Comparison of cerebrospinal fluid lactate with physical, cytological, and other biochemical characteristics as prognostic factors in acute bacterial meningitis / Comparação do lactato no líquido cefalorraquidiano com as características físicas, citológicas e outros marcadores bioquímicos, como fator prognostico nas meningites bacterianas agudas

ABSTRACT Bacterial meningitis (BM) is associated with a high morbidity and mortality. Cerebrospinal fluid (CSF) lactate may be used as a prognostic marker of this condition. We hypothesized that CSF lactate levels would remain elevated in participants who died of acute BM compared with those who recovered from this disease. Objective: To evaluate the potential use of lactate and other CSF biomarkers as prognostic markers of acute BM outcome. Methods: This retrospective, longitudinal study evaluated dynamic CSF biomarkers in 223 CSF samples from 49 patients who fulfilled the inclusion criteria of acute BM, with bacteria identified by CSF culturing. The participants were grouped according to outcome: death (n = 9; 18.37%) and survival (n = 40; 81.63%). All participants received appropriate antibiotic treatment. Results: In the logistic regression model, lactate concentration in the final CSF sample, xanthochromia, and CSF glucose variation between the first and last CSF samples were predictors of a poor outcome (death). In contrast, decrease in CSF white blood cell count and CSF percentage of neutrophils, increase in the percentage of lymphocytes, and normalization of the CSF lactate concentration in the last CSF sample were predictors of a good prognosis. Conclusion: The study confirmed the initial hypothesis. The longitudinal analysis of CSF lactate is an important predictor of prognosis in acute BM.

RESUMO As meningites bacterianas (MB) estão associadas à alta morbidade e mortalidade. O lactato no líquido cefalorraquidiano (LCR) pode ser usado como biomarcador de prognóstico nas MB. A hipótese desse estudo é que os níveis de lactato no LCR se mantém elevados entre pacientes com MB aguda que evoluem para óbito, ao contrário do que ocorre em pacientes com bom prognóstico. Objetivo: Avaliar o uso potencial do lactato e outros marcadores no LCR como indicador de prognóstico na MB aguda. Métodos: Foi realizado um estudo retrospectivo longitudinal da dinâmica dos biomarcadores bioquímicos, celulares e físicos no LCR. Foram analisadas 223 amostras de 49 pacientes com MB aguda com bactérias identificadas por cultura do LCR. Os participantes foram divididos em dois grupos de acordo com o desfecho: óbito (n = 9; 18,37%) e não óbito (n = 40; 81,63%). Todos os participantes receberam antibioticoterapia adequada. Resultados: No modelo de regressão logística, as variáveis que diferiram significativamente entre os dois grupos foram concentração de lactato na amostra final de LCR, xantocromia e variação da concentração de glicose entre a primeira e a última amostra de LCR. A alteração desses fatores indicou desfechos negativos (óbito), enquanto a diminuição do número de leucócitos e da porcentagem de neutrófilos, assim como a normalização da concentração de lactato no LCR foram preditores de bom prognóstico. Conclusão: O estudo confirmou a hipótese inicial. A análise longitudinal do lactato no LCR é um importante preditor de prognóstico na MB aguda.

Fatal meningitis caused by vancomycin-resistant enterococci: Report of two cases from south India.

Vancomycin-resistant enterococci rarely cause meningitis and present a therapeutic challenge. Antimicrobial susceptibility testing was done for strains of Enterococcus species isolated from CSF samples of patients with meningitis by phenotypic methods. Multiplex polymerase chain reaction was performed to determine the genetic basis of vancomycin resistance of such isolates. We report here two cases of enterococcal meningitis caused by vancomycin-resistant Enterococcus species. One of the isolates was identified as Enterococcus faecalis and the other as Enterococcus gallinarum. We also report the simultaneous presence of vanC1 and vanA resistance genes in the strain of E. gallinarum. To the best of our knowledge, this is the first report of vanA resistance gene in an isolate of E. gallinarum from the Indian subcontinent. This is also the first Indian report of vancomycin-resistant Enterococcus causing meningitis.

Neurotrasmisores en niños con meningitis bacteriana / Neurotransmitters in children with bacterial meningitis

La meningitis bacteriana continúa siendo una enfermedad potencialmente fatal, especialmente en países en vías de desarrollo. Los aminoácidos excitatorios están fuertemente implicados en la patogénesis del daño neuronal en meningitis bacteriana. El objetivo fue medir niveles de glutamato, GABA, glicina y taurina en liquido cefalorraquídeo y correlacionarlos con el grado de severidad, complicaciones y secuelas. Estudio prospectivo en 31 pacientes con meningitis bacteriana y 10 pacientes con líquido cefalorraquídeo normal (control), con edades de 1 mes - 13 años de edad. El análisis de aminoácidos se realizó al ingreso y al tercer día mediante cromatografía líquida de alta presión. De los 31 pacientes que ingresaron al estudio 64,5 % fueron de género femenino, 13 lactantes, 8 preescolares y 10 escolares. El promedio de aminoácidos en los niños con meningitis fue más alto que en el grupo control (P<0,01). El glutamato disminuyó significativamente en pacientes con hidrocefalia. El GABA está disminuido en pacientes con parálisis cerebral y la taurina está disminuida en higroma y aumentada en lesión de pares craneales, trastornos de la conducta e hipoacusia. Los cambios en los niveles de aminoácidos en líquido cefalorraquídeo refleja el estado patológico y severidad del daño cerebral. Este estudio provee información del eventual papel de la inmunomodulación y posible uso de antagonistas de aminoácidos excitatorios, con efecto neuroprotector, en el tratamiento de meninigitis bacteriana e indica que esta clase de molécula neurotóxica puede represetar un importante blanco en la terapia adyuvante para meningitis bacteriana.

Bacterial meningitis rmains a potentially fatal disease, especially in developing countries. Exitatory amino acids are strongly implicated in the pathogenesis of neuronal damage in bacterial meningitis. To measure levels of glutamate, GABA, glycine and taurine in cerebroespinal fluid and correlate with the degree of severity, complications and sequelae. Prospective study in 31 patients with bacterial meningitis and 10 patients with normal cerebrospinal fluid (control), aged 1 month - 13 years old. Amino acid analysis was performed on admission and on the third day using high pressure liquid chromatography. Of the 31 patients entering the study 64.5 % were females, 13 infants, 8 preschoolers and 10 elementary school students. The average number of amino acids in children with meningitis was higher than in the control group (P<0.01). Glutamate levels significantly decreased in patients with hydrocephalus. GABA levels decreased in patients with cerebral pasly, and taurine diminished in hygroma, and increased in cranial nerve injury, eating disorders and hearing loss. Changes in amino acid levels in cerebrospinal fluid reflect pathological state and severity of brain damage. This study provides information on the possible role of immunomudulation and possible use of excitatory amino acid antogonists with neuroprotective effects in the treatment of bacterial meningitis, indicating that this class of neurotoxic molecules may represent important target in adjuvant therapy for bacterial meningitis.

Doença meningocócica: indicadores de gravidade e sua importância para vigilância e assistência médico-hospitalar / Meningococcal disease: indicators of severity and its importance for surveillance and hospital medical care

Descrever o comportamento da Doença Meningocócica (DM) focalizando aspectos clínicos e seus desfechos, analisar o possível impacto da descentralização da assistência hospitalar, investigando também fatores associados à sua gravidade no município de São Paulo (SP), de 1986 a 2004. Metodologia: Trata-se de um estudo de corte transversal com componente descritivo e analítico, abrangendo o período de 1986 a 2004. A população de estudo abrange pacientes de DM, residentes no município de SP, notificados à vigilância. Os dados foram obtidos junto à vigilância passiva da DM e ao Instituto Adolfo Lutz de São Paulo. A descrição da doença foi efetuada segundo aspectos relativos ao tempo, espaço e pessoa. Para a investigação dos fatores associados à gravidade da DM tomou-se como variável dependente o óbito por DM e como variável independente, as exposições de interesse. Elas foram investigadas por meio das estimativas das odds ratio não ajustadas e ajustadas pela regressão logística não condicional, com os respectivos intervalos de confiança de 95 por cento. Resultados: Foram confirmados 10.087 casos de DM no município de São Paulo, durante o período de interesse. No pico epidêmico de 1995, a taxa de incidência média da DM foi de 8,1 casos/100.000 habitantes (hab), a mortalidade de 1,8 casos/hab/ano e letalidade média de 22 por cento. Crianças menores de quatro anos foram as mais atingidas, constituindo 54 por cento dos casos, principalmente entre os menores de um ano, com taxa de incidência média de 60,1/100000 casos/hab. Em 1986, o Hospital Especializado atendia 83 por cento dos casos e os Assistenciais apenas 12 por cento. No final do período estudado (2004), com a descentralização do serviço, o Hospital Especializado passou a atendeu 22 por cento dos casos e 71 por cento dos casos os Assistenciais. O Hospital Especializado manteve a letalidade anual dos casos de DM constante durante todo período, em torno de 11 por cento...

To describe the behavior of meningococcal disease (MD) focusing on clinical features and outcomes, analyze the potential impacts of decentralization of hospital care, also investigating factors associated with the severity of MD in São Paulo (SP) city, from 1986 to 2004. Methods: This is a cross-sectional study with descriptive and analytical component covering the period 1986 to 2004. The population of the study was inhabitants in SP city, registered in the surveillance system. The data were obtained from the surveillance system of the DM MD and the Adolfo Lutz Institute of São Paulo. The descriptive analysis was presented by aspects of the time, space and person. The investigation of factors associated with the severity of the MD, it was considered as dependent variable death, and as independent variable, the exposure of interest. They were investigated by unadjusted and adjusted odds ratios by unconditional logistic regression, with their confidence intervals of 95 per cent. Results: There were 10,087 confirmed cases of MD in SP city, from 1986 to 2004. In epidemic peak (1995), the average rate of incidence of MD was 8.1 cases/100000 inhabitants (inhabit), the mortality rate was 1.8 cases/inhab/year and average case fatality rate (CFR) was of 22 per cent. Children under four years were the highest risk, representing 54 per cent of cases, especially among children under one year with average incidence rate of 60.1/100000 cases/inhab. In 1986, the specialized hospital cared 83 per cent of cases and non-specialized hospital only 12 per cent. At the end of the period studied (2004), with the decentralization of service...

Non-typhoid Salmonella meningitis complicated by a infarction of basal ganglia

A previously healthy 16-month-old Korean girl with symptoms of fever, vomiting, and generalized tonic seizure was diagnosed to have Group D non-typhoid Salmonella meningitis. The patient was treated with ceftriaxone (100 mg/kg/day) and amikin (22.5 mg/kg/day) initially and ciprofloxacin (30 mg/kg/day) was added later because of clinical deterioration and disseminated intravascular coagulation. Brain CT performed on the second day showed a well-demarcated low density lesion in the right lentiform nucleus and both caudate nuclei, without evidence of increased intracranial pressure. MRI performed on the 11th day confirmed CT scan findings as well as right subdural fluid collection, brain atrophy, and ventriculomegaly. She underwent subdural drainage and later ventriculo-peritoneal shunt operation. Despite receiving intensive treatment, she still has severe neurologic sequelae. Our case shows that infarctions of basal ganglia and thalami are not specific for tuberculous meningitis and that meningitis complicated by infarction is indicative of grave prognosis.

Fatores prognosticos na meningite pneumococcica / Prognostic factors in the pneumococcal meningites

Estudou-se 67 casos de meningite pneumococcica no Hospital Infantil Joana de Gusmao, em Florianopolis, Santa Catarina, no periodo de janeiro de 1980 a dezembro de 1989. Obteve-se um indice de letalidade geral de 26,86 por cento. Foram analisados os seguintes fatores prognosticos: idade, presenca de coma, convulsoes, pleocitose discreta no LCR, septicemia, hemiparesia, hipoglicorraquia, leucopenia e hiperproteinorraquia. Evidenciou-se correlacao estatisticamente relevante em relacao ao obito para os fatores coma, pleocitose discreta e hipoglicorraquia, em ordem decrescente de importancia, quando aplicada analise de regressao multipla.

Recurrent salmonella meningitis in a two-month old infant

Bacterial meningitis caused by Salmonella is rare and has a high fatality rate with about 75% of the reported cases below 2 years in age and a peak incidence below 3 months. We report here a case with two recurrences after therapy