[Identification of infection agent in diagnostic material from patients with suspicion of enteroviral meningitis]

Clinical diagnosis of enteroviral infections of the central nervous system are performed by virus isolation in sensitive cell lines and RT-PCR assay. The aim of the study was evaluation these techniques for fast diagnosis meningitis caused by enteroviruses. 69 samples (cerebrospinal fluid, CSF) were collected and analised by RT-PCR reaction. 39 samples were positive (56.5%). 20 positive sample were selected and simultaneously 20 stool samples from the same patients were collected for virus isolation in sensitive cell line. Positive isolation was observed only in one CSF (5.3%) and in 9 stool samples (45%).

[Diagnostics of selected viral infections of central nervous system]

Viral infections of CNS are difficult to diagnose, especially in an early phase. In diagnosis, beside the examination of the cerebrospinal fluid, many other diagnostic tools are used, such a serological tests (in cases with TBE suspicion), PCR (in cases with CMV, VZV, HSV, WNV, enteroviruses infection), CNS imaging and EEG (in cases with HSE, VZV infection). Properly chosen diagnostic tools may result in fast diagnosis and proper treatment.

Viral infections of the central nervous system: a case-based review

Three patients with viral infections of the central nervous system (CNS) were evaluated on an inpatient infectious diseases consultation service within a two-week period. These cases, caused by herpes simplex virus, varicella zoster virus and enterovirus, highlight the importance of viral pathogens in causing debilitating infections of the CNS and provide examples of the utility of molecular diagnostics in evaluating patients with encephalitis and meningitis. The importance of antiviral therapy is particularly underscored by these cases, as is the variability in response of patients to such agents.

Epidemiology of meningitis in Oman, 2000-2005

We reviewed the epidemiologic features and trends for 771 cases of meningitis in Oman from January 2000 to December 2005. We found 69% were bacterial in origin and 13% were viral. Leading bacterial pathogens included Haemophilus influenzae (15%), Streptococcus pneumoniae (14%) and Nesseria meningitidis (12%). For 56% of patients with suspected pyogenic meningitis, no specific bacterial pathogen could be identified. Peak occurrence was in children under 2 years old. The incidence of H. influenzae type b decreased by almost 100% after implementation of the national immunization programme in 2001, while the incidence of cases caused by S. pneumoniae and N. meningitidis remained steady.

[A case of meningo-encephalitis due to West Nile virus in Libreville, Gabon]

Acute forms of meningo-encephalitis due to West Nile virus are rare. The purpose of this report is to describe the first case of acute meningoencephalitis due to West Nile virus diagnosed in Gabon. The patient was a 20-year-old Gabonese man. Diagnostic was confirmed by molecular biology. The patient died 12 days after admission to the hospital. This case is discussed based on a review of the literature.

Diagnosis of neurological herpesvirus infections: real time PCR in cerebral spinal fluid analysis

Human herpesviruses (HHVs) cause many serious acute and persistent central nervous system (CNS) disorders. Because these infections manifest with various, often non-specific, symptoms and signs, and because specific therapy is often available, accurate diagnosis is essential. Cerebrospinal fluid (CSF) from 146 patients with acute meningitis or meningoencephalitis and 9 with "other neurological disorders" were analyzed by using an automatic system for nucleic acid extraction and quantitative real-time polymerase chain reaction (PCR) for herpes simplex 1 and 2 (HSV-1, HSV-2), Epstein-Barr virus (EBV), human cytomegalovirus (HCMV), herpesvirus-6 (HHV-6), and varicella-zoster virus (VZV). HHVs DNA was detected in 52 of 155 (33.5%) analyzed samples. In 39 CSF samples from patients with meningoencephalitis we found: VZV in 13, HSV-1 in 12, EBV in 6, HHV-6 in 4, and HSV-2 in 4. Co-infections of EBV and HSV-2, HSV-1 and HSV-2, HSV-1 and VZV were also disclosed in four cases. In addition, two patients with Guillain-Barré syndrome had HCMV and one showed HHV6 positivity, two patients with myelitis / polymyeloradiculitis had VZV and HCMV respectively, HHV-6 DNA was found in one patient with lateral amyotrophic sclerosis. Three CSF specimens from HIV-infected patients with CNS complications had HHV-6 or EBV DNA. Moreover quantitative data were also correlated to clinical conditions to obtain more information on the virus aetiopathogenic role.

CSF lactate level: a useful diagnostic tool to differentiate acute bacterial and viral meningitis

OBJECTIVES

To evaluate the potential role of CSF lactate level in the diagnosis of acute bacterial meningitis and in the differentiation between viral and bacterial meningitis.

METHODS

This was a hospital based observational study, conducted at Infectious Diseases Unit, Rashid Hospital Dubai, United Arab Emirates, from July 2004 to June 2007. The patients with clinical diagnosis of acute bacterial meningitis and who had CSF Gram stain/culture positive, CSF analysis suggestive of bacterial meningitis with negative Gram stain and culture but blood culture positive for bacteria and patients with clinical diagnosis suggestive of viral meningitis supported by CSF chemical analysis with negative Gram stain and culture as well as negative blood culture for bacteria were included in the study. CT scan brain was done for all patients before lumber puncture and CSF and blood samples were collected immediately after admission. CSF chemical analysis including lactate level was done on first spinal tap. The CSF lactate level was tested by Enzymatic Colorimetric method.

RESULTS

A total 95 adult patients of acute meningitis (53 bacterial and 42 viral) fulfilled the inclusion criteria. Among 53 bacterial meningitis patients, Neisseria meningitides were isolated in 29 (54.7%), Strept. Pneumoniae in 18 (33.96%), Staph. Aureus in 2 (3.77%), Klebsiell Pneumoniae in 2 (3.77%), Strept. Agalactiae in 1 (1.8%) and E. Coli in 1 (1.8%). All the patients with bacterial meningitis had CSF lactate > 3.8 mmol/l except one, whereas none of the patients with viral meningitis had lactate level > 3.8 mmol/l. The mean CSF lactate level in bacterial meningitis cases amounted to 16.51 +/- 6.14 mmol/l, whereas it was significantly lower in viral group 2.36 +/- 0.6 mmol/l, p < .0001.

CONCLUSION

CSF lactate level was significantly high in bacterial than viral meningitis and it can provide pertinent, rapid and reliable diagnostic information. Furthermore, CSF lactate level can also differentiate bacterial meningitis from viral one in a quick and better way.

Differential diagnosis of acute central nervous system infections in children using modern microbiological methods

AIM

Except bacterial meningitis, the agents causing acute central nervous system (CNS) infections in children are disclosed in only approximately half of the cases, and even less in encephalitis. We studied the potential of modern microbiological assays to improve this poor situation.

METHODS

In a prospective study during 3 years, all children attending hospital with suspected CNS infection were examined using a wide collection of microbiological tests using samples from the cerebrospinal fluid, serum, nasal swabs and stool.

RESULTS

Among 213 patients, 66 (31%) cases suggested CNS infection and specific aetiology was identified in 56 patients. Of these microbiologically confirmed cases, viral meningitis/encephalitis was diagnosed in 25 (45%), bacterial meningitis in 21 (38%) and neuroborreliosis in 9 (16%) cases while 1 child had fungal infection. In meningitis patients, the causative agent was identified in 85% (35/41) cases and in encephalitis in 75% (12/16). The most common bacteria were Streptococcus agalactiae, Streptococcous pneumonie and Neisseria meningitidis, while the most frequently detected viruses were enteroviruses and varicella zoster virus.

CONCLUSION

In 75% to 85% of paediatric CNS infections, specific microbiological diagnosis was obtained with modern laboratory techniques. The results pose a basis for prudent approach to these potentially serious diseases.

Serum S100B levels in patients with cerebral and extracerebral infectious disease

S100B has been shown to increase in cerebrospinal fluid (CSF) and serum after various neurological diseases and it has been postulated that S100B could serve as a serum marker for brain damage. However there is limited information concerning serum S100B levels in infectious diseases of the brain. Blood samples were collected from patients at the Department of Infectious Diseases at or soon after admission. The different diagnoses studied were bacterial meningitis, pneumonia, viral meningitis, cerebral abscess, enteritis, erysipelas, viral encephalitis and neuroborreliosis. A serum S100B level > 0.15 microg/l was defined as increased. 57 patients were included in the study. S100B was elevated in 33% of patients (19/57). 73% (8/11) of patients with bacterial meningitis showed increased levels compared to 7% (1/14) of patients with viral meningitis. Viral encephalitis showed the highest mean S100B levels (mean 0.58 microg/l). 25% (6/24) of patients with extracerebral infections showed raised S100B levels. S100B levels were generally higher in patients with cerebral infections than in extracerebral infections. However, both false negative and false positive S100B levels were observed which may limit the use of S100B as a brain specific serum marker.

A case of meningoencephalitis associated with G1P[8] rotavirus infection in a Japanese child

We report the case of a 2-y, 11-month-old boy with G1P[8] rotavirus infection accompanied by acute meningoencephalitis. Substitutions in both the VP4 and VP7 genes were found in the identified strain. A commonly circulating G1P[8] rotavirus with such mutations might be associated with the pathogenesis of CNS complications, including meningoencephalitis.

[Analysis of 62 adult patients with viral meningitis]

OBJECTIVE

To investigate the clinical manifestation, cerebrospinal fluid (CSF) and auxiliary examination findings of adult viral meningitis.

METHODS

62 adult patients with viral meningitis were retrospectively analyzed.

RESULTS

Headache occurred in all the 62 (100%) patients, fever occurred in 61 (98%) patients, meningeal irritation sign occurred in 48 (77%) patients. The abduction of left eye was limited in one patient. Seizure occurred in 2 patients. The mean duration time was 17 days, 93% patients less than 30 days. The pressure of CSF increased in 80% patients, leukocyte counts increased in 91% patients, protein level increased in 81% patients, chloride level was normal in 35% patients and slightly lower in 65% patients, glucose level was normal in 94% patients. 7 patients had positive IgM antibody of Coxackievirus B group both in serum and CSF, one patient had positive IgM antibody of EB virus in CSF. Cranial CT scan had no special findings in all patients. 23 patients performed MRI examination, meningeal enhancement occurred in 9 patients. 52% patients had abnormal EEG, mainly increased local or diffuse slow waves.

CONCLUSION

Adult viral meningitis was a kind of self-limited disease, chloride level was slightly lower in more than half patients, meningeal enhancement was detected in MRI in part patients.

An assessment of the necessity of lumbar puncture in children with seizure and fever

OBJECTIVE

It is frequently thought that lumbar puncture (LP), is a mandatory procedure in all children who have fever and a seizure; because a convulsion may be the sole clinical manifestations of bacterial meningitis. To assess whether meningitis could be recognized using readily available clinical information.

METHODS

This study was done during a 4 yr period from 2002-2006. A total of 254 previously healthy children aged 6 months to 5 years, were brought consecutively to the paediatric department of a teaching university hospital after their first fever-associated-seizure; lumbar puncture (LP) was performed in all cases. Children with seizure and fever and meningitis served as cases and those with fever and seizure, but no meningitis, served as control. Factors compared in the two groups were: age, lethargy, irritability, vomiting, nuchal rigidity, bulging fontanel, headache, drowsiness, toxicity, coma, complex seizure, and prior antibiotic use.

RESULTS

Twelve, (4.7%), cases were diagnosed as meningitis. Risk factors significantly associated with meningitis were: age < 12 months, lethargy, irritability, vomiting, nuchal rigidity, bulging fontanel, headache, drowsiness, toxicity, coma, complex seizure, and prior antibiotic use, (p < 0.05). All children with meningitis had at least one of the risk factors mentioned above.

CONCLUSION

Our results indicate that based on available clinical data, meningitis can be ruled out in children presenting with seizure and fever; thus there is no need for routine lumbar puncture in all children who present with fever and seizure. However a lumbar puncture is mandatory in infants younger than 12 months or who have received prior antibiotics.

Cerebrospinal fluid lysozyme in bacterial and viral meningitis

The concentration of lysozyme (LZM) in cerebrospinal fluid was determined in 25 patients with bacterial meningitis, in 18 patients with viral meningitis and in 25 control patients who had other fibrile illnesses. The concentration of LZM was less than 1.5 microgram/ml in all control patients, and slightly to markedly raised in 10 patients with viral meningitis and in 11 out of 13 patients with untreated bacterial meningitis. The concentration of LZM was significantly different in the viral and bacterial meningitis patients (p less than 0.001). Most raised concentrations of cerebrospinal fluid LZM persisted for at least one week after the start of antibiotic treatment. The concentrations of LZM correlated well with concentrations of lactic dehydrogenase. These results show that the determination of cerebrospinal fluid LZM is a useful tool in the differential diagnosis of meningitis, particularly when the prehospital treatment with antibiotics may be responsible for a diagnostically misleading negative bacterial culture of the cerebrospinal fluid and altered cerebrospinal fluid cytology.

[Study of 312 children with meningitis treated at a University Hospital in the South of Brazil]

The aim of this study is to evaluate the clinical and laboratorial aspects, as well as the etiological profile and the evolution characteristics, of the diverse types of severe meningitis treated at a Pediatric Clinic of a public university hospital. From a descriptive and retrospective study, 312 children at the Pediatric Clinic of the Hospital de Clínicas of the Federal University of Paraná were evaluated between January 2003 and January 2007. All of them had a probable diagnosis of meningitis based on clinical signs, and on the cytological and biochemical alterations in the cerebrospinal fluid routine examination. Viral meningitis (VM) was present in 140 children (45%), 58 had bacterial meningitis (BM - 19%) and etiology was undetermined in 114 (36%). In MB, Neisseria meningitidis was the most frequent etiological agent (25 cases). Predominant clinical symptoms were fever, sickness and headache. The cerebrospinal fluid test showed a high number of polymorphonuclear leukocytes, high protein and low glucose level in MB; mononuclear cells were predominant in VM. Neurological complications were more frequent in BM, and convulsion the most common symptom (6/58 patients). Death happened to one case in VM and 3 in BM. Our conclusions were that the classical triad (headache, vomiting and fever) was the most common clinical manifestation, the cytological and biochemical abnormalities were typical, helping in the differentiation of MB from VM, although a good number of cases ended up with no etiological definition and, finally, immediate neurological complications and death were rare.

[Clinical relevance of haptoglobin/IgG index and Boyer's score to the differential diagnosis of bacterial and viral meningitis]

INTRODUCTION

The meningitis is one of the most severe diseases in children due to its mortality or sequels. However, timely knowledge of whether the infection is bacterial or viral in origin and applied a specific therapeutic would be beneficial for the patients and clinician. The haptoglobin/IgG index and Boyer's score have been use in this purpose.

PATIENTS AND METHODS

39 pediatric patients, 14 suffering from viral meningoencephalitis and 25 from bacterial meningoencephalitis were study. Boyer's score and Hp/IgG index were applied in order to evaluate its diagnostic accuracy. The clinical relevance of haptoglobin/IgG index and Boyer's score were compared by the analysis of the receiver-operating characteristic (ROC) curves.

RESULTS

There were no association between Boyer's score and the cause of the meningitis. The sensitivity and specificity of haptoglobin/IgG index were de 71.4 and 64%, respectively. The same parametric to Boyer's score were de 28 and 100%. Increased haptoglobin/IgG index presents bigger precision for the differential diagnostic of the bacterial and viral meningitis than the scale of Boyer according to the curves ROC.

CONCLUSION

The index haptoglobin/IgG showed its diagnostic superiority with relationship to the scale of Boyer to establish the origin of the meningoencephalitis.

Investigation of pituitary functions in patients with acute meningitis: a pilot study

OBJECTIVE

Although long-term pituitary consequences of tuberculous meningitis are well documented in the literature, there have been few case reports of pituitary dysfunction after acute bacterial or viral meningitis. In this preliminary study, we have assessed the pituitary functions in adult patients who had acute bacterial or viral meningitis.

DESIGN AND METHODS

Fourteen patients (8 men, 6 women; mean age 35.3+/-13.3) were included in the study. The diagnosis of bacterial and viral meningitis was proven by clinical findings, cerebrospinal fluid (CSF) examination, gram staining, and blood and CSF cultures. Pituitary functions were evaluated ranging from 6 to 48 months (mean 20 months) after acute meningitis. GH deficiency was investigated by the GHRH+arginine stimulation test.

RESULTS

Four of 14 patients (28.6%) had isolated GH deficiency. In GH-deficient patients, the earliest duration was 6 months and the latest duration was 48 months after the diagnosis of acute meningitis. Three of the GH-deficient patients had acute bacterial meningitis and 1 patient had acute viral meningitis. Pituitary magnetic resonance imaging revealed normal pituitary gland in the patients with GH deficiency.

CONCLUSIONS

This is the first systematic study evaluating the anterior pituitary function long term after the diagnosis of acute meningitis. Based on the present study, it is tempting to speculate that pituitary dysfunction is a more common sequel of acute bacterial or viral meningitis than hitherto reported. Studies with high numbers of patients are warranted to ascertain the prevalence of meningitis-induced hypopituitarism.