Sleep disorders are long-term sequelae of both bacterial and viral meningitis

Post-Meningitic Syndrome: Pathophysiology and Consequences of Streptococcal Infections on the Central Nervous System

Streptococcus species represent a significant global cause of meningitis, leading to brain damage through bacterial virulence factors and the host inflammatory response. Upon entering the central nervous system (CNS), excessive inflammation leads to various neurological and psychological complications. This review explores the pathophysiological mechanisms and associated outcomes of streptococcal meningitis, particularly its short- and long-term neurological sequelae. Neurological symptoms, such as cognitive impairment, motor deficits, and sensory loss, are shown to vary in severity, with children being particularly susceptible to lasting complications. Among survivors, hearing loss, cognitive decline, and cranial nerve palsies emerge as the most frequently reported complications. The findings highlight the need for timely intervention, including neurorehabilitation strategies that focus on optimizing recovery and mitigating long-term disabilities. Future recommendations emphasize improving early diagnosis, expanding vaccine access, and personalizing rehabilitation protocols to enhance patient outcomes. As a novel contribution, this review proposes the term "post-meningitic syndrome" to showcase the broad spectrum of CNS complications that persist following streptococcal meningitis, providing a framework for a future clinical and research focus.

Long-term sequelae after viral meningitis and meningoencephalitis are frequent, even in mildly affected patients, a prospective observational study

Introduction

An increasing number of studies demonstrate that viral meningitis and meningoencephalitis, even those with a mild course of meningitis, can result in residual sequelae.

Methods

We aimed to investigate the long-term outcome in both viral meningitis and meningoencephalitis/encephalitis patients and impact of long-term sequelae on patients' social and professional daily lives in a prospective observational study with a follow-up period of 20 months.

Results

A total of 50 patients (12% encephalitis, 58% meningoencephalitis and 30% meningitis) and 21 control persons participated in the study. The most common cause was the tick-borne encephalitis (TBE) virus. The most important persistent signs and symptoms after 2 years were subjective cognitive impairment (36%), fatigue and/or excessive daytime sleepiness (31%), disturbed nighttime sleep (31%) and headaches (13%), as well as feeling more rapidly exhausted after cognitive effort (53%). Independent of disease severity in the acute phase, almost one third of patients still reported mildly impaired social and/or professional life due to the long-term sequelae, with scores in the health status assessment still significantly lower compared to healthy controls.

Discussion

Regardless of the severity of the acute illness and despite constant improvement within 2 years, 67% of patients still had persistent signs and symptoms, but these were only relevant to everyday social or professional life in about 30% of these patients.

Persistent headaches one year after bacterial meningitis: prevalence, determinants and impact on quality of life

BACKGROUND

Little is known on headaches long-term persistence after bacterial meningitis and on their impact on patients' quality of life.

METHODS

In an ancillary study of the French national prospective cohort of community-acquired bacterial meningitis in adults (COMBAT) conducted between February 2013 and July 2015, we collected self-reported headaches before, at onset, and 12 months (M12) after meningitis. Determinants of persistent headache (PH) at M12, their association with M12 quality of life (SF 12), depression (Center for Epidemiologic Studies Depression Scale) and neuro-functional disability were analysed.

RESULTS

Among the 277 alive patients at M12 87/274 (31.8%), 213/271 (78.6%) and 86/277 (31.0%) reported headaches before, at the onset, and at M12, respectively. In multivariate analysis, female sex (OR: 2.75 [1.54-4.90]; p < 0.001), pre-existing headaches before meningitis (OR: 2.38 [1.32-4.30]; p < 0.01), higher neutrophilic polynuclei percentage in the CSF of the initial lumbar puncture (OR: 1.02 [1.00-1.04]; p < 0.05), and brain abscess during the initial hospitalisation (OR: 8.32 [1.97-35.16]; p < 0.01) were associated with M12 persistent headaches. Neither the responsible microorganism, nor the corticoids use were associated with M12 persistent headaches. M12 neuro-functional disability (altered Glasgow Outcome Scale; p < 0.01), M12 physical handicap (altered modified Rankin score; p < 0.001), M12 depressive symptoms (p < 0.0001), and M12 altered physical (p < 0.05) and mental (p < 0.0001) qualities of life were associated with M12 headaches.

CONCLUSION

Persistent headaches are frequent one year after meningitis and are associated with quality of life alteration.

CLINICAL TRIAL

NCT01730690.

Clinical features and prognostic factors in adults with viral meningitis

Clinical features applicable to the entire spectrum of viral meningitis are limited, and prognostic factors for adverse outcomes are undetermined. This nationwide population-based prospective cohort study included all adults with presumed and microbiologically confirmed viral meningitis in Denmark from 2015 until 2020. Prognostic factors for an unfavourable outcome (Glasgow Outcome Scale score of 1-4) 30 days after discharge were examined by modified Poisson regression. In total, 1066 episodes of viral meningitis were included, yielding a mean annual incidence of 4.7 episodes per 100 000 persons. Pathogens were enteroviruses in 419/1066 (39%), herpes simplex virus type 2 in 171/1066 (16%), varicella-zoster virus in 162/1066 (15%), miscellaneous viruses in 31/1066 (3%) and remained unidentified in 283/1066 (27%). The median age was 33 years (IQR 27-44), and 576/1066 (54%) were females. In herpes simplex virus type 2 meningitis, 131/171 (77%) were females. Immunosuppression [32/162 (20%)] and shingles [90/149 (60%)] were frequent in varicella-zoster virus meningitis. The triad of headache, neck stiffness and hyperacusis or photophobia was present in 264/960 (28%). The median time until lumbar puncture was 3.0 h (IQR 1.3-7.1), and the median CSF leucocyte count was 160 cells/µl (IQR 60-358). The outcome was unfavourable in 216/1055 (20%) 30 days after discharge. Using unidentified pathogen as the reference, the adjusted relative risk of an unfavourable outcome was 1.34 (95% CI 0.95-1.88) for enteroviruses, 1.55 (95% CI 1.00-2.41) for herpes simplex virus type 2, 1.51 (95% CI 0.98-2.33) for varicella-zoster virus and 1.37 (95% CI 0.61-3.05) for miscellaneous viruses. The adjusted relative risk of an unfavourable outcome was 1.34 (95% CI 1.03-1.75) for females. Timing of acyclovir or valacyclovir was not associated with the outcome in meningitis caused by herpes simplex virus type 2 or varicella-zoster virus. In summary, the outcome of viral meningitis was similar among patients with different aetiologies, including those with presumed viral meningitis but without an identified pathogen. Females had an increased risk of an unfavourable outcome. Early antiviral treatment was not associated with an improved outcome in meningitis caused by herpes simplex virus type 2 or varicella-zoster virus.

Epidemiological characteristics and climatic variability of viral meningitis in Kazakhstan, 2014-2019

Background

The comprehensive epidemiology and impact of climate on viral meningitis (VM) in Kazakhstan are unknown. We aimed to study the incidence, in-hospital mortality and influence of climatic indicators on VM from 2014 to 2019.

Methods

Nationwide electronic healthcare records were used to explore this study. ICD-10 codes of VM, demographics, and hospital outcomes were evaluated using descriptive statistics and survival analysis.

Results

During the 2014-2019 period, 10,251 patients with VM were admitted to the hospital. 51.35% of them were children, 57.85% were males, and 85.9% were from the urban population. Enteroviral meningitis was the main cause of VM in children. The incidence rate was 13 and 18 cases per 100,000 population in 2014 and 2019, respectively. Case fatality rate was higher in 2015 (2.3%) and 2017 (2.0%). The regression model showed 1°C increment in the daily average temperature might be associated with a 1.05-fold (95% CI 1.047-1.051) increase in the daily rate of VM cases, 1hPa increment in the average air pressure and 1% increment in the daily average humidity might contribute to a decrease in the daily rate of VM cases with IRRs of 0.997 (95% CI 0.995-0.998) and 0.982 (95% CI 0.981-0.983), respectively. In-hospital mortality was 35% higher in males compared to females. Patients residing in rural locations had a 2-fold higher risk of in-hospital death, compared to city residents. Elderly patients had a 14-fold higher risk of in-hospital mortality, compared to younger patients.

Conclusion

This is the first study in Kazakhstan investigating the epidemiology and impact of climate on VM using nationwide healthcare data. There was a tendency to decrease the incidence with outbreaks every 5 years, and mortality rates were higher for Russians and other ethnicities compared to Kazakhs, for males compared to females, for elder patients compared to younger patients, and for patients living in rural areas compared to city residents. The climatic parameters and the days of delay indicated a moderate interaction with the VM cases.

Etiology, Clinical Phenotypes, Epidemiological Correlates, Laboratory Biomarkers and Diagnostic Challenges of Pediatric Viral Meningitis: Descriptive Review

Meningitis is an inflammation of the brain and spinal cord meninges caused by infectious and non-infectious agents. Infectious agents causing meningitis include viruses, bacteria, and fungi. Viral meningitis (VM), also termed aseptic meningitis, is caused by some viruses, such as enteroviruses (EVs), herpesviruses, influenza viruses, and arboviruses. However, EVs represent the primary cause of VM. The clinical symptoms of this neurological disorder may rapidly be observed after the onset of the disease, or take prolonged time to develop. The primary clinical manifestations of VM include common flu-like symptoms of headache, photophobia, fever, nuchal rigidity, myalgia, and fatigue. The severity of these symptoms depends on the patient's age; they are more severe among infants and children. The course of infection of VM varies between asymptomatic, mild, critically ill, and fatal disease. Morbidities and mortalities of VM are dependent on the early recognition and treatment of the disease. There were no significant distinctions in the clinical phenotypes and symptoms between VM and meningitis due to other causative agents. To date, the pathophysiological mechanisms of VM are unclear. In this scientific communication, a descriptive review was performed to give an overview of pediatric viral meningitis (PVM). PVM may occasionally result in severe neurological consequences such as mental retardation and death. Clinical examinations, including Kernig's, Brudzinski's, and nuchal rigidity signs, were attempted to determine the clinical course of PVM with various success rates revealed. Some epidemiological correlates of PVM were adequately reviewed and presented in this report. They were seen depending mainly on the causative virus. The abnormal cytological and biochemical features of PVM were also discussed and showed potentials to distinguish PVM from pediatric bacterial meningitis (PBM). The pathological, developmental, behavioral, and neuropsychological complications of PVM were also presented. All the previously utilized techniques for the etiological diagnosis of PVM which include virology, serology, biochemistry, and radiology, were presented and discussed to determine their efficiencies and limitations. Finally, molecular testing, mainly PCR, was introduced and showed 100% sensitivity rates.

Review on inactivation of airborne viruses using non-thermal plasma technologies: from MS2 to coronavirus

Although several non-thermal plasmas (NTPs) technologies have been widely investigated in air treatment, very few studies have focused on the inactivation mechanism of viruses by NTPs. Due to its efficiency and environmental compatibility, non-thermal plasma could be considered a promising virus-inactivation technology. Plasma is a partly or fully ionized gas including some species (i.e., electrons, free radicals, ions, and neutral molecules) to oxidize pollutants or inactivate harmful organisms. Non-thermal plasmas are made using less energy and have an active electron at a much higher temperature than bulk gas molecules. This review describes NTPs for virus inactivation in indoor air. The different application processes of plasma for microorganism inactivation at both laboratory and pilot-scale was also reviewed This paper reports on recent advances in this exciting area of viral inactivation identifying applications and mechanisms of inactivation, and summarizing the results of the latest experiments in the literature. Moreover, special attention was paid to the mechanism of virus inactivation. Finally, the paper suggests research directions in the field of airborne virus inactivation using non-thermal plasma.

Meningitis, meningoencephalitis and encephalitis in Bern: an observational study of 258 patients

Background

Depending on geographic location, causes of encephalitis, meningoencephalitis and meningitis vary substantially. We aimed to identify the most frequent causes, clinical presentation and long-term outcome of encephalitis, meningoencephalitis and meningitis cases treated in the Inselspital University Hospital Bern, Switzerland.

Methods

In this monocentric, observational study, we performed a retrospective review of clinical patient records for all patients treated within a 3-year period. Patients were contacted for a telephone follow-up interview and to fill out questionnaires, especially related to disturbances of sleep and wakefulness.

Results

We included 258 patients with the following conditions: encephalitis (18%), nonbacterial meningoencephalitis (42%), nonbacterial meningitis (27%) and bacterial meningoencephalitis/meningitis (13%). Herpes simplex virus (HSV) was the most common cause of encephalitis (18%); tick-borne encephalitis virus (TBEV) was the most common cause of nonbacterial meningoencephalitis (46%), enterovirus was the most common cause of nonbacterial meningitis (21%) and Streptococcus pneumoniae was the most common cause of bacterial meningoencephalitis/meningitis (49%). Overall, 35% patients remained without a known cause. After a median time of 16 months, 162 patients participated in the follow-up interview; 56% reported suffering from neurological long-term sequelae such as fatigue and/or excessive daytime sleepiness (34%), cognitive impairment and memory deficits (22%), headache (14%) and epileptic seizures (11%).

Conclusions

In the Bern region, Switzerland, TBEV was the overall most frequently detected infectious cause, with a clinical manifestation of meningoencephalitis in the majority of cases. Long-term neurological sequelae, most importantly cognitive impairment, fatigue and headache, were frequently self-reported not only in encephalitis and meningoencephalitis survivors but also in viral meningitis survivors up to 40 months after acute infection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02502-3.

Living on the Edge of the CNS: Meninges Cell Diversity in Health and Disease

The meninges are the fibrous covering of the central nervous system (CNS) which contain vastly heterogeneous cell types within its three layers (dura, arachnoid, and pia). The dural compartment of the meninges, closest to the skull, is predominantly composed of fibroblasts, but also includes fenestrated blood vasculature, an elaborate lymphatic system, as well as immune cells which are distinct from the CNS. Segregating the outer and inner meningeal compartments is the epithelial-like arachnoid barrier cells, connected by tight and adherens junctions, which regulate the movement of pathogens, molecules, and cells into and out of the cerebral spinal fluid (CSF) and brain parenchyma. Most proximate to the brain is the collagen and basement membrane-rich pia matter that abuts the glial limitans and has recently be shown to have regional heterogeneity within the developing mouse brain. While the meninges were historically seen as a purely structural support for the CNS and protection from trauma, the emerging view of the meninges is as an essential interface between the CNS and the periphery, critical to brain development, required for brain homeostasis, and involved in a variety of diseases. In this review, we will summarize what is known regarding the development, specification, and maturation of the meninges during homeostatic conditions and discuss the rapidly emerging evidence that specific meningeal cell compartments play differential and important roles in the pathophysiology of a myriad of diseases including: multiple sclerosis, dementia, stroke, viral/bacterial meningitis, traumatic brain injury, and cancer. We will conclude with a list of major questions and mechanisms that remain unknown, the study of which represent new, future directions for the field of meninges biology.

Quality of life of HIV-negative, previously healthy individuals following cryptococcal meningoencephalitis

The morbidity and mortality of cryptococcal meningoencephalitis (CM) in previously healthy, HIV-negative individuals is increasingly recognized. We administered a healthcare associated quality of life (QOL) survey to the largest longitudinally followed cohort of these patients in the United States. We identified moderate or severe self-reported impairment in at least one QOL domain in 61% of subjects at least one year following diagnosis. Self-reported cognitive impairment was noted in 52% and sleep disturbance was noted in 55%. This is the first comprehensive study of cross-sectional long-term QOL in previously healthy patients following cryptococcal infection.

Sleep-Wake Disturbances After Acquired Brain Injury in Children Surviving Critical Care

BACKGROUND

Sleep-wake disturbances are underevaluated among children with acquired brain injury surviving critical care. We aimed to quantify severity, phenotypes, and risk factors for sleep-wake disturbances.

METHODS

We performed a prospective cohort study of 78 children aged ≥3 years with acquired brain injury within three months of critical care hospitalization. Diagnoses included traumatic brain injury (n = 40), stroke (n = 11), infectious or inflammatory disease (n = 10), hypoxic-ischemic injury (n = 9), and other (n = 8). Sleep Disturbances Scale for Children standardized T scores measured sleep-wake disturbances. Overall sleep-wake disturbances were dichotomized as any total or subscale T score ≥60. Any T score ≥70 defined severe sleep-wake disturbances. Subscale T scores ≥60 identified sleep-wake disturbance phenotypes.

RESULTS

Sleep-wake disturbances were identified in 44 (56%) children and were classified as severe in 36 (46%). Sleep-wake disturbances affected ≥33% of patients within each diagnosis and were not associated with severity of illness measures. The most common phenotype was disturbance in initiation and maintenance of sleep (47%), although 68% had multiple concurrent sleep-wake disturbance phenotypes. One third of all patients had preadmission chronic conditions, and this increased risk for sleep-wake disturbances overall (43% vs 21%, P = 0.04) and in the traumatic brain injury subgroup (52% vs 5%, P = 0.001).

CONCLUSIONS

Over half of children surviving critical care with acquired brain injury have sleep-wake disturbances. Most of these children have severe sleep-wake disturbances independent of severity of illness measures. Many sleep-wake disturbances phenotypes were identified, but most children had disturbance in initiation and maintenance of sleep. Our study underscores the importance of evaluating sleep-wake disturbances after acquired brain injury.

Encephalitis and aseptic meningitis: short-term and long-term outcome, quality of life and neuropsychological functioning

For those surviving encephalitis, the influence on daily life of patients and their relatives may be substantial. In contrast, the prognosis after aseptic meningitis (ASM) is considered good. In this prospective study in patients with encephalitis (n = 20) and ASM (n = 46), we show that both groups experienced reduced Health Related Quality of Life (HRQoL) at two months after discharge, and that workability was reduced in 37% of the patients with ASM. However, 12 months after discharge no neuropsychological deficits were detected in the ASM group, whereas patients with encephalitis had lower scores on tests of fine motor and psychomotor skills as well as on learning and memory. We also found that for patients with encephalitis, neopterin, as a marker of Th1 cell induced macrophage activation, and a putatively neurotoxic ratio of the kynurenine pathway (KP) measured during the acute phase was associated with lower HRQoL. Our data show that not only encephalitis, but also ASM has substantial short-term influence on HRQoL and workability. For patients with encephalitis we suggest a link between immune activation and activation of the KP during the acute phase with impaired HRQoL.

Incidence, aetiology, and sequelae of viral meningitis in UK adults: a multicentre prospective observational cohort study

BACKGROUND

Viral meningitis is increasingly recognised, but little is known about the frequency with which it occurs, or the causes and outcomes in the UK. We aimed to determine the incidence, causes, and sequelae in UK adults to improve the management of patients and assist in health service planning.

METHODS

We did a multicentre prospective observational cohort study of adults with suspected meningitis at 42 hospitals across England. Nested within this study, in the National Health Service (NHS) northwest region (now part of NHS England North), was an epidemiological study. Patients were eligible if they were aged 16 years or older, had clinically suspected meningitis, and either underwent a lumbar puncture or, if lumbar puncture was contraindicated, had clinically suspected meningitis and an appropriate pathogen identified either in blood culture or on blood PCR. Individuals with ventricular devices were excluded. We calculated the incidence of viral meningitis using data from patients from the northwest region only and used these data to estimate the population-standardised number of cases in the UK. Patients self-reported quality-of-life and neuropsychological outcomes, using the EuroQol EQ-5D-3L, the 36-Item Short Form Health Survey (SF-36), and the Aldenkamp and Baker neuropsychological assessment schedule, for 1 year after admission.

FINDINGS

1126 patients were enrolled between Sept 30, 2011, and Sept 30, 2014. 638 (57%) patients had meningitis: 231 (36%) cases were viral, 99 (16%) were bacterial, and 267 (42%) had an unknown cause. 41 (6%) cases had other causes. The estimated annual incidence of viral meningitis was 2·73 per 100 000 and that of bacterial meningitis was 1·24 per 100 000. The median length of hospital stay for patients with viral meningitis was 4 days (IQR 3-7), increasing to 9 days (6-12) in those treated with antivirals. Earlier lumbar puncture resulted in more patients having a specific cause identified than did those who had a delayed lumbar puncture. Compared with the age-matched UK population, patients with viral meningitis had a mean loss of 0·2 quality-adjusted life-years (SD 0·04) in that first year.

INTERPRETATION

Viruses are the most commonly identified cause of meningitis in UK adults, and lead to substantial long-term morbidity. Delays in getting a lumbar puncture and unnecessary treatment with antivirals were associated with longer hospital stays. Rapid diagnostics and rationalising treatments might reduce the burden of meningitis on health services.

FUNDING

Meningitis Research Foundation and UK National Institute for Health Research.

Fatigue following Paediatric Acquired Brain Injury and its Impact on Functional Outcomes: A Systematic Review

Fatigue is a commonly reported sequela following an acquired brain injury (ABI), and can have a negative impact on many areas of a child's life. However, there is minimal research that focuses on fatigue specifically, and so factors such as its occurrence, duration, and impact on functioning remain uncertain. This systematic review aims to provide a comprehensive summary of the research to date, bringing together a number of studies with a focus on paediatric ABI and fatigue. Terms were searched in relevant databases (PsycInfo, Medline, CINAHL), and articles were included or excluded based on specified criteria. Of the 1177 papers identified in the original search, a total of 9 papers met inclusion criteria, and were categorised as traumatic brain injury (TBI; n = 4), meningitis and meningococcal disease (n = 2), brain tumours (n = 2), and mixed ABI group (n = 1). Key findings suggest that fatigue is a problem encountered by a significant proportion of patients in all the studies reviewed, and often occurred regardless of the cause; fatigue was also associated with poor academic achievement, limited physical activity, and social and emotional problems. Injuries of greater severity were associated with higher levels of fatigue and worse outcomes. Several management options were suggested, though their efficacy was not reported. Future research is required with a suggested focus on using multiple time points to better understand the trajectories of fatigue following childhood ABI, and to build an evidence base to determine which management options are most suitable.

The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults

Bacterial meningitis and meningococcal sepsis are rare conditions with high case fatality rates. Early recognition and prompt treatment saves lives. In 1999 the British Infection Society produced a consensus statement for the management of immunocompetent adults with meningitis and meningococcal sepsis. Since 1999 there have been many changes. We therefore set out to produce revised guidelines which provide a standardised evidence-based approach to the management of acute community acquired meningitis and meningococcal sepsis in adults. A working party consisting of infectious diseases physicians, neurologists, acute physicians, intensivists, microbiologists, public health experts and patient group representatives was formed. Key questions were identified and the literature reviewed. All recommendations were graded and agreed upon by the working party. The guidelines, which for the first time include viral meningitis, are written in accordance with the AGREE 2 tool and recommendations graded according to the GRADE system. Main changes from the original statement include the indications for pre-hospital antibiotics, timing of the lumbar puncture and the indications for neuroimaging. The list of investigations has been updated and more emphasis is placed on molecular diagnosis. Approaches to both antibiotic and steroid therapy have been revised. Several recommendations have been given regarding the follow-up of patients.

Prevalence and predictors of bacterial meningitis in young infants with fever without a source

BACKGROUND

Classical criteria differ when performing cerebrospinal fluid (CSF) analysis in infants younger than 90 days with fever without a source (FWS). Our objectives were to analyze the prevalence and microbiology of bacterial meningitis in this group and its prevalence in relation to clinical and laboratory risk factors.

METHODS

This is a substudy of a prospective registry including all infants of this age with FWS seen between September 2003 and August 2013 in a Pediatric Emergency Department of a Tertiary Teaching Hospital.

RESULTS

Lumbar puncture was performed in 639 (27.0%) of the 2362 infants with FWS seen, the rate being higher in not well-appearing infants [60.9% vs. 25.7%; odds ratio (OR), 4.49] and in those ≤21 days old (70.1% vs. 20.4%; OR, 9.14). Eleven infants were diagnosed with bacterial meningitis: 9 were ≤21 days old (prevalence 2.8% vs. 0.1%; OR, 30.42) and 5 were not well-appearing infants (5.7% vs. 0.2%; OR, 23.06). Bacteria isolated were Streptococcus agalactiae (3), Escherichia coli (3), Listeria monocytogenes (3), Streptococcus pneumoniae (1) and Neisseria meningitidis (1). None of the 1975 well-appearing infants >21 days old were diagnosed with bacterial meningitis, regardless of whether biomarkers were altered.

CONCLUSIONS

In infants younger than 90 days with FWS, performing CSF analysis for ruling out bacterial meningitis must be strongly considered in not well-appearing infants and in those ≤21 days old. The recommendation of systematically performing CSF analysis in well-appearing infants 22-90 days of age on the basis of analytical criteria alone must be reevaluated.

Long-term neuropsychiatric consequences of aseptic meningitis in adult patients

Aseptic meningitis is considered a benign and self-limiting clinical condition. In contrast to viral encephalitis and bacterial meningitis, the prognosis is usually good. The existing literature is scarce on the potential long-term neuropsychiatric consequences of aseptic meningitis. Previous studies have primarily been retrospective and differences in methodologies make it difficult to draw conclusions regarding the prevalence and nature of neuropsychiatric manifestations. However, studies have reported decreased psychomotor speed and impaired executive and visuo-constructive functions following aseptic meningitis. Larger controlled prospective studies are urgently needed to elucidate the neuropsychiatric complications of aseptic meningitis.

Review: apoptotic mechanisms in bacterial infections of the central nervous system

In this article we review the apoptotic mechanisms most frequently encountered in bacterial infections of the central nervous system (CNS). We focus specifically on apoptosis of neural cells (neurons and glia), and provide first an overview of the phenomenon of apoptosis itself and its extrinsic and intrinsic pathways. We then describe apoptosis in the context of infectious diseases and inflammation caused by bacteria, and review its role in the pathogenesis of the most relevant bacterial infections of the CNS.

Clinical and analytical characteristics and short-term evolution of enteroviral meningitis in young infants presenting with fever without source

OBJECTIVE

The objective of this study was to describe the characteristics of the enteroviral meningitis diagnosed in a pediatric emergency department among infants younger than 3 months with fever without source and its short-term evolution.

METHODS

This was a retrospective, cross-sectional, 6-year descriptive study including all infants younger than 3 months who presented with fever without source and who were diagnosed with enteroviral meningitis.

RESULTS

A lumbar puncture was practiced at their first emergency visit in 398 (29.5%) of 1348 infants, and 65 (4.8%) were diagnosed with enteroviral meningitis, 33 of them (50.7%) between May and July. Among these 65 infants, 61 were classified as well-appearing; parents referred irritability in 16 (25.3%) of them (without statistical significance when compared with infants without meningitis). Forty-one (63.0%) had no altered infectious parameters (white blood cell [WBC] count between 5000 and 15,000/μL, absolute neutrophil count less than 10,000/μL, and C-reactive protein less than 20 g/L), and 39 (60%) had no pleocytosis. All of the 65 infants recovered well, and none of them developed short-term complications.

CONCLUSIONS

The symptoms in infants younger than 3 months with enteroviral meningitis were similar to those in infants with a self-limited febrile process without intracranial infection. C-reactive protein and WBC count were not good enteroviral meningitis predictors. Cerebrospinal fluid WBC count was normal in many of these infants, so performing a viral test is recommended for febrile infants younger than 3 months in which a lumbar puncture is practiced during warm months. The short-term evolution was benign.

[Managing adult patients with acute community-acquired meningitis presumed of bacterial origin]

Early clinical data must lead to suspect bacterial meningitis if fever, the most frequent sign, is present and if it is associated with more or less constant neurological and meningeal signs (consciousness impairment, headache, neck stiffness, focal neurological deficit, seizure, etc.). A skin rash is frequent in case of meningococcal meningitis whereas cranial nerve palsy is more in favor of tuberculous or Listeria meningitis. Presence of otitis, sinusitis, pneumonia, or a recent head trauma strongly suggests a pneumococcal involvement. Tuberculous meningitis is generally characterized by a slow evolution of meningeal signs together with aspecific signs. The main prognostic factors are consciousness impairment, circulatory instability, focal neurological signs, and advanced age. Morbidity and mortality are increased in case of pneumococcal compared to meningococcal meningitis. Cranial tomodensitometry gives further information about intracranial complications of meningitis. In some cases, particularly if focal neurological or intracranial hypertension signs are present, it must be performed before a lumbar puncture. The risk factors of meningitis must be investigated and treated if possible according to the bacterium. The management of patient after hospital discharge depends on evolution after treatment. The presence of neurological sequels imposes a specialized ambulatory follow-up. Neuropsychological sequels (cognitive dysfunction, memory impairment) can also persist for years even in absence of other neurological disorders.

Abnormal sleep-wake cycles in patients with tuberculous meningitis: a case-control study

BACKGROUND

Patients with tuberculous meningitis (TBM) have been frequently observed to have excessive sleep during the day and frequent awakenings during night. We undertook this study to evaluate sleep related abnormalities in patients with TBM since there is no published literature pertaining to the same.

AIMS AND OBJECTIVES

To study sleep wake cycles in patients with tuberculous meningitis by actigraphy and sleep logs and compare these with age and sex matched controls.

METHODS

Consecutive patients admitted with tuberculous meningitis were studied clinically and with three days of continuous wrist actigraphy and sleep/wake parameters were compared to those of age and gender matched normal healthy controls.

RESULTS

Forty three patients with tuberculous meningitis were enrolled in the study. Of these, twenty-eight patients (15 females, 13 males; mean age 31.64 years) who were able to complete adequate actigraphy were compared with an equal number of controls (15 females, 13 males; mean age 30.93 years). Patients were found to have greater sleep time (p<0.0005) and more sleep episodes (p<0.0005) during the day while during the night they had less sleep (p<0.0005) with more frequent (p=0.019) and longer (p<0.0005) awakenings as compared to normal controls. Majority of the patients had reversal of sleep/wake cycles. There was poor co-relation between sleep parameters measured by actigraphy and sleep logs.

CONCLUSIONS

Tuberculous meningitis is associated with significant alteration of sleep-wake circadian cycles. This needs to be further characterized through studies involving polysomnography. There is a need to address these specific sleep difficulties to improve the quality of life of the patient as well as the care-giver.

Postmeningitis headache: case report

We report a case of a 18-year-old female patient that developed a migraine-like headache following an acute meningococcal meningitis. She had no previous history of recurrent headaches. The pain was intense, pulsatile and throbbing, typically unilateral, without aura. Its frequency increased during the following weeks and a prophylactic treatment with amitriptyline and atenolol was initiated. There was remission of the attacks.

Long-term neuropsychological deficits after central nervous system infections despite adequate therapy

Neuropsychological deficits are common consequences of central nervous system infections despite adequate treatment. The frequency and severity depends on the causative pathogen and the site(s) of injured brain parenchyma. The severity ranges from mild cognitive abnormalities not interfering with everyday life performance to fully developed Wernicke-Korsakow syndrome with complete inability to incorporate new information into long-term memory and to persistent vegetative state. In several conditions, rapid initiation of adequate therapy is crucial to minimise neuropsychological impairment.