Hydrocephalus is a rare outcome in community-acquired bacterial meningitis in adults: a retrospective analysis

Fluids and flows in brain cancer and neurological disorders

Interstitial fluid (IF) and cerebrospinal fluid (CSF) are an integral part of the brain, serving to cushion and protect the brain parenchymal cells against damage and aid in their function. The brain IF contains various ions, nutrients, waste products, peptides, hormones, and neurotransmitters. IF moves primarily by pressure-dependent bulk flow through brain parenchyma, draining into the ventricular CSF. The brain ventricles and subarachnoid spaces are filled with CSF which circulates through the perivascular spaces. It also flows into the IF space regulated, in part, by aquaporin channels, removing waste solutes through a process of IF-CSF mixing. During disease development, the composition, flow, and volume of these fluids changes and can lead to brain cell dysfunction. With the improvement of imaging technology and the help of genomic profiling, more information has been and can be obtained from brain fluids; however, the role of CSF and IF in brain cancer and neurobiological disease is still limited. Here we outline recent advances of our knowledge of brain fluid flow in cancer and neurodegenerative disease based on our understanding of its dynamics and composition. This article is categorized under: Cancer > Biomedical Engineering Neurological Diseases > Biomedical Engineering.

Acute Hydrocephalus Associated with Streptococcus anginosus Meningitis

Introduction

Meningitis-related acute hydrocephalus is rare, challenging to diagnose, and has a high mortality rate.

Case description

Here we describe the case of a 76-year-old patient diagnosed with bacterial meningitis who developed acute hydrocephalus and subsequently died.

Discussion

Although meningitis-related acute hydrocephalus is usually non-occlusive, occlusive hydrocephalus may also occur. Moreover, worsening hydrocephalus despite cerebrospinal fluid drainage should prompt a diagnosis of obstructive hydrocephalus. In such conditions, potential management strategies include ventriculoperitoneal shunt and endoscopic third ventriculostomy.

Conclusion

In patients with meningitis-related hydrocephalus, worsening despite appropriate antibiotic administration, treatment may be complicated by ventriculitis and obstructive hydrocephalus, which can be fatal. If intracranial pressure is not medically controlled, bilateral decompression craniectomy should be considered as a potential management strategy.

LEARNING POINTS

The extreme rarity of obstructive hydrocephalus caused by bacterial meningitis can lead to delayed diagnosis and treatment.Ventriculoperitoneal shunt and endoscopic third ventriculostomy are the indicated management strategies for early diagnosis of obstructive hydrocephalus.Bilateral decompression craniectomy may be an option in such cases.

Persistent Severe Cerebral Edema with Neutrophil Infiltration Following Listeria Meningitis

A 51-year-old man was admitted to the hospital with a diagnosis of Listeria monocytogenes meningitis. Diffuse cerebral edema appeared after improvement of meningitis with appropriate treatment and worsened for two months. Due to brain herniation, brain tissue leaked through the incision made during the drain insertion in a hydrocephalus surgery. We found pathological evidence of significant neutrophil infiltration with a few lymphocytes without bacterial detection in the degraded brain tissue. The present case indicates that fatal cerebral edema with significant neutrophil infiltration may develop even after appropriate treatment for L. monocytogenes meningitis.

A Nomogram to Predict Bacterial Meningitis-associated Hydrocephalus: A Single-Center Retrospective Study

OBJECTIVE

We aimed to develop a predictive nomogram for the early detection of hydrocephalus in children with bacterial meningitis.

METHODS

This retrospective study was based on data of children with bacterial meningitis admitted to our hospital between January 2016 and December 2020. Risk factors were evaluated using univariate analysis, and the predictive model/nomogram was built using binary logistic analysis. A nomogram calibration plot, Hosmer-Lemeshow test and receiver operating characteristic (ROC) curve evaluated the predictive performance. Ordinary bootstrapping processed the internal validation.

RESULTS

We enrolled 283 patients who matched the inclusion criteria, among whom 41 cases (14.49%) had confirmed bacterial meningitis-associated hydrocephalus (BMAH). The incidence of sequelae in the patients with BMAH was 88.9% (24/27), which was significantly higher than that in the patients without BMAH. Univariate regression analysis revealed that 14 clinical indicators were associated with BMAH. Multivariate analysis identified 4 variables as independent risk factors to establish the predictive model: repeated seizures, loss of consciousness, procalcitonin ≥7.5 ng/dL and mechanical ventilation. And a graphical nomogram was designed. The area under the ROC curve was 0.910. In the Hosmer-Lemeshow test the P value was 0.610. The mean absolute error in the calibration plot was 0.02. Internal validation showed the testing set was in good accordance with the original set when internal validation was performed.

CONCLUSIONS

The predictive model/nomogram of BMAH could be used by clinicians to determine hydrocephalus risk.

First reported case of hydrocephalus in jointly diagnosed bacterial meningitis and a colloid cyst: how Ockham's razor became Hickam's dictum

We report the first case in the literature of acute hydrocephalus due to a simultaneous diagnosis of bacterial (not asceptic) meningitis and a colloid cyst. Diagnosing disease is the cornerstone skill of a medical practitioner. Both education and experience allow for sharpening of this skill throughout years of medical practice. Disease is fraught with nuances and inconsistencies which can render an accurate diagnosis a difficult task. Medical practitioners can be guilty of cognitive biases such as Ockham's razor. We present the case of a patient with an initial diagnosis of obstructive hydrocephalus secondary to a colloid cyst. However, pneumococcal meningitis blunted Ockham's razor in favour of Hickam's dictum.

Neisseria gonorrhoeae: An Unexpected Cause of Polyarthritis and Meningitis

Neisseria gonorrhoeae, a gram-negative coccus, is a major cause of morbidity among sexually active individuals. Hematogenous spread of N gonorrhoeae from the initial site of infection is thought to occur in only 0.5% to 3% of infected patients. Disseminated gonococcal infections can rarely lead to serious sequelae, such as endocarditis or meningitis. In this article, we present a case that demonstrates a rare finding of disseminated gonococcal infection leading to N gonorrhoeae meningitis, complicated by hydrocephalus. The patient in this case initially presented with intermittent polyarthralgias for two years and later developed a rash. Cultures from blood and joint aspirate were negative. Urine nucleic acid amplification test for N gonorrhoeae was also negative. He was initially started on steroids for what was believed at first to be an autoimmune polyarthritis. The patient later developed acute encephalopathy. Head imaging revealed hydrocephalus. Cerebrospinal fluid analysis was consistent with bacterial meningitis. Blood, joint, and mucosal membrane studies failed to isolate the causative organism, but his cerebrospinal fluid grew N gonorrhoeae. He was treated with high-dose intravenous ceftriaxone for two weeks with rapid improvement in his mental status and resolution of his joint pains and rash.

Neuroinfectious Disease Emergencies

Neuroinfectious diseases can affect immunocompetent and immunosuppressed individuals and cause a variety of emergencies including meningitis, encephalitis, and abscess. Neurologic infections are frequently complicated by secondary injuries that also present emergently such as cerebrovascular disease, acute obstructive hydrocephalus, and seizure. In most cases, timely recognition and early treatment of infection can improve the morbidity and mortality of infectious neurologic emergencies.

[Extra-ventricular drainage for the treatment of pneumococcal meningitis and hydrocephalus: a case report]

A 53-year-old man was referred to our hospital because of fever and disturbed consciousness with a left-sided toothache from 5 days ago. Neurological examinations revealed a low level of consciousness, nuchal rigidity, bilateral mydriasis, and positive Babinski sign. A lumbar puncture yielded clouded fluid with a WBC 22,698/μl (polynuclear cell 98%), 681 mg/dl of protein and 0 mg/dl of glucose. The antigen of Streptococcus pneumoniae in urine and cerebrospinal fluid (CSF) were positive. Streptococcus pneumoniae was isolated from CSF culture. Brain CT on admission showed a communicating hydrocephalus. Diagnosis of pneumococcal meningitis with hydrocephalus was made and we treated with ceftriaxone and dexamethasone. The lumbar drainage placed at L 3/4 level became occluded, thus, extra-ventricular drainage was performed. Intracranial pressure (ICP) was 20 cmH₂O upon insertion of the ICP sensor. At Day 2, the ICP decreased to 10 cmH₂O and never increased during his course of hospitalization. Repeat brain CT showed no hydrocephalus. He responded to antimicrobial therapy and became lucid and afebrile. At Day 4, the extra-ventricular drainage was removed because of bleeding from right choroid plexus on brain CT. We treated with antimicrobial therapy until Day 21. He was transferred to another hospital for rehabilitation with mild neurological sequelae at Day 31. The cases presenting with hydrocephalus in the acute phase of bacterial meningitis has a high mortality rate. The presence of hydrocephalus is a poor prognostic factor. Although the therapeutic value of extra-ventricular drainage for hydrocephalus has been unclear, his report represents a case for neurologists to consider performing extra-ventricular drainage for hydrocephalus.

Clinical Features of and Risk Factors for Hydrocephalus in Childhood Bacterial Meningitis

OBJECTIVE

To explore the clinical characteristics of and analyze the risk factors for hydrocephalus in children with bacterial meningitis.

METHODS

Retrospective study of a sample of children with bacterial meningitis seen on the pediatric service of Shengjing Hospital of China Medical University between January 1, 2010, and December 31, 2016.

RESULTS

Overall, 9.36% (25/267) of patients presented with hydrocephalus. Among patients with hydrocephalus, the age at onset of bacterial meningitis was usually <6 months, 15 patients had confirmed bacterial etiology, and 1 patient died. The most significant results of multivariate analysis for hydrocephalus were a rural living situation, altered level of consciousness, previous treatment with antibiotics, initial cerebrospinal fluid protein >2 g/L, C-reactive protein >100 mg/L, and dexamethasone use.

CONCLUSIONS

A severe clinical manifestation and significant laboratory index at admission are the most important predictors of hydrocephalus in children with bacterial meningitis.

Pneumococcal Meningitis Complicated by Cerebral Vasculitis, Abscess, Hydrocephalus, and Hearing Loss

Intracranial abscesses, postinfectious vasculitis, and hydrocephalus are rare complications of Streptococcus pneumoniae (S. pneumoniae) meningitis, and to our knowledge, there have been no case reports where all these 3 complications occurred in a single patient with Streptococcus pneumoniae meningitis. Here, we report a case of a 48-year-old male who developed postinfectious vasculitis, abscess, hydrocephalus, and hearing loss after S. pneumoniae meningitis. Clinicians ought to be aware of the possible adverse outcomes of S. pneumoniae meningitis and the limitations of current treatment options.

Age-specific global epidemiology of hydrocephalus: Systematic review, metanalysis and global birth surveillance

Background

Hydrocephalus is a debilitating disorder, affecting all age groups. Evaluation of its global epidemiology is required for healthcare planning and resource allocation.

Objectives

To define age-specific global prevalence and incidence of hydrocephalus.

Methods

Population-based studies reporting prevalence of hydrocephalus were identified (MEDLINE, EMBASE, Cochrane, and Google Scholar (1985–2017)). Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Two authors reviewed abstracts, full text articles and abstracted data. Metanalysis and meta-regressions were used to assess associations between key variables. Heterogeneity and publication bias were assessed. Main outcome of interest was hydrocephalus prevalence among pediatric (≤ 18 years), adults (19–64 years), and elderly (≥ 65) patients. Annual hydrocephalus incidence stratified by country income level and folate fortification requirements were obtained (2003–2014) from the International Clearinghouse for Birth Defects Surveillance and Research (ICBDSR).

Results

Of 2,460 abstracts, 52 met review eligibility criteria (aggregate population 171,558,651). Mean hydrocephalus prevalence was 85/100,000 [95% CI 62, 116]. The prevalence was 88/100,000 [95% CI 72, 107] in pediatrics; 11/100,000 [95% CI 5, 25] in adults; and 175/100,000 [95% CI 67, 458] in the elderly. The ICBDSR-based incidence of hydrocephalus diagnosed at birth remained stable over 11 years: 81/100,000 [95% CI 69, 96]. A significantly lower incidence was identified in high-income countries.

Conclusion

This systematic review established age-specific global hydrocephalus prevalence. While high-income countries had a lower hydrocephalus incidence according to the ICBDSR registry, folate fortification status was not associated with incidence. Our findings may inform future healthcare resource allocation and study.

Pitfalls in the Diagnosis and Management of Invasive Pneumococcal Meningoencephalitis - What We Can Learn From a Case

Invasive pneumococcal meningitis is a life-threatening infectious disease affecting the central nervous system. It continues to be the most common type of community-acquired acute bacterial meningitides. Despite advances in neuro-critical care, the case fatality rate remains high. Rapid diagnosis and initiation of antibiotic therapy precludes mortality and long-term neurological sequelae in survivors. However, not all cases are easily recognised, and unanticipated complications may impede optimal course and outcome. Here, we describe a case of invasive pneumococcal meningoencephalitis in a 65-year-old man with an unusual initial presentation and pitfalls in the course of the disease. We highlight the importance of early diagnosis and treatment as well as recognition and management of complications.

Neurological sequelae of bacterial meningitis

OBJECTIVES

We reported on occurrence and impact of neurological sequelae after bacterial meningitis.

METHODS

We reviewed occurrence of neurological sequelae in children and adults after pneumococcal and meningococcal meningitis.

RESULTS

Most frequently reported sequelae are focal neurological deficits, hearing loss, cognitive impairment and epilepsy. Adults with pneumococcal meningitis have the highest risk of developing focal neurological deficits, which are most commonly caused by cerebral infarction, but can also be due to cerebritis, subdural empyema, cerebral abscess or intracerebral bleeding. Focal deficits may improve during clinical course and even after discharge, but a proportion of patients will have persisting focal neurological deficits that often interfere in patient's daily life. Hearing loss occurs in a high proportion of patients with pneumococcal meningitis and has been associated with co-existing otitis. Children and adults recovering from bacterial meningitis without apparent neurological deficits are at risk for long-term cognitive deficits. Early identification of neurological sequelae is important for children to prevent additional developmental delay, and for adults to achieve successful return in society after the disease.

CONCLUSIONS

Neurological sequelae occur in a substantial amount of patients following bacterial meningitis. Most frequently reported sequelae are focal neurological deficits, hearing loss, cognitive impairment and epilepsy.

Brain ventricular dimensions and relationship to outcome in adult patients with bacterial meningitis

Background

Experimental studies suggest that changes in brain ventricle size are key events in bacterial meningitis. This study investigated the relationship between ventricle size, clinical condition and risk of poor outcome in patients with bacterial meningitis.

Methods

Adult patients diagnosed with bacterial meningitis admitted to two departments of infectious diseases from 2003 through 2010 were identified. Clinical and biochemical data as well as cerebral computed tomographic images were collected. The size of the brain ventricles were presented as a Ventricle to Brain Ratio (VBR). Normal range of VBR was defined from an age matched control group. A multivariate analysis was performed to identify predictors of 30-day mortality.

Results

One hundred and seven patients were included. Eighty-one patients had a CT scan at the time of diagnosis. VBR was identified as an independent risk factor of 30-day mortality, Mortality Rate Ratio: 6.03 (95 % confidence interval: 1.61-22.64, p = 0.008) for highest versus lowest tertile. A VBR deviating more than 2 standard deviations from the normal range was associated with increased mortality.

Conclusions

Brain ventricles are commonly subject to marked changes in size as a consequence of meningitis. Increased brain ventricle size in the acute phase of bacterial meningitis was associated with increased mortality.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-015-1097-3) contains supplementary material, which is available to authorized users.

Bacterial meningitis: new therapeutic approaches

Bacterial meningitis remains a disease with high mortality and long-term morbidity. Outcome critically depends on the rapid initiation of effective antibiotic therapy. Since a further increase of the incidence of pathogens resistant to antibacterials can be expected both in community-acquired and nosocomial bacterial meningitis, the choice of an optimum initial empirical antibiotic regimen will gain significance. In this context, the use of antibiotics which are bactericidal but do not lyse bacteria, may emerge as a therapeutic option. Conversely, the role of corticosteroids, which decrease the entry of hydrophilic antibacterials into the cerebrospinal fluid, as adjunctive therapy will probably decline as a consequence of the increasing antibiotic resistance of bacteria causing meningitis. Consequent vaccination of all children at present is the most efficient manner to reduce disease burden.