Group B Streptococcal Meningitis in a 5-year-old boy

Group B Streptococcus (Streptococcus agalactiae) is a well-known cause of early and late onset infections in neonates and very young infants. Recently attention has focused on the changing spectrum of invasive Group B Streptococcus (GBS) disease, including children beyond early infancy and non-pregnant adults. There is very little information available on invasive GBS infection especially meningitis in pediatric population older than three months of age. We report a case of uncomplicated meningitis due to GBS in a previously healthy 5-year-old boy. The literature on infection especially meningitis caused by Group B Streptococcus beyond infancy is reviewed.     

Uncommon clinical presentation of a common bug: Group A Streptococcus meningitis

Group A Streptococcus (GAS) is a common pathogen in paediatric infections. However, it is a rare etiologic agent of bacterial meningitis. We describe a case of Streptococcus pyogenes meningitis complicated by sensorineural hearing loss in an immunocompetent 7-year-old boy. Clinicians should be aware of GAS as a potential cause of paediatric meningitis, especially with prominent symptoms suggestive of frontal sinusitis. Meningitis caused by GAS has been shown to be associated with significant mortality and morbidity, including neurological complications. Early screening for sensorineural hearing loss in patients with GAS meningitis can facilitate timely cochlear implant.     

Streptococcus pneumoniae sepsis in the newborn

Background: Streptococcus pneumoniae (SP) is an uncommon cause of neonatal sepsis. Aims: To report on the spectrum of morbidity associated with SP infections in the neonatal period. Methods: A case series of SP infection in the neonatal period was studied. Maternal and neonatal outcomes were noted. Results: Four cases of neonatal SP infection are reported, one of which was due to a strain with reduced susceptibility to penicillin. All four cases had very early onset of severe clinical disease with bacteremia and pneumonia. In one case a retrospective diagnosis of meningitis was made as well. Maternal illness was a feature in one of these infants. Conclusions: Although less common now than in the pre‐antibiotic era, Streptococcus pneumoniae remains a rare but important cause of neonatal sepsis and can mimic early onset Group B streptococcal sepsis. It is unclear whether current infant or adult pneumococcal immunisation programs might influence its incidence in the neonatal period. The potential for strains with reduced susceptibility to β‐lactam antibiotics to cause neonatal infection needs to be considered in relevant settings.     

Possible Role of Streptococcus Pyogenes in Mucocutaneous Lymph Node Syndrome

Migration inhibitory factor (M1F)-induced activity of patients with mucocutaneous lymph node syndrome (MCLS) to antigens associated with Streptococcus pyogenes infection was compared to that of control populations consisting of children with illnesses not related to streptococcal infections (group A), and of patients with streptococcal pharyngitis (group B), with the following results. 1. Though a consiaerable number of patients in the acute state of MCLS failed to respond to antigens consisting of (1) a coccus preparation of S. pyogenes (Picibanil), (2) streptococcal pyrogenic exotoxin (SPE) and (3) an extract from cells of a virally transformed human B-cell line, a complete restoration of their responsiveness was observed in parallel with the decrease of fever. 2. While almost all patients of group A were refractory not only to Picibanil and SPE but also to the extract from the transformed human cells, some children with infections due to intracellular microbes showed responsiveness to the extract from the transformed cells. 3. In group B, some patients showed a marked responsiveness and the other a complete refractoriness to these antigens throughout the observation period. These results raise the possibility that S. pyogenes may play a principal role in the pathogenesis of MCLS.     

Streptococcus gallolyticus subsp. pasteurianus meningitis in an infant

Streptococcus gallolyticus subsp. pasteurianus was formerly classified as S. bovis biotype II/2, which is recognized as a rare cause of neonatal sepsis and meningitis. Since the taxonomy classification change, there have not been many reports of meningitis due to S. gallolyticus subsp. pasteurianus. Moreover, the pathogenesis of late onset S. gallolyticus subsp. pasteurianus meningitis in infants is unclear. Here we report a case of meningitis in a 5‐week‐old infant with preceding diarrhea. S. bovis biotype II/2 was isolated from the blood, cerebrospinal fluid and stool, and then was identified as S. gallolyticus subsp. pasteurianus on 16S rRNA gene sequencing. Isolates from all three sample types had identical profiles on pulsed‐field gel electrophoresis. The intestinal tract was thought to be the source of the infection.     

Haemolytic-uraemic syndrome associated with Streptococcus pneumoniae meningitis

We report the first case of Haemolytic-uraemic syndrome (HUS) associated with Streptococcus pneumoniae meningitis. This supports a common pathogenic mechanism in HUS following infections by neuraminidase-producing organisms and in pneumococcal meningitis. We recommend that HUS must be considered in cases of renal failure and/or anaemia associated with pneumococcal meningitis, and that bacterial meningitis be considered in all patients with HUS and central nervous system involvement.Abbreviations CSF cerebrospinal fluid - HUS haemolyticuraemic syndrome - RBC red blood cells - T-ag Thomsen-Friedenreich antigen     

Possible Role of Streptococcus pyogenes in Mucocutaneous Lymph Node Syndrome. XV. Potential Utility of Streptococcal Pyrogenic Exotoxin Toxoid for the Prophylaxis and Treatment of MCLS

Mice made tolerant to streptococcal pyrogenic exotoxin (SPE) by neonatal inoculation with SPE emulsified in incomplete Freund's adjuvant demonstrated early thrombocytopenia followed by thrombocytosis. This state is the perfect counterpart of patients with mucocutaneous lymph node syndrome (MCLS). We have hypothesized that by inducing tolerance to SPE, the biological activities of the toxin might play leading roles in the pathogenesis of MCLS. In the present investigations, the efficacy of SPE on the prophylaxis and treatment of diseases caused by Streptococcus pyogenes (including MCLS) were monitored using the murine model system accompanied with a platelet-counting technique. The mice, rendered tolerant due to neonatal SPE inoculation and followed by immunization with SPE toxoid about 1 month prior to the provocative injections with SPE, demonstrated an almost complete lack of response to the provocation, keeping platelet counts within the normal range of values (except for a marginally significant thrombocytosis 7 days postprovocation). Moreover, anti-SPE titers of the sera from the mice sacrificed on day 35, at which point the observation was terminated, were proved to be markedly elevated when compared with controls. These findings seem to suggest that immunization with the toxoid could overcome tolerance, resulting in the production of an antitoxin. In a second experiment that examined the effect of administration with rabbit antiserum raised against the toxoid, the antiserum-treated mice demonstrated a transitory thrombocytosis on 7 days postprovocation with SPE, followed by an abrupt decrease in the number of platelets from day 10 onward. Such a finding was in complete agreement with that observed in tolerant mice administered with antiserum specific for SPE, suggesting a strong neutralizing activity against SPE of the antitoxoid serum. A third experiment evaluated the effect of F(ab')₂ fragments of the rabbit antiserum to the toxoid on platelet activity. The tolerant mice passively administered i.v. with the F(ab')2 fractions demonstrated a complete lack of responsiveness, except for a small thrombocytosis on days 7 and 10.     

Recurrent Streptococcus pneumoniae meningitis in a child with traumatic anterior cranial base defect

Acute bacterial meningitis is a potentially life-threatening infection of the cranial and spinal leptomeninges. Recurrent episodes of meningitis are rarely seen, but when they occur, an extensive investigation has to be made to find out responsible factors. A single episode of acute meningitis may result from bacteriemia, but when followed by recurrent meningitis in pediatric patients, other possible routes of the bacteria invasion to the cerebrospinal fluid (CSF) should be considered. Patients with head injury have the highest risk of acquiring recurrent bacterial meningitis, followed by patients with a congenital anatomic lesion of the skull or duramater, such as meningomyelocele. The underlying cause is a transdural communication between the meningeal space and paranasal sinuses or skin. The first attack of meningitis may occur several weeks to 12 years after the head injury. In addition, recurrent bacterial meningitis may be due to disorders of the immune system, such as complement deficiency. We report a 14-year-old boy, who suffered from recurrent Streptococcus pneumoniae meningitis due to a well-defined defect at the ethmoid roof after a head trauma.     

A retrospective epidemiological study of bacterial meningitis in an urban area in Belgium

In order to obtain epidemiological data on the incidence of bacterial meningitis (BM) before the systematic introduction of vaccination against Haemophilus influenzae type b, a retrospective study of 124 children with proven BM was performed in an urban area in Belgium. N. meningitidis was the most prevalent cause, followed by H. influenzae and S. pneumoniae. Over a period of 6 years the incidence of BM increased ten fold, mainly due to an increase in N. meningitidis. The median age of the children with BM was 17 months and 35% of those with H. influenzae were younger than 1 year. Significant risk factors for BM as a whole were: age under 1 year, male gender, non-Caucasian descent and winter time. These findings may have implications for future vaccination policy in Belgium. Conclusion Future vaccination schemes in Belgium should take into account that N. meningitis was the prevalent cause of bacterial meningitis and that certain factors increase the risk for developing bacterial meningitis. Received: 26 February 1996 / Accepted: 14 October 1996     

Possible role for a polysaccharide antigen shared between Streptococcus pyogenes and S. mutans in the pathogenesis of poststreptococcal glomerulonephritis

Streptococcus mutans has been shown to share a polysaccharide (PS) antigen with S. pyogenes strains isolated from patients with acute poststreptococcal glomerulonephritis (PSGN), using a monoclonal antibody f-77 reactive with the PS.¹ To investigate the pathogenetic role of the shared PS in PSNG experimental nephritis was induced in animals. Rats were immunized thrice with heat-killed cells of S. mutans or S. pyogenes, followed by an intravenous injection of live cells of S. pyogenes. Histologic examination showed that both animal groups had comparable degrees of diffuse proliferative nephritis characterized by immune deposits. The shared PS antigen was detected in glomeruli of all nephritic rats by immunofluorescence using monoclonal antibody f-77. Furthermore, all nephritic rats had an elevated antibody titer to the shared PS antigen. These results suggest that prior sensitization (infections such as dental caries) to S. mutans modulates immune responses to subsequent S. pyogenes infections and induces immune-complex disease (PSGN) through the shared PS antigen.     

Characteristics of Streptococcus pyogenes strains isolated from Chinese children with scarlet fever

Aim: To analyse the characteristics of Streptococcus pyogenes isolates from Chinese children with scarlet fever. Methods: Minimal inhibitory concentration with nine antibiotics was performed on 145 Streptococcus pyogenes isolates acquired from Beijing and Shanghai in 2007. Their macrolide‐resistant genes (mefA, ermB and ermA– a subclass of ermTR), superantigens (speA and speC), and en‐coding mature M protein gene (emm gene) were amplified by PCR. Results: A total of 97.9% of the isolates exhibited resistance to the macrolides, while 96.6% manifested resistance to tetracycline. All isolates were sensitive to chloramphenicol, penicillin, cefradine, and ofloxacin. Moreover, 94.5% exhibited a cMLSB phenotype, while 90.3% had the ermB gene. Five emm types (emm1.0, emm4.0, emm12.0, emm22.0 and st5240) were discovered, of which 9.7% carried the superantigen speA, 35.9% carried the speC, 42.8% carried both speA and speC and 11.7% carried neither speA nor speC. Finally, 85.5% of emm1.0 and 15.5% of emm12.0 isolates carried speA, while 79.0% of emm1.0 and 75.9% of emm12.0 isolates carried speC. Conclusion: The Streptococcus pyogenes isolates had high resistance rates against macrolides and tetracycline. They mainly expressed the ermB gene type and cMLSB phenotype. Their common emm types are emm1.0 and emm12.0, which have different frequencies of speA and speC.     

Neonatal Escherichia coli meningitis: spinal adhesions as a late complication

We describe two boys who had severe spinal complications in adolescence after a favorable initial recovery from neonatal Escherichia coli meningitis. Due to spinal granulomatous adhesions, one boy died after an attempted scoliosis operation (high cord lesion). The other showed severe progressive neurological deterioration with spinal and cerebellar symptoms. Conclusion The severe complication of chronic arachnoiditis with spinal adhesion may occur many years after neonatal acute bacterial meningitis. Received: 7 October 1998 / Accepted: 1 May 1999     

Bacterial antigen detection test in meningitis

Objective : To evaluate the role of bacterial antigen detection test in cerebrospinal fluid (CSF) for a rapid etiological diagnosis of bacterial meningitis.Methods : The study included 36 cases of bacterial meningitis and 14 controls. Latex particle agglutination test (LPA test) for detection of bacterial antigen was done in the CSF using slidex meningitis kit (Biomeriux, France).Results : Using LPA test, an etiological diagnosis could be made in 83% cases of bacterial meningitis. In contrast, CSF Gram stain and culture showed 36% and 6% positivity, respectively. The sensitivity and specificity of LPA test were 83% and 100%, respectively. The common etiological organisms were S.pneumoniae, H. influenzae type b andN. meningitidis A. S. pneumoniae was encountered in all age groups whileH. influenzae type b was found only below one year of age.Conclusions : LPA test is a rapid and superior diagnostic tool as compared to CSF Gram stain and culture. The study recommends LPA test as an adjunct laboratory test for rapid etioiogical diagnosis of bacterial meningitis for prompt institution of proper antibiotics.     

Pasteurella multocida meningitis in infancy – (a lick may be as bad as a bite)

Pasteurella multocida is the commonest cause of local infection after an animal bite, but is an unusual cause of meningitis. We report a case of P. multocida meningitis occurring in a 7-week-old infant which was contracted after non-traumatic contact with a household pet, that is, without any animal bite or scratch. The organism may be easily confused with more common Gram-negative pathogens. In this case, it was initially incorrectly diagnosed as Haemophilus influenzae type b (Hib); a possibility which has important implications in the era of routine use of Hib vaccine in infant immunisation programs. Conclusion Pasteurella multocida is an unusual, but serious cause of meningitis in infancy. It is potentially preventable by the avoidance of contact between young infants and the saliva of household pets, in particular by assiduous hand hygiene. Received: 13 March 1998 / Accepted in revised form: 17 February 1999     

Bacterial meningitis in India: An IJP survey

Conclusions It can be concluded that bacterial meningitis is an important cause of childhood morbidity and mortality. Isolation of causative pathogenes is poor in our country. A routine gram staining of CSF and use of rapid diagnostic kits with better culture facilities would be helpful in improving the outcome. In first 3 months of life, therapy should include one of the 3rd generation cephalosporins with an aminoglycoside. For meningitis in age groups between 3 months to 12 years, chloramphenicol and ampicillin should be the first line empirical therapy. If gram-ve organisms are suspected or isolated, one of the 3rd generation cephalosporins with or without an aminoglycoside is good alternative. The treatment can be stopped in uncomplicated case after 7–10 days (5 days of afebride period) in meningitis caused by meningococcus, pneumococcus andH. infuenzae. For BM caused by gram-ve bacilli treatment for 21 days is recommended. There is no need to perform CSF examination at the conclusion of therapy in cases of bacterial meningitis beyond neonatal period. There is a need to further evaluate therapeutic regimens like chloramphenicol alone, ceftriaxone home therapy, especially for rural areas etc. to decrease the cost of hospitalisation in referral hospitals.     

Group C streptococcal meningitis: case report and review of the literature

Group C streptococci are a common cause of epidemic bacterial infection in animals. These organisms are a rare but frequently fatal cause of meningitis in humans. We report the case of a 13-year-old girl with meningitis caused by a group C Streptococcus (Streptococcus zooepidemicus) successfully treated with vancomycin and third generation cephalosporins. We also review cases of group C streptococcal meningitis reported previously.     

Interleukin-8 levels in children with bacterial,tuberculous and aseptic meningitis

Objective : Interleukin-8 (IL-8) is produced in monocytes and vascular endothelial cells in response to stimulation with bacteria or lipopolysaccharides, and is released from these cells into blood stream or tissue fluid.Methods Cerebrospinal fluid (CSF) levels of interleukin-8 in 56 children with nonbacterial, bacterial and tuberculous meningitis (TBM), and in 15 control subjects were analyzed to evaluate the involvement of this cytokine in the pathogenesis acute bacterial meningitis and their discriminative value between different etiologies of meningitis. The kinetics of IL-8 concentrations during the course of bacterial meningitis was also evaluated in patients. IL-8 levels were significantly higher in bacterial and TBM than in aseptic meningitis and in control subjects (p<0.0001).Results: There was no difference in the levels of IL-8 between the non-bacterial meningitis and control groups. The analysis of the kinetics of production of IL-8 in patients with bacterial meningitis showed that the SSF concentrations of this cytokine decreased to undetectable values in recovery stage. Conversely in patients with TBM the concentrations of IL-8 were elevated in two weeks after beginning the specific treatment.Conclusion : The results suggest that determining IL-8 levels may be useful in the differential diagnosis.     

Rapid diagnosis of bacterial meningitis by using multiplex PCR and real time PCR

BACKGROUND: The purpose of the present study was to improve a method for a rapid identification of bacteria in bacterial meningitis by using multiplex polymerase chain reaction (PCR). METHODS: Ten species of bacteria which cause meningitis in children were investigated, and cerebrospinal fluid from patients with purulent meningitis was studied. The ribosomal RNA genes of bacteria are essential, and are highly conserved in the bacterial kingdoms with consensus region. The 23S rRNA region shows a larger variation among species than in the 16S rRNA region. The authors set primers in the universal region and specific region of 23S rRNA, then amplified these regions by multiplex PCR and real-time PCR. RESULTS: All species of bacteria showed one band by PCR using universal primer. Haemophilus influenzae and Streptococcus pneumoniae showed two bands by multiplex PCR using a combination of universal primers and specific primers. The authors detected H. influenzae within 15 min by using real-time PCR. CONCLUSION: It was possible to identify clinically significant bacterial species in cerebrospinal fluid by multiplex PCR, and to identify H. influenzae by real-time PCR within a short period.     

Bacterial meningitis following introduction of Hib conjugate vaccine in northern Uganda

BACKGROUND: St Mary's Hospital, Lacor is in Gulu district in northern Uganda. Owing to conflict and insurgency, the majority of the hospital population live in internally displaced people's camps. There is ongoing public health surveillance of paediatric bacterial meningitis by the hospital. Before the introduction of Haemophilus influenza type b (Hib) conjugate vaccine in June 2002, Hib was the leading cause of bacterial meningitis in the area. METHODS: All patients with suspected bacterial meningitis between April 2003 and August 2006 were recruited. Meningitis was confirmed by isolation of bacteria. RESULTS: During the study period, 4986 cases of suspected bacterial meningitis were identified, 395 of whom had purulent cerebrospinal fluid (CSF). A culture was obtained from 259 (65%): Streptococcus pneumoniae 132 (51%), H. influenzae 22 (8.5%), salmonella spp 85 (32.8%), Neisseria meningitidis 9 (3.5%) and others 11 (4.2%). Over the surveillance period, there was a remarkable decline in the prevalence of H. influenza meningitis to only three cases or fewer per year compared with 42 in 2001. The minimum incidence of Streptococcus pneumoniae meningitis among children under 5 years of age was 33.7/100,000 of population and it was more prevalent during the dry season. The minimum incidence of non-typhoidal salmonella spp meningitis was 22.7/100,000, making it the second most common cause of paediatric bacterial meningitis with a case fatality rate of 18.2%. CONCLUSION: Hib conjugate vaccine delivered through the national immunisation programme is very effective in reducing Hib meningitis in children under 5 years of age. Continued laboratory-based surveillance of bacterial meningitis in Africa is needed to assess the effectiveness of vaccination programmes and detect other vaccine-preventable pathogens.