Comparison of Scrub Typhus Meningitis with Acute Bacterial Meningitis and Tuberculous Meningitis

Objective

To compare scrub typhus meningitis with bacterial and tuberculous meningitis.

Methods

Children aged<15 years admitted with meningitis were screened and those who fit criteria for diagnosis of scrub typhus meningitis (n=48), bacterial meningitis (n=44) and tuberculous meningitis (n=31) were included for analysis. Clinical features, investigations and outcomes were compared between the three types of meningitis.

Results

Mean age, duration of fever at presentation, presence of headache and, altered sensorium and presence of hepatomegaly/splenomegaly were statistically significantly different between the groups. Scrub typhus had statistically significant thrombocytopenia, shorter hospital stay and a better neurological and mortality outcome.

Conclusions

Sub-acute presentation of meningitis in older age group children, and good outcome is associated with scrub typhus when compared to bacterial and tuberculous meningitis.

     

儿童结核性脑膜炎的诊断和治疗

结核性脑膜炎是严重威胁儿童生命健康的神经系统感染性疾病.在小儿肺外结核病中结核性脑膜炎是最常见的,尽管目前开展了足量的化疗,结核性脑膜炎仍有高发病率和病死率的特点.虽然近年来研究者从细菌学、分子生物学及免疫学等方面对小儿结核性脑膜炎的诊断进行了研究,但均末获得突破性进展,对小儿结核性脑膜炎的诊断仍依靠综合分析患儿的临床特点以及通过辅助检查的结果判断.早期及时诊断和完善的治疗是降低结核性脑膜炎病死率及后遗症发生率的关键.     

以呕吐为首发症状的结核性脑膜炎16例

目的探讨以呕吐为首发症状的结核性脑膜炎的临床特点,提高对结核性脑膜炎的认识。方法回顾分析1997～2005年天津市儿童医院就诊的16例以呕吐为首发症状的结核性脑膜炎患儿的临床资料,包括病史、血液及脑脊液检测、影像学检查、治疗及转归。结果以呕吐首发的结核性脑膜炎入院前误诊率高,小婴儿呕吐发生率低,当以呕吐为突出症状就诊时,多数病程已在中至晚期。较大年龄组呕吐症状出现较早,预后较婴幼儿好。结论对于有呕吐症状的患儿,要引起足够的重视,其中部分患儿是由结核性脑膜炎所致,避免漏诊、误诊。     

脑脊液置换联合鞘内注射药物治疗中晚期儿童结核性脑膜炎的疗效

目的 探讨脑脊液置换联合鞘内注射药物治疗中晚期儿童结核性脑膜炎的疗效.方法 选择2005年1月-2010年 4月本院收治住院的64例中晚期结核性脑膜炎患儿,随机分为治疗组和对照组各32例.对照组予常规抗结核药物治疗,治疗组在常规抗结核药物治疗基础上行脑脊液置换,并鞘内注射抗结核药物,治疗8周后对比2组治疗效果.结果 治疗组治愈24例,好转 5例,无效 2例,死亡1例,总有效率为90.6%;对照组治愈17例,好转5例,无效7例,死亡2例,总有效率为68.8%.2组总有效率比较差异有统计学意义(χ2=4.729,P<0.05).结论 脑脊液置换联合鞘内射注药物治疗中晚期儿童结核性脑膜炎疗效好,且不良反应少.     

Results of the Treatment of 191 Children with Tuberculous Meningitis in the Years 1949–54

The primary series of 191 children treated for tuberculous meningitis at the Children's Hospital, University of Helsinki, in 1949–54 is analysed to provide a background for the 103 recoveries who were given a thorough follow-up examination. The incidence of patients under 12 months of age was 12.5 per cent, and of those under 2 years of age 44.6 per cent. The youngest patient to recover was 7 weeks of age when tuberculous meningitis was diagnosed. The treatment schedules followed were mainly those used in the centres of D ebré and C occhi , although some personal modifications were introduced and new trends adopted.
The primary mortality rate dropped to 11 per cent in the last years from the high figure of 75 per cent in the first year of the streptomycin era. However, late mortality up to 3 1/2 years after discontinuing the treatment increased the final, total mortality rate of the series to 44.5 per cent. This emphasizes the importance of long-term treatment, which is now the generally accepted method in the treatment of tuberculous meningitis.     

Late Otological Sequelae of Tuberculous Meningitis

An otological follow-up study in 1956 and 1959—62 of 103 children treated for and cured of tuberculous meningitis in 1949—54 is presented. Impaired hearing was observed in 63 per cent, severe loss of hearing in 15 per cent and total deafness in 7 per cent. In 36 per cent there was a hearing loss of more than 10 dB in the speech range (500—2,000 cps). The initial and the follow-up results of otological investigations were in close accordance with each other — only in 3 cases was there some improvement and in 11 some deterioration of hearing. The cases with hearing loss were evenly distributed between the different age groups excepting the youngest one — 0—12 months — which displayed a considerably lower frequency of impaired hearing as a whole but a much higher frequency of severe hearing loss. There was no correlation between hearing sequelae and the duration of meningeal symptoms prior to hospitalization or the severity of the disease on admission. There was, however, a correlation between the frequency of hearing sequelae and the daily and total doses of streptomycin given: the frequency of hearing loss was 49 per cent (severe hearing loss 22 per cent) when 50 mg/kg daily was used compared with an incidence of 15 per cent (severe hearing loss in 4 per cent) when 10—20 mg/kg of streptomycin was used intramuscularly and 1—3 mg/kg intrathecally daily.
No correlation was found between loss of hearing and neurological, mental, eye or EEG disturbances.
Disturbances of vestibular function were found in 54 per cent altogether and they were severe in 31 per cent.
Five of the 15 children with severe hearing loss used hearing aids with considerable success, 3 got along without them in ordinary schools and 10 children attended schools for the deaf.     

Late Neurological Sequelae of Tuberculous Meningitis

The neurological findings in a follow-up study of 103 children treated for and cured of tuberculous meningitis in 1949—54, are presented. Fifty children were found to be free of late neurological sequelae, 29 had minor neurological sequelae including 2 with cranial nerve palsies, nystagmus, and ataxia, 13 with mild disturbances of coordination and 10 with symptoms of upper motor neuron lesion without subjective complaints. Gross neurological sequelae were found in 22 cases, including 8 with spastic palsies, 9 with spastic palsies and convulsions, and 5 with convulsions without spastic palsies. Two children were found to have sequelae of spinal lesions; one had paraplegia and the other disturbance of sensation on the dorsum of the left foot. Fourteen children had convulsions.     

Late Ophthalmological Sequelae of Tuberculous Meningitis

One hundred and three patients who had recovered from tuberculous meningitis in 1949—54 were thoroughly re-examined ophthalmologically an average of 8 1/2 years (range 6—12 1/2 years) after recovery. One blind patient and one with severe visual impairment were found. In addition to these, a number of cases with ophthalmological sequelae of minor importance were found; partial structural and functional lesions of the optic nerve were found in 17 cases (including 1 case with associated abducens nerve palsy), nystagmus was found in 2, pupillary disturbances in 6 and scars of choroidal tubercles in 16 cases. Thus 36 cases (35 per cent) showed ophthalmological sequelae of the past illness. Permanent visual disability was found in the 2 cases mentioned above, both of them being late cases with a high block treated with trephination. Of the other sequelae of the disease only intracranial calcification showed some degree of correlation with the ophthalmological sequelae.     

Modern Treatment and Late Prognosis of Tuberculous Meningitis

Certain controversial subjects in the treatment of tuberculous meningitis are analyzed, amongst them intrathecal administration of streptomycin, the toxicity of isoniazid, long-term treatment with INH, and the etiological role of the primarily resistant strains of tubercle bacilli. The corticoid problem is given special consideration and the possibility of iatrogenic late sequelae due to corticoids is discussed at length. The importance of proper neurosurgical management in cases with increased intracranial pressure and signs of block formation and the value of preventive measures, like BCG vaccination, chemoprophylaxis and isolation are also stressed.
In addition, the methods of treatment presently employed at the Children's Hospital are presented in detail and certain therapeutical problems are discussed in this connection. The recent results, from the years 1956—62, are outlined. Finally, in the late prognosis of the survivors of tuberculous meningitis the emphasis is laid upon certain sociomedical aspects and the children are grouped into: Group A — 50 –60 per cent — fully recovered individuals with no handicaps; Group B – 30—40 per cent — individuals with minor handicaps requiring efficient rehabilitation and special training but with a favourable socio-medical prognosis when given these; and Group C — 10 per cent — severely handicapped individuals at the mercy of the domestic environment and or the community.     

Late Psychological and Psychiatric Sequelae of Tuberculous Meningitis

The psychological and psychiatric sequelae of tuberculous meningitis in 103 children were studied by thorough clinical follow-up examinations at the Children's Hospital, University of Helsinki, and extensive correspondence with the parents and teachers of the children. Forty five per cent of the series were found to be of subnormal or borderline intelligence. The achievements of those attending school were, on the whole, comparable with those of the siblings and classmates. Only 4 children were found to be severely mentally disturbed — of these 1 has greatly improved in the last 2 years — and 17 were slightly disturbed. Mental retardation was found to be more frequent in the youngest age groups (under 3 years of age) and social re-adjustment problems more frequent in the older age groups, particularly the school-age children. The latter seemed to pose the major problems in this series, especially the cases with major intellectual, sensory or motor handicaps.     

神经元特异性烯醇化酶对脑膜炎患儿的诊断价值

目的探讨脑脊液神经元特异性烯醇化酶(CSF-NSE)对脑膜炎患儿的诊断价值。方法采用ELISA对18例化脓性脑膜炎(化脑)、13例结核性脑膜炎(结脑)及25例病毒性脑膜炎(病脑)及18例正常儿童CSF-NSE进行测定。结果与对照组比较,化脑及结脑患儿CSF-NSE水平均显著升高(P均<0.05);病脑患儿无显著性差异(P>0.05);化脑及结脑患儿CSF-NSE水平较病脑患儿显著升高(P<0.05);化脑、结脑、病脑患儿CSF-NSE与其CSF白细胞数及蛋白水平均无相关性(P>0.05)。结论CSF-NSE测定可作为鉴别化脑和病脑的重要参考指标之一,也可作为评价脑膜炎患儿病情严重程度及预后的生化指标。     

隐球菌性脑膜炎预后的相关因素

目的探讨影响隐球菌性脑膜炎预后的相关因素。方法对1986~2004年确诊为隐球菌性脑膜炎13例患儿进行回顾性分析。结果在疗效成功的8例中,两性霉素B(Amp B)联用氟胞嘧啶(5-FC)和(或)氟康唑治疗效果肯定,其中6例联合鞘内注射给药,1例经Ommaya囊侧脑室放液给药术。5例死亡,影响预后的因素主要有诊断延误,病情进展快,早期未合理使用抗真菌药物,未及时鞘注和施行Ommaya囊侧脑室放液给药术。结论早期诊断,早期合理使用抗真菌药物,早期采用鞘内注射给药和经Ommaya囊侧脑室放液给药,可显著改善本病预后。