Seizures in adults with bacterial meningitis.

OBJECTIVE: To evaluate the occurrence and prognostic relevance of seizures in adults with community-acquired bacterial meningitis. METHODS: An observational cross-sectional study, in which patients with seizures are selected from a prospective nationwide cohort of 696 episodes of community-acquired bacterial meningitis, confirmed by culture of CSF in patients aged >16 years. We retrospectively collected data on EEGs. RESULTS: Seizures occurred in 121 of 696 episodes (17%). Death occurred in 41% of patients with seizures compared to 16% of patients without seizures (p < 0.001). The median number of seizures was 2 (interquartile range [IQR] 1 to 4). The median time between admission and the first seizure was 1 day (IQR 0 to 3). Patients with in-hospital seizures were more likely to have a CSF leukocyte count below 1,000 cells/mm(3) (36% vs 25%; p = 0.01), had higher median CSF protein levels (4.8 g/L [IQR 3.4 to 7.6] vs 4.1 g/L [IQR 2.1 to 6.8]), and higher median erythrocyte sedimentation rate (46 mm/hour [IQR 31 to 72] vs 36 mm/hour [IQR 18 to 69]; p = 0.02) than patients without in-hospital seizures. Focal cerebral abnormalities developed more often in patients with in-hospital seizures than in those without (41% vs 14%; p < 0.001). In a multivariate analysis, seizures were significantly more likely in patients with predisposing conditions, tachycardia, a low Glasgow Coma Scale score on admission, infection with Streptococcus pneumoniae, and focal cerebral abnormalities. Neuroimaging was performed on admission in 70% of episodes with prehospital seizures, with CT revealing a focal lesion in 32% of those episodes. Antiepileptic drugs were administered in 82% of patients with seizures and EEG was performed in 31% of episodes; a status epilepticus was recorded in five patients. CONCLUSIONS: Seizures occur frequently in adults with community-acquired bacterial meningitis. Seizures are associated with severe CNS and systemic inflammation, structural CNS lesions, pneumococcal meningitis, and predisposing conditions. The high associated mortality rate warrants a low threshold for starting anticonvulsant therapy in those with clinical suspicion of a seizure.

Nosocomial bacterial meningitis in adults: a prospective series of 50 cases.

In order to evaluate characteristics of nosocomial meningitis in adults, we performed a prospective cohort study of 50 episodes of nosocomial bacterial meningitis. These cases were confirmed by culture of cerebrospinal fluid (CSF) in patients aged >16 years. Classic symptoms of bacterial meningitis (headache, neck stiffness and fever) were present in >70% of the episodes, although only a minority (41%) presented with impairment of consciousness. Underlying conditions, such as a history of neurosurgery, recent head injury, CSF leakage or a distant focus of infection, were present in 94% of the episodes. Staphylococcus aureus was the most common pathogen in patients with a history of neurosurgery, causing 10 of 32 episodes (31%). Patients with a distant focus of infection, such as otitis, sinusitis or pneumonia were more likely to have meningitis due to Streptococcus pneumoniae than patients without [six of nine episodes (67%) vs seven of 41 (17%); P=0.01]. Complications occurred in 50% of the episodes and 16% of the patients died. Our study confirms that adults with nosocomial meningitis are a distinct patient group with specific bacterial pathogens, as compared to those with community-acquired bacterial meningitis. Underlying conditions, especially a history of neurosurgery or a distant focus of infection, were present in the large majority of patients, and mortality and morbidity rates were high.

Dexamethasone treatment in adults with pneumococcal meningitis: risk factors for death.

In experimental meningitis, adjunctive treatment with steroids reduces cerebrospinal fluid inflammation and thereby improves neurological outcome. On the basis of these findings, several clinical trials have assessed treatment with adjunctive steroids in bacterial meningitis, with conflicting results. Recently, the results of the European Dexamethasone Study showed a beneficial effect of adjunctive dexamethasone in adults with bacterial meningitis. In that study, the effect of dexamethasone on outcome was most striking in patients with pneumococcal meningitis. The aim of the present study was to further evaluate the effect of dexamethasone in adults with pneumococcal meningitis by performing a post hoc analysis of the European Dexamethasone Study. In a multivariate analysis, tachycardia (p=0.02), advanced age (p=0.03), low score on the Glasgow Coma Scale (p=0.03), positive blood culture (p=0.04), and absence of dexamethasone therapy (p=0.05) were independent predictors for death. Patients who were treated with adjunctive dexamethasone were less likely to develop both systemic and neurological complications during hospitalisation, compared with patients who received placebo. In conclusion, independent risk factors for death in pneumococcal meningitis are tachycardia, advanced age, low level of consciousness, bacteraemia, and absence of dexamethasone therapy. Treatment with adjunctive dexamethasone in adults with pneumococcal meningitis reduces both systemic and neurological complications.

[Headache and impaired consciousness due to the spontaneous intracranial hypotension syndrome]. / Hoofdpijn en verminderd bewustzijn veroorzaakt door het spontane liquorhypotensiesyndroom.

A 51-year-old man presented with a 6-week history of progressive headache, confusion and ataxic gate. The symptoms were not preceded by trauma or lumbar puncture. A CT-scan of the brain revealed bilateral subdural fluid accumulation and hyperdensities in the subarachnoid space. In view of the signs of a subarachnoid haemorrhage, angiography was performed but showed no indications of an aneurysm. An MRI-scan of the head revealed abnormalities in line with intracranial hypotension. CT-myelography of the whole spine revealed a cerebrospinal fluid leak at the level of the fifth and sixth thoracic vertebrae. The patient recovered completely after placement of an epidural blood patch at this level. Spontaneous intracranial hypotension shows clinical similarities with the symptoms following a lumbar puncture. In most cases it can be treated by conservative measures. However, invasive measures are sometimes necessary to close the defect in the meninges.

Psychometric properties of the Subjective Well-Being Under Neuroleptics scale and the Subjective Deficit Syndrome Scale.

RATIONALE: Subjective experience of antipsychotic drugs is relevant for medication compliance and quality of life. There is, however, sparse knowledge about the assessment of subjective experience. OBJECTIVES: To examine the internal consistency, test-retest reliability, sensitivity to medication change and concurrent validity of two test instruments: the Subjective Well-Being Under Neuroleptics (SWN) and the Subjective Deficit Syndrome Scale (SDSS). METHODS: Both instruments were used at admission and after 6 weeks of medication stabilization in 105 consecutively admitted patients diagnosed with DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th edn) diagnoses of recent-onset schizophrenia, schizophreniform disorder or schizoaffective disorder. RESULTS: Almost all patients were capable of reproducing their subjective experience in a consistent way both before and after medication stabilization. The internal consistency of both instruments was high. The test-retest reliability was high if medication was not changed, especially for the SWN. The SWN was sensitive for changes in medication and dosage. The short form of the SWN (SWN-20 items) had comparable psychometric qualities to the original instrument (SWN-38 items). The concurrent validity of the SWN and the SDSS was good, indicating that both tests measure the same concept. CONCLUSIONS: The assessment of subjective experience with the SWN (both versions) may be used in evaluating differential effects of anti-psychotics and dose on subjective well-being.

[Hyperactive behavior in adults; possibly attention deficit/hyperactivity disorder (ADHD)]. / Druk gedrag bij volwassenen; mogelijk aandachtstekort-hyperactiviteitstoornis (ADHD).

Two men aged 34 and 41 years, respectively, displayed hyperactive and chaotic behaviour. On the basis of the symptoms and their effect on the patients' functioning during childhood and adulthood, the diagnosis of attention deficit/hyperactivity disorder (ADHD) was made. The patients became calmer with methylphenidate treatment, but a few months later they chose to stop taking the medication and to accept their hyperactive behaviour. To establish the diagnosis of ADHD in adults, it is essential that some of the symptoms started before seven years of age and that the symptoms and resulting impairment persist over time from childhood into adulthood. To investigate this, it is necessary to obtain heteroanamnestic information from the parents or other people who knew the patient at that age. Treatment with medication and psychoeducation is effective and can prevent further suffering.