION: It is feasible, clinically safe and less costly to treat a subgroup of children with aseptic meningitis in an ambulatory setting. Although absolute criteria for ambulatory follow-up could not be defined, age >1 year, a nontoxic clinical appearance, normal white blood cell count, mild cerebrospinal fluid pleocytosis (even with a high percentage of polymorphonuclear cells), negative CSF Gram stain, and a reliable family setting could serve as guidelines for decision-making regarding emergency department discharge. Further prospective research is needed to better specify these criteria.     

儿童结核性脑膜炎近期预后的影响因素

目的：探讨影响儿童结核性脑膜炎（TBM）近期预后的因素。方法：采用回顾性病例分析的方法,收集2007年1月至2011年2月137 例住院治疗的TBM患儿的临床资料,对30个可能影响近期预后的因素进行了单因素及多因素logistic回归分析。结果：137例TBM患儿中,临床分期为早、中、晚期病例分别为21例（15.3%）、67例（48.9%）、49例（35.8%）。单因素分析显示TBM的临床分期为晚期、昏迷、Babinski征阳性、颅神经损害、肢体瘫痪、抽搐、头颅CT或MRI明显异常、脑脊液蛋白量升高等因素与近期预后不良有关;而糖皮质激素的使用、PPD皮试反应阳性、住院时间延长与预后良好有关。多因素分析显示：临床分期为晚期（OR=11.168,95%CI 3.521~35.426）和脑膜刺激征阳性（OR=4.275, 95%CI 1.043~17.521）是影响TBM近期预后的危险因素,而住院时间延长（OR=0.893, 95%CI 0.825~0.968）是影响近期预后的保护因素。结论：TBM患儿出现脑膜刺激征及临床分期越晚提示预后不良,适当的延长住院时间有利于改善近期预后。     

Long-term outcome for children with bacterial meningitis in rural Papua New Guinea

This study was undertaken to evaluate the long-term neurological outcome for survivors of bacterial meningitis in rural Papua New Guinea. Children who were discharged from Nonga Base Hospital in Rabaul with a diagnosis of bacterial meningitis between 1992 and 2000 were evaluated in their home villages or on review at hospital. Neurological and developmental complications were documented. The outcomes for 80 of 121 eligible children were determined; eight had died following hospital discharge and 41 were lost to follow-up. Major neurological sequalae were found in 50 (63 per cent) of surviving children, and 27 (34 percent) had multiple severe complications. In rural Papua New Guinea meningitis causes high rates of mortality and severe long-term disability in a high proportion of survivors. High-level resistance to chloramphenicol is likely to be part of the reason for this, but widespread availability of third-generation cephalosporins for the treatment of meningitis, although urgently required, will not overcome the other problems of delayed presentation with established complications. There is a need for the introduction of conjugate Haemophilus influenzae vaccine, and affordable vaccination strategies against Streptococcus pneumoniae. Richer countries could sponsor these vaccines in developing countries, and apply pressure on vaccine producers to lower the costs.     

Factors influencing outcome of cardiopulmonary resuscitation in children

We evaluated 47 pediatric patients after cardiopulmonary arrest. Patients entered the study with the onset of advanced life support. We followed them until death, or discharge from the hospital, occurred. We identified three groups of patients: long-term survivors, who survived to discharge, short-term survivors, who survived longer than 24 hours after CPR but not until discharge, and nonsurvivors, who died within 24 hours of their arrest. All of the long-term surviving patients were discharged from the hospital without gross neurologic deficit attributable to the arrest or resuscitation effort. Twenty-seven (57%) children were successfully resuscitated. Eighteen (38%) were long term-survivors, while nine (19%) were short-term survivors. Favorable outcome is associated with the following factors: inhospital arrest, extreme bradycardia as the presenting arrhythmia, successful resuscitation with only ventilation, oxygen and closed chest massage, and a duration of CPR of less than 15 minutes. Age, sex, and race, as well as pupillary reaction and motor response at the onset of advanced life support, did not correlate with long-term survival.     

Arthritis in children with bacterial meningitis

Forty-eight patients with arthritis and meningitis were identified by hospital chart review among 2,089 cases of bacterial meningitis treated between 1969 and 1984. The etiologic agents were Haemophilus influenzae in 38 cases (79%), Neisseria meningitidis in nine cases (19%), and Staphylococcus aureus in one case (2%). Thirteen patients had more than one joint affected: two affected joints, ten patients; three affected joints, two patients; and four affected joints, one patient. The elbow (34%) and knee (29%) were most frequently affected. Joint-fluid aspirations were done in 44 patients; 22 cases (50%) had bacteria or bacterial antigen identified in joint fluid by culture, Gram's stain, or counter-immunoelectrophoresis: H influenzae (20 cases), N meningitidis (one case), and S aureus (one case). Of the 48 patients, 14 patients were noted to have arthritis at the time of diagnosis of meningitis, 16 patients on the first to sixth day, and 17 patients on the seventh day of treatment or later; one patient developed arthritis 12 days after treatment of H influenzae meningitis had been stopped. Fourteen cases with a culture-proved bacterial etiology of the arthritis developed arthritis within four days of treatment; the exception was a patient who developed arthritis after treatment of meningitis was stopped. Of the 21 patients with culture-negative joint fluid and who developed arthritis later in the course of treatment, 19 patients were considered to have possible immune complex arthritis. Management consisted of antibiotic therapy in all patients, open incision and drainage in 17 patients (36%), and multiple aspirations in 12 patients (25%). Of the remaining 19 patients, 15 patients had a single arthrocentesis performed and four patients had no aspiration. Early-onset arthritis appeared to be related to bacteremia whereas late-onset arthritis may be immune complex mediated.     

Identifying children with pneumonia in the emergency department

Emergency physicians need to clinically differentiate children with and without radiographic evidence of pneumonia. In this prospective cohort study of 510 patients 2 to 59 months of age presenting with symptoms of lower respiratory tract infection, 100% were evaluated with chest radiography and 44 (8.6%) had pneumonia on chest radiography. With use of multivariate analysis, the adjusted odds ratio (AOR) and 95% confidence intervals (CI) of the clinical findings significantly associated with focal infiltrates were age older than 12 months (AOR 1.4, CI 1.1-1.9), RR 50 or greater (AOR 3.5, CI 1.6-7.5), oxygen saturation 96% or less (AOR 4.6, CI 2.3-9.2), and nasal flaring (AOR 2.2 CI 1.2-4.0) in patients 12 months of age or younger. The combination of age older than 12 months, RR 50 or greater, oxygen saturation 96% or less, and in children under age 12 months, nasal flaring, can be used in determining which young children with lower respiratory tract infection symptoms have radiographic pneumonia.     

Lipoprotein alterations in children with bacterial meningitis

Abnormalities in serum lipids, including hypertriglycerideinia, are common during infectious disorders. However, the lipoprotein pattern during infections, particularly in children, has been investigated to only a limited extent. We have monitored alterations in serum lipoproteins in eight children with a severe baclcrial infcction (meningitis) by a quantitating method measuring cholesterol and triglyccrides in each major class. The levels of triglyccrides in serum and in low-density lipoproteins were markedly elevated during the infection, whereas the amount of cholesterol in high-density lipoprotcins was decreased. The cholesterol to triglyceride ratio was decreased in low-, as well as in high-density lipoproteins. These lipoprotein abnormalities may, at least in part, be explained by a depressed lipolytic activity of lipoprotein lipasc, the key enzyme for removal of triglycerides in man. Serum triglycerides and the levels of cholesterol in high-density lipoproteins, as well as the ratio between these parameters, may be used as indicators of inflammatory activity.     

Lipoprotein alterations in children with bacterial meningitis

Abnormalities in serum lipids, including hypertriglycerideinia, are common during infectious disorders. However, the lipoprotein pattern during infections, particularly in children, has been investigated to only a limited extent. We have monitored alterations in serum lipoproteins in eight children with a severe baclcrial infcction (meningitis) by a quantitating method measuring cholesterol and triglyccrides in each major class. The levels of triglyccrides in serum and in low-density lipoproteins were markedly elevated during the infection, whereas the amount of cholesterol in high-density lipoprotcins was decreased. The cholesterol to triglyceride ratio was decreased in low-, as well as in high-density lipoproteins. These lipoprotein abnormalities may, at least in part, be explained by a depressed lipolytic activity of lipoprotein lipasc, the key enzyme for removal of triglycerides in man. Serum triglycerides and the levels of cholesterol in high-density lipoproteins, as well as the ratio between these parameters, may be used as indicators of inflammatory activity.     

Poison exposure and outcome of children admitted to a pediatric emergency department

Background  

This paper reports the characteristics, outcomes and clinical features of children with poisoning treated at an emergency department (ED).