Nitric oxide production during bacterial and viral meningitis in children.

Nitric oxide is very likely to play a role in physiopathological mechanisms of bacterial meningitis. As shown by in vitro studies, nitric oxide is toxic to endothelial cells, as well as to neurones, and thus may be responsible for neurological sequelae in bacterial meningitis. Increased level of nitric oxide can also inhibit mitochondrial respiration, enhancing anaerobic glycolysis. Twenty-seven children with documented bacterial meningitis, 73 with viral (mumps and enteroviral) meningitis, and 51 controls were studied. All children with bacterial meningitis were given cefotaxime (200 mg/kg per day). Glucose and protein concentrations and cerebrospinal fluid cell counts were determined routinely, as well as nitrite and nitrate levels. The levels of nitrite and nitrate in cerebrospinal fluid on admission were higher in patients with bacterial meningitis than in controls or in children with viral meningitis. In 10 patients, dexamethasone therapy (0.4 mg/kg every 12 h for 2 days) was started about 10 min before the first antibiotic dose. A significantly lower nitrite concentration was observed after 24-48 h of treatment compared with non-steroid-treated patients. Significant positive correlations between the nitrite and granulocyte counts and the protein concentration in cerebrospinal fluid were found in all patients with meningitis. Increased nitric oxide production in cerebrospinal fluid during the acute phase of bacterial meningitis may result from the inflammatory process and tissue injury. Dexamethasone administered before the first parenteral antibiotic dose seems to reduce nitric oxide production in the cerebrospinal fluid during bacterial meningitis.

[The thyroid function in children with viral meningitis]. / Czynnosc tarczycy u dzieci chorych na wirusowe zapalenie opon mózgowo-rdzeniowych.

Thyroid function was investigated in children affected with viral meningitis caused by Mumpsvirus or enteroviruses. Serum or plasma levels of thyroid-stimulating hormone (TSH), triiodothyronine (T3), free triiodothyronine (FT3), thyroxine (T4) and free thyroxine (FT4) were measured twice in course of the disease: at admission and at recovery (day 10-14 from the onset of illness). The levels of hormones were measured by radioimmunoassay (RIA) or by enzyme linked fluorescent assay (ELFA). A decrease in serum or plasma concentrations of TSH, T3, FT3 and T4 (T4--only when measured by RIA) was found at the beginning of illness as compared to the controls, which indicates the low-T3 syndrome in children with viral meningitis. These disturbances were present also at recovery. When comparing thyroid function in children suffering from bacterial and viral meningitis, a more significant decrease in the levels of thyroid hormones (especially T3 and FT3) was found at the beginning of bacterial than viral meningitis. Un resolved questions are the causes and the importance of low-T3 syndrome in children with viral meningitis.

[The thyroid function in children with purulent meningitis]. / Czynnosc tarczycy u dzieci chorych na ropne zapalenie opon mózgowo-rdzeniowych.

Purulent meningitis (BM) is a complex process and its outcome is largely influenced by host's response, both inflammatory or endocrine, to the infection. In this study thyroid function in children with BM was investigated by measuring serum or plasma levels of thyroid-stimulating hormone (TSH), triiodothyronine (T3), free triiodothyronine (FT3), thyroxine (T4) and free thyroxine (FT4) 3 times in course of the disease: at admission, after 24-48 hrs. of treatment and at recovery (day 10-14 from the onset of the disease). The levels of hormones were measured by radioimmunoassay (RIA) or by enzyme linked fluorescent assay (ELFA). A decrease in serum or plasma concentrations of all measured hormones was found at the beginning of BM as compared to the controls. This indicates the low T4 variant of sick euthyroid syndrome in children with BM, which usually occurs in seriously ill patients. The levels of measured hormones rose at recovery in comparison to their initial values, but T3 concentrations and TSH (TSH - measured by RIA) were still lower in comparison to the controls. Serum T3 concentrations were significantly lower in children with sequelae of BM than in children who recovered without sequelae. This indicates a possible adverse effect of disturbed thyroid function resulting in low-T3 syndrome on the outcome from BM. An adjunctive anti-inflammatory treatment with dexamethasone started 10-15 minutes before the first antibiotic dose and, given every 12 hrs in a dose of 0.4 mg/kg for 2 days, it resulted in greater decrease in T3, FT3, T4 and FT4 plasma levels in comparison to non-steroid treated children.

[Supportive (antiinflammatory) treatment of bacterial meningoencephalitis with dexamethasone]. / Wspomagajace (przeciwzapalne) leczenie bakteryjnego zapalenia opon mózgowo-rdzeniowych i mózgu, ze szczególnym uwzglednieniem deksametazonu.

With improved understanding of the pathophysiology of bacterial meningitis, a number of points in the deleterious inflammatory cascade have been identified as possible sites for modulation. Dexamethasone attenuates tissue injury by inhibiting host mediators at several steps in the inflammatory process. Animal and clinical trials have demonstrated that adjunctive corticosteroid therapy reduces the production of cytokines in the CSF. This results in decreased severity of the inflammatory process and fewer neurologic sequelae. However, routine use of steroids adjunctive treatment of bacterial meningitis remains controversial. Data support the use of adjunctive corticosteroid therapy in children with S. pneumoniae and H. influenzae type b meningitis. There is not sufficient evidence supporting the use of adjunctive corticosteroid therapy in patients with meningitis caused by N. meningitidis, which is the main cause of purulent meningitis in Poland. Also, the routine use of the dexamethasone in children and adult meningitis in Poland cannot presently be recommended. When using dexamethasone timing and dosage seems to be crucial. Administration before or with antibiotics is optimal for attenuating the subarachnoid space inflammatory response. The host's inflammatory response can be accompanied by the neuroendocrine response which is complex and its mediators are not well understood. Data indicate that the large component of the neuroendocrine response (e.g. inadequate secretion of ADH and large adrenocortical stress response) adversely affects the outcome from bacterial meningitis. So, the modulating effect of dexamethasone on both inflammatory and neuroendocrine response may be beneficial in bacterial meningitis and can probably be, achieved with sufficiently high dose of dexamethasone w has not yet been specified. Based on present pathophysiological and pharmacokinetic data, and to achieve maximum benefits and minimum complications, dexamethasone therapy started 10 min before the first dose of antibiotic and given every 12 h for only 2 days in a dose 0.8 mg/kg/day is suggested. Future studies of the pathogenesis and pathophysiology of bacterial meningitis may lead to the development of other adjunctive treatment strategies, improving the outcome of this serious disease.

[Nitric oxide (NO) in children with meningitis]. / Tlenek azotu (NO) w zapaleniu opon mózgowo-rdzeniowych u dzieci.

Twenty seven children with a documented bacterial (BM)-, 73 with viral (mumps and enteroviral) meningitis and 51 controls were included. CSF white blood cell counts, glucose and protein concentrations were determined routinely. CSF nitrite and nitrate levels (the stable degradation product of NO) were determined by a modified Griess reaction. The mean +/- levels of nitrite and nitrate in CSF on admission were higher in patients with BM in comparison with controls and in children with viral meningitis. In 10 patients dexamethasone therapy was started about 10 minutes before the first antibiotic dose and given every 12 hours of 0.4 mg/kg for 2 days. At 24 to 48 hours those who received dexamethasone therapy had a significantly lower mean +/- SD CSF nitrite concentration compared with that in non-steroid treated patients. In all patients with meningitis a significant positive correlation was found between CSF nitrite and CSF granulocyte counts and also CSF protein concentration. Increased production of NO in the CSF compartment during the acute phase of BM may contribute to the inflammatory process and tissue injury. Dexamethasone therapy administered before the first parenteral antibiotic dose reduces the production of NO in the CSF during BM.

[Diagnostic value of rapid streptococcal antigen test provided by Abbott "test pack strep A": current report]. / Ocena wartosci diagnostycznej pakietu testowego "Test packstrep A" firmy Abbott--doniesienie wstepne.

The upper respiratory tract infections are the most frequent infectious diseases in human. Beta haemolytic streptococcus group A is the most common etiologic factor of bacterial pharyngitis. Delayed or inadequate treatment of streptococcal pharyngitis can cause serious subsequent complications. Only a part of patients show typical features of the disease so that the diagnosis can be based on clinical appearance alone. For this reason we propose direct antigen test as a rapid useful method which allows detection of group A streptococci in throat swabs. The aim of the study is to estimate clinical value of rapid antigen test in differential diagnosis of pharyngitis in children and adults. We have performed 50 tests using commercial kit--Abbott Test Pack Strep A. Simultaneously conventional bacterial throat cultures were performed. The comparison of results acquired by both methods did not revealed any differences.

[Beta 2 microglobulin in children with neuroinfections]. / Beta2 mikroglobulina w neuroinfekcjach u dzieci.

CSF and plasma beta2 microglobulin (B2M) concentrations were determined by an enzyme linked fluorescent assay (ELFA) (Vidas-bioMerieux) in children with bacterial (B2M), viral (mumps and enteroviral) meningitis and in the controls. CSF B2M concentrations in children with B2M at admission, at 24-48 hrs of treatment and at recovery (day 10), in children with viral meningitis at admission and at recovery were significantly higher in comparison with the control group of children with non-pleiocytic CSF. The levels of CSF B2M at 24-48 hrs of treatment of B2M cases were significantly higher than those at the beginning of both mumps and enteroviral meningitis cases which may be helpful in differential diagnosis of meningitis, especially in cases of retarded diagnosis or partially treated B2M. Plasma levels of B2M during bacterial and mumps meningitis did not differ from those in healthy children but in children with enteroviral meningitis were significantly higher. There was a positive correlation between CSF B2M at the beginning of B2M and some laboratory findings of inflammatory response (CRP, ERS). The CSF B2M levels were significantly higher than its plasma levels in patients with B2M at 24-48 hours (second stage) of disease, mumps meningitis on admission and recovery which may suggest intrathecal production of B2M during central nervous system infection.

[Herpes simplex meningoencephalitis in an infant observed during an epidemic of enteroviral infections of the nervous system]. / Opryszczkowe zapalenie opon mózgowo-rdzeniowych i mózgu u niemowlecia, obserwowane w czasie epidemii neuroinfekcji enterowirusowych.

An infant with Herpes simplex meningoencephalitis which occurred during an epidemic of enteroviral neuroinfections is described. Clinical and laboratory signs of meningitis as well as preceding aphtous oropharyngeal inflammation, initially suggested an enteroviral etiology. The appearance of signs of encephalitis with focal neurologic disturbances and the results of brain imaging by computed tomography, primarily the detection of temporoparietal areas of hypodensity, raised the possibility of HSV infection. Thanks to early specific treatment with acyclovir, the infant recovered from meningoencephalitis and 4 months later presented only minor neurological sequelae (slight left hemiparesis). The diagnosis of Herpes simples meningoencephalitis was confirmed by detecting IgM and IgG anti-HSV antibodies in the serum and cerebrospinal fluid both at the beginning and after 10 days of treatment and also by a eightfold rise of the anti-HSV-1 antibody level in serum. The authors emphasize the role of brain imaging (computed tomography and magnetic resonance) in the differential diagnosis of viral nervous system infections and suggest early treatment with acyclovir in case of suspicion of HSV-encephalitis.

[Diagnostic problems in pediatric tuberculosis: a description of two cases]. / Problemy diagnostiyczne gruzlicy wieku dzieciecego--opis dwóch przypadków.

This paper describes two cases of tuberculosis (tbc) in children in whom tbc was misdiagnosed and who were initially treated with antibiotics (and corticosteroids) as for non-specific lower respiratory tract infections. Chest radiograms, good response to antituberculosis drugs (in both children), bacteriologic and histologic examinations and a history of family contact with infectious tbc (in case I) confirmed the diagnosis of tbc. We suggest that the most important factor in rapidly diagnosing tuberculosis is a high index of suspicion in children with respiratory tract infections.

[Mucocutaneous lymph node syndrome (Kawasaki disease) in 2 children]. / Zespól skrno - sluzówkowo - wezlowy (choroba Kawasaki)u 2 dzieci.

Two children with Kawasaki disease (KD), a girl 3 yrs. and a boy 2.5 yrs., were described. The children met all criteria for the diagnosis of KD (fever, conjunctivitis, oral changes, extremity changes, rash, lymphadenopathy), and other diseases were excluded. In both children or one of them other clinical and laboratory findings occasionally detected in KD were observed: arthralgia, hepatomegaly and splenomegaly, slight elevation of transaminases and bilirubin level, slight elevation of CSF pleocytosis, sterile pyuria and hematuria. Electrocardiograms revealed sinus tachycardia and transient disturbances of heart repolarization. In both children changes in blood morphology and biochemical disturbances typical for inflammatory processes were noted. Thrombocytosis was seen in the 2nd week of the illness in the child in whom platelet counts were controlled. The child in whom diagnosis of KD was established in the first week of symptoms was treated with acetylsalicylic acid along with an oral penicillin. A child with retrospectively diagnosed KD was treated with antibiotics and corticosteroids. Clinical and laboratory findings of KD resolved in both children within 4-6 weeks without complications from coronary blood vessels.

[Systemic candidiasis with meningeal involvement in a newborn infant]. / Kandydoza narzadowa z zajeciem opon mózgowo-rdzeniowych u noworodka.

The newborn with sepsis (E. coli) and salmonellosis was described. After treatment with broad-spectrum antibiotics it was suffered from Candida albicans (Meningitis with Hydrocephalus internus, Chorioretinitis and Ostitis). The authors difficulties connected with diagnosis and anti-fungal therapy have showed. They have punctated the necessity of combined anti-mycotic therapy.

[Intravenous catheters (venflons) in children as a possible cause of hospital infections]. / Cewniki dozylne (wenflony) u dzieci jako mozliwa przyczyna zakazenia szpitalnego.

The authors made 106 cultures from the endings of intravenous catheters used in children hospitalized in the teaching hospital in the years 1987-88. In 30 cases (28%) the cultures were positive. The most common cultures were those of Staphylococcus and Micrococcus. No correlation was found between the time of keeping a catheter in the vein and the number of positive cultures from the catheter. The children not receiving antibiotics had 2.6 as many positive cultures as those receiving antibiotics.

Humoral and cellular immunity in infants infected with Salmonella typhimurium.

In infants carriers of Salmonella typhimurium IgA, IgG, IgM and IgD-level in serum was increased as compared with acute period of illness. In the acute state of salmonellosis an increase of lymphocytosis especially of B lymphocytes was observed. The absolute value of T lymphocytes was increased but their percentage was decreased. The levamisole therapy was not effective. On the 2nd day after administration of concentrated IgA preparation (Behringwerke), 20 mg/kg b.w., a rise of IgA level in the stool and saliva was observed.