Clinical, microbiological and molecular characteristics of six cases of group A streptococcal meningitis in western Norway

Group A Streptococcal meningitis in children: a short case series and systematic review

BACKGROUND

Group A streptococcal(GAS) meningitis is a severe disease with a high case fatality rate. In the era of increasing GAS meningitis, our understanding about this disease is limited.

PURPOSE

To gain a better understanding about GAS meningitis.

METHODS

Five new cases with GAS meningitis were reported. GAS meningitis related literatures were searched for systematic review in PUBMED and EMBASE. Case reports and case series on paediatric cases were included. Information on demographics, risk factors, symptoms, treatments, outcomes, and emm types of GAS was summarized.

RESULTS

Totally 263 cases were included. Among 100 individuals, 9.9% (8/81) had prior varicella, 11.1% (9/81) had anatomical factors, and 53.2% (42/79) had extracranial infections. Soft tissue infections were common among infants (10/29, 34.5%), while ear/sinus infections were more prevalent in children ≥ 3 years (21/42, 50.0%). The overall case fatality rate (CFR) was 16.2% (12/74). High risk of death was found in patients with shock or systemic complications, young children(< 3 years) and cases related to hematogenic spread. The predominate cause of death was shock(6/8). Among the 163 patients included in case series studies, ear/sinus infections ranged from 21.4 to 62.5%, while STSS/shock ranged from 12.5 to 35.7%, and the CFR ranged from 5.9 to 42.9%.

CONCLUSIONS

A history of varicella, soft tissue infections, parameningeal infections and CSF leaks are important clinical clues to GAS in children with meningitis. Young children and hematogenic spread related cases need to be closely monitored for shock due to the high risk of death.

Detection and Management of Elevated Intracranial Pressure in the Treatment of Acute Community-Acquired Bacterial Meningitis: A Systematic Review

Acute bacterial meningitis (ABM) is associated with severe morbidity and mortality. The most prevalent pathogens in community-acquired ABM are Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae. Other pathogens may affect specific patient groups, such as newborns, older patients, or immunocompromised patients. It is well established that ABM is associated with elevated intracranial pressure (ICP). However, the role of ICP monitoring and management in the treatment of ABM has been poorly described.An electronic search was performed in four electronic databases: PubMed, Web of Science, Embase, and the Cochrane Library. The search strategy chosen for this review used the following terms: Intracranial Pressure AND (management OR monitoring) AND bacterial meningitis. The search yielded a total of 403 studies, of which 18 were selected for inclusion. Eighteen studies were finally included in this review. Only one study was a randomized controlled trial. All studies employed invasive ICP monitoring techniques, whereas some also relied on assessment of ICP-based on clinical and/or radiological observations. The most commonly used invasive tools were external ventricular drains, which were used both to monitor and treat elevated ICP. Results from the included studies revealed a clear association between elevated ICP and mortality, and possibly improved outcomes when invasive ICP monitoring and management were used. Finally, the review highlights the absence of clear standardized protocols for the monitoring and management of ICP in patients with ABM. This review provides an insight into the role of invasive ICP monitoring and ICP-based management in the treatment of ABM. Despite weak evidence certainty, the present literature points toward enhanced patient outcomes in ABM with the use of treatment strategies aiming to normalize ICP using continuous invasive monitoring and cerebrospinal fluid diversion techniques. Continued research is needed to define when and how to employ these strategies to best improve outcomes in ABM.

The needs for diagnostic imaging in cases of group A streptococcal meningitis in children: a case report and review of the literature

Group A streptococcus (GAS) is a rare cause of bacterial meningitis in children and is associated with a high cerebral complication rate. In this case report, we present a 9-year-old girl with GAS meningitis complicated with cerebritis. Clear guidelines about choice of treatment and indications of follow-up by imaging tests are lacking, making GAS meningitis unpredictable and difficult to treat. Eventually, we found 25 paediatric cases of GAS meningitis presented in the literature and reviewed their treatment choices, outcomes and follow-up by imaging tests. Penicillin and ceftriaxone are most preferred for the treatment of GAS meningitis and adding rifampicin to the antibiotic treatment could be of potential benefit. When considering the duration of antibiotic treatment and follow-up by imaging tests, no clear recommendations were found. We found that GAS meningitis is associated with higher mortality and cerebral complication rates compared to other, more common, bacterial causes of meningitis in children. This should alert the clinician to consider imaging tests routinely, even if the patient improves clinically. We advise clinicians to routinely evaluate for possible cerebral complications through magnetic resonance imaging (MRI) scans. When cerebral complications are found, antibiotic treatment should be prolonged and adding rifampicin to the antibiotic regime may be considered.

Community-acquired meningitis caused by beta-haemolytic streptococci in adults: a nationwide population-based cohort study

The objective of this study was to examine the clinical presentation of community-acquired beta-haemolytic streptococcal (BHS) meningitis in adults. This is a nationwide population-based cohort study of adults (≥ 16 years) with BHS meningitis verified by culture or polymerase chain reaction of the cerebrospinal fluid (CSF) from 1993 to 2005. We retrospectively evaluated clinical and laboratory features and assessed outcome by Glasgow Outcome Scale (GOS). We identified 54 adults (58% female) with a median age of 65 years (IQR 55-73). Mean incidence rate was 0.7 cases per 1,000,000 person-years. Alcohol abuse was noted among 11 (20%) patients. Group A streptococci (GAS) were found in 17 (32%) patients, group B (GBS) in 18 (34%), group C (GCS) in four (8%) and group G (GGS) in 14 (26%). Patients with GAS meningitis often had concomitant otitis media (47%) and mastoiditis (30%). Among patients with GBS, GCS or GGS meningitis, the most frequent concomitant focal infections were bone and soft tissue infections (19%) and endocarditis (16%). In-hospital mortality was 31% (95% CI 19-45), and 63% (95% CI 49-76) had an unfavourable outcome at discharge (GOS < 5). BHS meningitis in adults is primarily observed among the elderly and has a poor prognosis. GAS meningitis is primarily associated with concomitant ear-nose-throat infection.

Group A Streptococcal meningitis in adults

OBJECTIVES

We report on the incidence, clinical characteristics, and bacterial genotype of group A streptococcal (GAS) meningitis in the Netherlands.

METHODS

We assessed the incidence, clinical characteristics, and outcome of patients with GAS meningitis from a nationwide cohort study of adults with community-acquired bacterial meningitis in the Netherlands from 2006 to 2013.

RESULTS

GAS was identified in 26 of 1322 patients with community-acquired bacterial meningitis (2%); 9 cases (35%) occurred in the first four months of 2013. GAS meningitis was often preceded by otitis or sinusitis (24 of 26 [92%]) and a high proportion of patients developed complications during clinical course (19 of 26 [73%]). Subdural empyema occurred in 8 of 26 patients (35%). Nine patients underwent mastoidectomy and in 5 patients neurosurgical evacuation of the subdural empyema was performed. Five of 26 patients (19%) died and 11 of 21 surviving patient had neurologic sequelae (52%). Infection with the emm1 and cc28 GAS genotype was associated with subdural empyema (both 4 of 6 [67%] vs. 2 of 14 [14%]; P = 0.037).

CONCLUSIONS

GAS meningitis is an uncommon but severe disease. Patients are at risk for empyema, which is associated with infection with the emm1 and cc28 genotype.

[Group A streptococcal meningitis: Streptococcus pneumoniae is not the only one to seep into the CSF fluid leak!]

We reported a case of group A streptococcal meningitis in a patient with a CSF fluid leak. This case underlined several relevant points: (i) an unfrequent cause of bacterial meningitis; (ii) the main diagnosis to evoke when the direct examination of CSF shows Gram+ cocci with a negative pneumococcal antigen; (iii) that bacteria other than Streptococcus pneumoniae are possible in front of a meningitis associated with a CSF fluif leak.

Group A streptococcus meningitis in children

OBJECTIVE

To characterize the epidemiologic burden and the molecular determinants of group A streptococcal (GAS) meningitis among the pediatric population of the state of Paraná, Brazil.

METHODS

Clinical and epidemiologic data were gathered by a compulsory notification system during the period 2003 to 2011. Bacterial identification, antibiotic resistance profile, emm-typing, pulsed-field gel electrophoresis typing and virulence profile were analyzed by a central reference laboratory. A review of published pediatric cases of GAS meningitis from the last 45 years was undertaken and compared with the Brazilian series.

RESULTS

The incidence of GAS meningitis among the pediatric population was 0.06 cases per 100,000 children per year and was associated with a case fatality rate of 43%. Neonatal age and the presence of an associated toxic shock syndrome were identified as risk factors for death. A distant focus of infection was present in more than half of the patients in the literature and in 36% in the Brazilian case series. A high diversity of emm-types was associated with GAS meningitis in Brazil. No single virulence determinant could be associated with death.

CONCLUSIONS

GAS meningitis is associated with high mortality and with a high diversity of GAS emm-types and virulence determinants in Brazil.

Group A streptococcal meningitis in a patient with palmoplantar pustulosis

A 64-year-old man with a 10-year history of palmoplantar pustulosis, a recent history of cranial surgery and a persistent upper airway infection presented with a high fever and deep coma. The patient was diagnosed with Group A Streptococcal meningitis and promptly treated with antibiotics. Although his general condition recovered well, sensorineural hearing loss and facial palsy remained. Group A Streptococcal meningitis is a rare condition, and its typical clinical picture and epidemiological features remain poorly understood. Physicians need to be more aware of this infection, which is extremely rare but frequently causes various complications and yields a high mortality.