Bacterial Meningitis in Children: Neurological Complications, Associated Risk Factors, and Prevention

Steno-occlusive Intracranial Large Vessel Arteriopathies in Childhood: A Pattern Oriented Approach to Neuroimaging Diagnosis

Intracranial steno-occlusive large vessel arteriopathies refer to abnormalities of the arterial wall that typically express luminal stenosis. Notably, some entities that can find themselves within this category may also express luminal dilation, and/or aneurysm formation as an alternative phenotype. Intracranial steno-occlusive large vessel arteriopathies are a leading cause of arterial ischemic stroke (AIS) in children, often progress, and can predispose to recurrent brain infarction. Intracranial arterial dissections account for a subset of cases expressing the focal cerebral arteriopathy (FCA) phenotype because the affected arterial segment, clinical presentation, and AIS patterns are very similar to the inflammatory subtype of FCA.

Frequency, risk factors, and outcome of neonatal meningitis in sepsis

Objective

To determine the frequency, associated risk factors, and outcome of meningitis in neonates presenting with sepsis at Aga khan Tertiary Care Hospital, Karachi.

Methods

A descriptive cross-sectional study was conducted at pediatrics department of Aga Khan Tertiary University Hospital, Karachi, Pakistan from July 31, 2020, till January 30, 2021. Neonates of either gender admitted with neonatal sepsis were enrolled using non-probability consecutive sampling technique. Meningitis was diagnosed as per the findings of cerebrospinal fluid (CSF) along with the outcome in terms of death and early neurological complications such as subdural effusions and hydrocephalus.

Results

Of 209 neonates with sepsis, meningitis was observed in 59 (28.2%) neonates. A significantly lower mean weight (p-value 0.024) while significantly higher mean duration of stay (p-value <0.001) was observed in patient with meningitis. Moreover, a significantly higher proportion of meningitis was observed in neonates who had fever (p-value 0.048), vomiting (p-value 0.009), abdominal distension (p-value <0.001), and blood culture positivity (p-value <0.001). Blood culture positive Methicillin-sensitive Staphylococcus aureus (MSSA) was considerably higher among neonates with meningitis. Of 59 neonates with meningitis, mortality was observed in 2 (3.4%) neonates. Positive CSF culture was observed in 6 (2.9%) while hydrocephalus was observed in 7 (11.9%) and effusion in 6 (10.2%) neonates.

Conclusion

Neonatal meningitis is common in neonates presenting with sepsis, but mortality rate is low. Positive cultures, particularly with MSSA, further underscore the bacterial etiology in neonatal meningitis.

Meta-analysis of the make-up and properties of in vitro models of the healthy and diseased blood-brain barrier

In vitro models of the human blood-brain barrier (BBB) are increasingly used to develop therapeutics that can cross the BBB for treating diseases of the central nervous system. Here we report a meta-analysis of the make-up and properties of transwell and microfluidic models of the healthy BBB and of BBBs in glioblastoma, Alzheimer's disease, Parkinson's disease and inflammatory diseases. We found that the type of model, the culture method (static or dynamic), the cell types and cell ratios, and the biomaterials employed as extracellular matrix are all crucial to recapitulate the low permeability and high expression of tight-junction proteins of the BBB, and to obtain high trans-endothelial electrical resistance. Specifically, for models of the healthy BBB, the inclusion of endothelial cells and pericytes as well as physiological shear stresses (~10-20 dyne cm-2) are necessary, and when astrocytes are added, astrocytes or pericytes should outnumber endothelial cells. We expect this meta-analysis to facilitate the design of increasingly physiological models of the BBB.

Study of pediatric invasive pneumococcal disease in the 13-pneumococcal conjugated vaccine era

BACKGROUND

Invasive pneumococcal disease (IPD) remains a significant concern among children under 5, despite vaccination efforts. This study assessed IPD prevalence and associated risks in pediatric population.

METHODS

An observational, retrospective, multicenter study in Comunidad Valenciana, Spain, of IPD cases in children under 13 from January 2012 to September 2022. Data from the CV Microbiology Surveillance Network (RedMIVA) and medical records were reviewed.

RESULTS

A total of 379 IPD cases in 377 patients were analyzed, predominantly males (54.11 %) under 5 (81.17 %). PCV13 vaccination notably reduced PCV13-serotypes IPD (p=0.0002), except serotype 3. Pneumonia was common, with half having underlying conditions (50.40 %). Worse outcomes occurred in patients with neurological disorders (ANOVA, p=0.57). Vaccine failures often involved underlying conditions (63 %) and serotypes 3 and 19A. Immunodeficiencies may relate to recurrent IPD, but evidence is limited.

CONCLUSION

Despite vaccination, IPD still impacts children, influenced by immunological status, affecting severity and mortality.

Risk of psychiatric neurodevelopmental disorders after meningitis in childhood: a nationwide, population-based cohort study

BACKGROUND

Few studies have investigated the risk of psychiatric neurodevelopmental disorders (PNDD) after childhood meningitis.

METHODS

Nationwide population-based cohort study (Denmark, 1995-2021) of children with positive cerebrospinal fluid for bacteria or enterovirus, stratified on age as young infants (0 to <90 days, n = 637) or older children (≥90 days to <17 years, n = 1,218). We constructed a comparison cohort from the general population (n = 18,550), and cohorts of siblings of participants. As risk estimates of PNDD we calculated age- and sex-adjusted hazard ratios (aHRs) with 95% confidence intervals (95%CI).

RESULTS

Children with bacterial meningitis had increased risks of PNDD, especially learning and intellectual developmental disorders (young infants: aHR 4.2, 95%CI: 2.4-7.1; older children: aHR 1.5, 95%CI: 1.0-2.3), attention deficit disorder (ADHD) (young infants: aHR 2.8, 95%CI: 1.5-5.2; older children: 1.4, 95%CI: 0.9-2.2) and redemption of ADHD medication (young infants: aHR 2.2, 95%CI: 1.0-4.7; older children: 1.5, 95%CI: 1.0-2.3). Young infants with bacterial meningitis additionally had increased risks of autism spectrum disorders (aHR 1.9, 95%CI: 0.9-4.1) and behavioural and emotional disorders (aHR 2.0, 95%CI: 1.0-3.9). In young infants, the excess risk of PNDD was especially observed in premature children. Siblings of older children with bacterial meningitis also had increased risks of PNDD. Children with enteroviral meningitis at any age did not have increased risks of PNDD or redemption of ADHD medication.

CONCLUSIONS

Bacterial meningitis in childhood is associated with subsequent diagnosis of PNDD, while enteroviral meningitis is not. The association appears to be partly explained by prematurity and familial and socioeconomic factors.

From cytokines to chemokines: Understanding inflammatory signaling in bacterial meningitis

Bacterial meningitis is a serious central nervous system (CNS) infection, claiming millions of human lives annually around the globe. The deadly infection involves severe inflammation of the protective sheath of the brain, i.e., meninges, and sometimes also consists of the brain tissue, called meningoencephalitis. Several inflammatory pathways involved in the pathogenesis of meningitis caused by Streptococcus pneumoniae, Neisseria meningitidis, Escherichia coli, Haemophilus influenzae, Mycobacterium tuberculosis, Streptococcus suis, etc. are mentioned in the scientific literature. Many in-vitro and in-vivo analyses have shown that after the disruption of the blood-brain barrier (BBB), these pathogens trigger several inflammatory pathways including Toll-Like Receptor (TLR) signaling in response to Pathogen-Associated Molecular Patterns (PAMPs), Nucleotide oligomerization domain (NOD)-like receptor-mediated signaling, pneumolysin related signaling, NF-κB signaling and many other pathways that lead to pro-inflammatory cascade and subsequent cytokine release including interleukine (IL)-1β, tumor necrosis factor(TNF)-α, IL-6, IL-8, chemokine (C-X-C motif) ligand 1 (CXCL1) along with other mediators, leading to neuroinflammation. The activation of another protein complex, nucleotide-binding domain, leucine-rich-containing family, pyrin domain-containing-3 (NLRP3) inflammasome, also takes place resulting in the maturation and release of IL-1β and IL-18, hence potentiating neuroinflammation. This review aims to outline the inflammatory signaling pathways associated with the pathogenesis of bacterial meningitis leading to extensive pathological changes in neurons, astrocytes, oligodendrocytes, and other central nervous system cells.

Cochlear Implantation in Post-Meningitis Deafness: Audiological, Imaging, and Postoperative Outcomes: A Systematic Review With Qualitative Synthesis

INTRODUCTION

Post-meningitis deafness (PMD) is a potentially devastating cause of hearing loss among pediatric and adult patients, for which hearing rehabilitation with cochlear implants (CIs) remains the standard of care. To date, there have been limited systematic studies on the impact of cochlear ossification (CO) and time-to-implantation (TTI) on audiological outcomes.

METHODS

An online database search was performed on the PubMed, Embase, and Scopus databases for articles within the past 20 years pertaining to audiological outcomes among pediatric and adult patients with PMD. Information on study characteristics, patient demographics, clinical outcomes, and postoperative complications was collected and analyzed.

RESULTS

From 8,325 articles generated in the original search, 11 were included in the final analysis, representing 376 patients in total. Of the articles discussing TTI, the majority (3 of 4) found that a shorter TTI of 6 months on average led to improved audiological outcomes compared with control groups with a longer TTI. Of the articles that discussed the impact of preoperative CO, the majority (4 of 6) found that the presence of CO had a detrimental effect on postoperative audiological outcomes after CI. Finally, of the articles that discussed long-term audiological outcomes for PMD compared with the non-PMD control group after CI, the majority (4 of 7) found that PMD patients had inferior long-term outcomes.

CONCLUSION

CI is a safe and effective treatment modality for PMD, with the majority of literature demonstrating improved long-term outcomes for patients without CO and a reduced TTI.

High-Resolution Ultrasound Platform for Infant Meningitis Detection: An In Vitro Demonstration

Infant meningitis remains a severe burden on global health, particularly for young infants. Traditional ultrasound imaging techniques are limited in spatial resolution to visualize white blood cells (WBCs) in the cerebrospinal fluid (CSF), which is considered a well-established marker for meningitis detection. This work presents a novel platform that uses high-resolution ultrasound to detect the backscatter signals from microscopic CSF WBCs through the anterior fontanelle of neonates and young infants. The whole system was built around a custom probe that allows for a 20 MHz focused transducer to be mechanically controlled to map the area of interest in the CSF. Data processing can be performed internally in the device without the need to extract the images for further analysis. The in vitro feasibility of the proposed solution was evaluated in imaging 7 μm particle suspensions at different concentrations relevant to meningitis diagnosis ranging from 7- to 646-particles (pp)/μL. The experimental tests were conducted from a simple setup using a sample container to a more realistic setup based on an anatomical phantom of the neonatal head. The results show high-quality images, where 7 μm particles can be resolved for the different concentrations.

Epidemiology and Clinical Outcomes of Bacterial Meningitis in Children and Adults in Low- and Middle-Income Countries

Purpose of Review

Despite the availability of effective vaccines against the three primary pathogens (Streptococcus pneumoniae, Haemophilus influenzae type b, and Neisseria meningitidis) that cause bacterial meningitis, this condition remains a significant cause of morbidity, neurologic sequelae, and mortality among children and adults living in low-income and middle-income countries.

Recent Findings

Bacterial meningitis represents a significant public health challenge for national and global health systems. Since vaccine-preventable meningitis remains highly prevalent in low-income and middle-income countries, the World Health Organization (WHO) recently developed a global roadmap to defeating meningitis by 2030 and ameliorating its associated neurological sequelae.

Summary

There is a need for a global approach to surveillance and prevention of bacterial meningitis. Increasing vaccination coverage with conjugate vaccines against pneumococcus and meningococcus with optimal immunization schedules are high-value healthcare interventions. Additionally, overcoming diagnostic challenges and the early institution of empirical antibiotic therapy and, when feasible, adjunctive steroid therapy constitutes the pillars of reducing the disease burden of bacterial meningitis in resource-limited settings.

Delayed presentation is associated with serious bacterial infections among febrile infants: A prospective cohort study

Introduction

Febrile young infants are at risk of serious bacterial infections (SBIs), which are potentially life-threatening. This study aims to investigate the association between delayed presentation and the risk of SBIs among febrile infants.

Method

We performed a prospective cohort study on febrile infants ≤90 days old presenting to a Singapore paediatric emergency department (ED) between November 2017 and July 2022. We defined delayed presentation as presentation to the ED >24 hours from fever onset. We compared the proportion of SBIs in infants who had delayed presentation compared to those without, and their clinical outcomes. We also performed a multivariable logistic regression to study if delayed presentation was independently associated with the presence of SBIs.

Results

Among 1911 febrile infants analysed, 198 infants (10%) had delayed presentation. Febrile infants with delayed presentation were more likely to have SBIs (28.8% versus [vs] 16.3%, P<0.001). A higher proportion of infants with delayed presentation required intravenous antibiotics (64.1% vs 51.9%, P=0.001). After adjusting for age, sex and severity index score, delayed presentation was independently associated with the presence of SBI (adjusted odds ratio [AOR] 1.78, 95% confidence interval 1.26-2.52, P<0.001).

Conclusion

Febrile infants with delayed presentation are at higher risk of SBI. Frontline clinicians should take this into account when assessing febrile infants.

Neuroinfectious Diseases in Children: Pathophysiology, Outcomes, and Global Challenges

Pathogens with affinity for the central nervous system (CNS) in children are diverse in their mechanisms of infecting and attacking the brain. Infections can reach the CNS via hematogenous routes, transneurally thereby avoiding the blood-brain barrier, and across mucosal or skin surfaces. Once transmission occurs, pathogens can wreak havoc both by direct action on host cells and via an intricate interplay between the protective and pathologic actions of the host's immune system. Pathogen prevalence varies depending on region, and susceptibility differs based on epidemiologic factors such as age, immune status, and genetics. In addition, some infectious diseases are monophasic, whereas others may lie dormant for years, thereby causing a dynamic effect on outcomes. Outcomes in survivors are highly variable for each particular pathogen and depend on the vaccination and immune status of the patient as well as the speed by which the patient receives evidence-based treatments. Given pathogens cause communicable diseases that can cause morbidity and mortality on a population level when spread, the burden is often the greatest and the outcomes the worst in low-resource settings. Here we will focus on the most common infections with a propensity to affect a child's brain, the pathologic mechanisms by which they do so, and what is known about the developmental outcomes in children who are affected by these infections.

Abnormal Neurologic Findings in Patients With Sickle Cell Disease Without a History of Major Neurologic Events

Background and Objectives

Patients with sickle cell disease (SCD) are prone to symptomatic neurologic complications. Previous studies reported accrual of neural injury starting at early age, even without having symptomatic neurologic events. The aim of this study was to assess the prevalence and risk factors of abnormal neurologic findings in patients with SCD with no history of major symptomatic neurologic events.

Methods

Our study extracted patients diagnosed with SCD from the Cooperative Study of Sickle Cell Disease. Patients who underwent a neurologic evaluation were included in our analysis. Patients with previous documented major symptomatic neurologic events were excluded. We compared patients with SCD with abnormal neurologic findings with those without in terms of clinical and laboratory parameters using multivariate binary logistic regression.

Results

A total of 3,573 patients with SCD were included (median age = 11 [IQR = 19] years, male = 1719 [48.1%]). 519 (14.5%) patients had at least one abnormal neurologic finding. The most common findings in descending order were abnormal reflexes, gait abnormalities, cerebellar dysfunction, language deficits, nystagmus, abnormal muscle tone and strength, Romberg sign, Horner syndrome, and intellectual impairment. History of eye disease (odds ratio [OR] = 2.76, 95% confidence interval [CI] = 1.63-4.68) and history of osteomyelitis (OR = 2.55, 95% CI 1.34-4.84) were the strongest predictors of abnormal neurologic findings, followed by smoking (OR = 1.59, 95% CI 1.08-2.33), aseptic necrosis (OR = 1.57, 95% CI 1.06-2.33), hand-foot syndrome (OR = 1.48, 95% CI 1.04-2.12), and male sex (OR = 1.42, 95% CI 1.01-2.02).

Discussion

Neurologic deficits are relatively common in patients with SCD, even without documented major neurologic insults. They range from peripheral and ophthalmic deficits to central and cognitive disabilities. Patients with SCD should have early regular neurologic evaluations and risk factor modification, particularly actively promoting smoking cessation.

Retrospective database analysis for clinical diagnoses commonly associated with pneumococcal diseases in the Malaysian healthcare system over a 3-year period (2013-2015)

BACKGROUND

Pneumococcal disease caused by Streptococcus pneumoniae is an important cause of morbidity and mortality across all ages, particularly in younger children and older adults. Here, we describe pneumococcal disease hospitalizations at Ministry of Health (MoH) facilities in Malaysia between 2013 and 2015.

METHODS

This was a retrospective databases analysis. Tabular data from the Malaysian Health Data Warehouse (MyHDW) were used to identify microbiologically confirmed, pneumococcal disease hospitalizations and deaths during hospitalization, using hospital-assigned ICD-10 codes (i.e., classified as meningitis, pneumonia, or non-meningitis non-pneumonia). Case counts, mortality counts, and case fatality rates were reported by patient age group and by Malaysian geographic region.

RESULTS

A total of 683 pneumococcal disease hospitalizations were identified from the analysis: 53 pneumococcal meningitis hospitalizations (5 deaths and 48 discharges), 413 pneumococcal pneumonia hospitalizations (24 deaths and 389 discharges), and 205 non-meningitis non-pneumonia pneumococcal disease hospitalizations (58 deaths and 147 discharges). Most hospitalizations occurred in children aged < 2 years. Crude mortality was highest among children aged < 2 years (for all three disease categories), among adults aged ≥ 65 years (for pneumococcal pneumonia), or among adults aged 65-85 years (for non-meningitis non-pneumonia pneumococcal disease). The case fatality rate, all ages included, was 5.8% for pneumococcal pneumonia, 9.1% for pneumococcal meningitis, and 28.3% for non-meningitis non-pneumonia pneumococcal disease.

CONCLUSIONS

Our study is the first to document pneumococcal disease hospitalizations and deaths during hospitalization in Malaysia. Although this database analysis likely underestimated case counts, and the true disease burden could be even greater, the study demonstrates a substantial burden of pneumococcal disease. Public health measures, including vaccination, would significantly contribute to the prevention of hospitalizations and deaths associated with pneumococcal disease in Malaysia.

Diagnostic status and epidemiological characteristics of community-acquired bacterial meningitis in children from 2019 to 2020: a multicenter retrospective study

Community-acquired bacterial meningitis (CABM) is the main cause of morbidity and mortality in children. The epidemiology of CABM is regional and highly dynamic. To clarify the diagnostic status and epidemiological characteristics of children with CABM in this region, and pay attention to the disease burden, so as to provide evidence for the prevention and treatment of CABM. By retrospective case analysis, the clinical data of 918 CABM cases in children aged 0-14 years in Zhejiang Province from January, 2019 to December, 2020 were collected. The etiological diagnosis rate of CABM in children was 23.1%, the annual incidence rate 4.42-6.15/100,000, the annual mortality rate 0.06-0.09/100,000,the cure and improvement rate 94.4%, and the case fatality rate 1.4%. The total incidence of neuroimaging abnormalities was 20.6%. The median length of stay for CABM children was 20(16) days, with an average cost of 21,531(24,835) yuan. In addition, the incidence rate was decreased with age. Escherichia coli(E.coli) and group B Streptococcus agalactiae(GBS) were the principal pathogens in CABM infant<3 months(43.3%, 34.1%), and Streptococcus pneumoniae(S. pneumoniae) was the most common pathogen in children ≥ 3 months(33.9%). In conclusion, the annual incidence and mortality of CABM in children aged 0-14 years in Zhejiang Province are at intermediate and low level. The distribution of CABM incidence and pathogen spectrum are different in age; the incidence of abnormal neuroimaging is high; and the economic burden is heavy.

A Severe Case of Streptococcus pneumoniae Meningoencephalitis in an Infant Resulting in Fatal Strokes

Streptococcus pneumoniae (S. Pneumoniae) is a common cause of bacterial meningitis in the pediatric population, but rarely causes complications such as encephalitis, abscess, and seizures with the prompt initiation of proper antimicrobial therapy. In this report, we present a rare and severe case of S. Pneumoniae meningoencephalitis in a full term 6-month-old which progressed to multiple cerebral and cerebellar infarcts with concomitant cerebellar tonsillar herniation and hypercarbic respiratory failure requiring intubation and mechanical ventilation despite early initiation of antibiotics. Given the patient's clinical status and poor neurological prognosis, the family eventually opted for palliative extubation.

Meningitis in Niger Republic amidst COVID-19: current issues and novel recommendations

Amidst coronavirus disease 2019 (COVID-19), there has been a misplaced priority on meningitis in the Niger Republic, thus refocusing resources and attention away from the continuing meningitis campaign in the Niger Republic. The over-strained state of public health resources and staff has also led to decreased surveillance, postponed diagnoses, and constrained immunization efforts in Niger Republic. This review aims to bridge the gaps regarding meningitis amid COVID-19 in Niger Republic and offer recommendations to government to mitigate meningitis in the country, with the hope of finding a permanent solution to this debilitating disease. The authors reviewed 45 past and present pieces of literature on meningitis and COVID-19 from 2013 to 2023 in well-renowned scientific databases such as PubMed, ResearchGate, Google Scholar, African Journals Online, Medline, and Embase. Since 2015, Niger Republic has experienced multiple meningitis epidemics that have resulted in 20, 789 cases and 1, 369 deaths [a case fatality rate (CFR) of 6.6%]. A total of 231 cases of meningitis were reported from 1 November 2021 to 31 January 2022. And recently, 559 cases of meningitis (of which 111 are laboratory confirmed), including 18 deaths (overall CFR 3.2%), occurred in the Zinder region, southeast of Niger Republic, from 1 November 2022 to 27 January 2023. Meningitis remains a public health concern in the world, especially in Niger Republic, which could lead to serious long-term complications. Therefore, adequate and novel measures and therapeutic actions should be implemented by the Niger Government to lessen the burden of the disease in the country.

Postmeningitic pediatric hearing loss from non-type b Haemophilus influenzae

BACKGROUND

Postmeningitic hearing loss from Haemophilus influenzae (H. influenzae) is increasingly due to encapsulated serotypes other than type b (Hib) and nontypeable strains (collectively, nHiB H. influenzae). Pediatric hearing loss after nHib H. influenzae meningitis remains poorly described.

METHODS

Retrospecive case series of nHiB H. influenzae meningitis cases identified from a microbiologic database at Children's Hospital Colorado from 2000 to 2020. Literature regarding nHiB H. influenzae and H. influenzae postmeningitic hearing loss was also reviewed.

RESULTS

Eleven cases of nHib H. influenzae meningitis (median age 15.9 months) were identified due to serotype f (36 %), serotype a (27 %), and nontypable strains (36 %). Seven (64 %) patients were male, 55 % were white and 18 % were Hispanic or Latino. Hearing loss was initially identified in 4 children (40 %), with two patients with moderate conductive hearing loss (CHL) and one child with unilateral moderate sensorineural (SNHL) hearing loss patients recovering normal hearing. One patient with bilateral profound sensorineural hearing loss and associated labyrinthitis ossificans required cochlear implantation. All children (4) with identified hearing loss were noted to have additional intracranial sequelae, which included empyema (2), sinus thrombosis (2), and seizures (2). Of patients receiving steroids, 25 % had hearing loss on initial testing, compared to 66 % of those who did not receive steroids.

CONCLUSIONS

nHib H. influenzae can cause both transient and permanent postmeningitic hearing loss. Steroids may offer otoprotection in nHib H. influenzae meningitis similar to Hib meningitis. Given the limited literature, further study is needed to better characterize hearing outcomes after nHib H. influenzae meningitis.

Neonatal bacterial meningitis: hearing screening and audiological monitoring outcomes

OBJECTIVE

This study reviewed the outcomes of universal newborn hearing screening (UNHS) and ongoing hearing monitoring in children following recovery from neonatal bacterial meningitis to determine (a) whether screening may be a suitable alternative to diagnostic audiology for detecting permanent childhood hearing loss (PCHL) and (b) whether infants who pass UNHS should be monitored throughout childhood.

DESIGN

Retrospective analysis of a UNHS database.

STUDY SAMPLE

Data were extracted from the state-wide UNHS database for all children born in Queensland Australia between 1 September 2004 and 30 June 2020 with the risk factor of bacterial meningitis (in isolation or in combination with other risk factors) identified at the time of the UNHS. This cohort included 231 children.

RESULTS

Results showed that all post-meningitic infants diagnosed with PCHL had a refer result on the UNHS or were medically excluded from screening. Additionally, no cases of PCHL were identified through the targeted surveillance program following a pass result on UNHS.

CONCLUSIONS

UNHS may be sufficient to detect PCHL in post-meningitic neonates and routine audiological monitoring may not be required for children who pass the screen.

Scope of an Integrative Neurophysiotherapy Approach in Achieving Gross Motor Milestones in a Child with Meningitis: A Case Report

Meningitis caused by bacteria, which is an inflammation of the meninges affecting the pia, arachnoid, and subarachnoid space, is still one of the leading causes of death and morbidity in infants and young children. Neisseria meningitidis, group B streptococcus (GBS), Haemophilus influenzae type B (Hib), Listeria monocytogenes, and Streptococcus pneumoniae have been found to be the most frequent causative agents. Infants and children can have modest, fluctuating, non-specific, or even absent clinical signs of bacterial meningitis. They may include bulging fontanelles, vomiting, diarrhea, respiratory distress, hypothermia, lethargy, irritability, poor feeding, and fever in babies. In this case report, an 18-month-old child presented to a local hospital with complaints of multiple episodes of high-grade fever. After 10 days, his symptoms worsened and he experienced two episodes of seizures at one-day intervals at night. He was taken to Acharya Vinoba Bhave Rural Hospital for further management. Blood investigations revealed seropositive results for dengue virus infection. On MRI and CT scan, it was diagnosed as an old case of subdural hematoma in the right frontotemporal region of the brain. The patient was on intravenous ceftriaxone and phenytoin. Gross motor developmental milestones in children with meningitis can be improved with early integrative neurophysiotherapy and a goal-oriented therapeutic regimen that includes mobility exercises, proprioceptive neuromuscular facilitation techniques, positioning, oromotor retraining, neurodevelopmental techniques, and balance and coordination retraining. A complex case presents with bacterial meningitis, hydrocephalus, and seizure disorder. The bacterial infection inflames the protective membranes of the brain, causing hydrocephalus. Increased cerebrospinal fluid puts pressure on the brain, leading to seizures. Managing these interconnected conditions requires a multidisciplinary approach making it unique, involving infectious disease, neurology, and neurosurgery expertise.

Disease Burden of Meningitis Caused by Streptococcus pneumoniae Among Under-Fives in China: A Systematic Review and Meta-analysis

INTRODUCTION

Streptococcus pneumoniae is the leading cause of meningitis, with a case fatality of up to about 50%. Children younger than 5 years are at greater risk for pneumococcal meningitis compared with other populations. It is of significant importance to provide a comprehensive understanding of the burden of pneumococcal meningitis among under-fives in the low pneumococcal conjugate vaccine (PCV) coverage period in China.

METHODS

A systematic review was conducted. We searched both English (PubMed, Ovid-EMBASE, Biosis, Web of Science, and Cochrane) and Chinese (CNKI, Wanfang, and ViP) databases for studies on bacterial meningitis in China published between January 1980 and July 2022. Ineligible studies were excluded based on study design and data integrity. Heterogeneity was assessed with I2 and estimates of bacterial meningitis morbidity and mortality were pooled using random-effects models. Subgroup analysis was conducted to trace the source of the heterogeneity and summarize average estimates.

RESULTS

A total of 13,082 studies were identified in the literature, and 56 studies were finally included for data analysis. The estimated incidence of pneumococcal meningitis was 2.10 cases per 100,000 children younger than 5 years each year (95% CI: 0.59-7.46), with a pooled case fatality rate of 24.59% (95%CI: 19.35-30.28%) in China. It was estimated that 1617.16 (95% CI: 454.35-5744.78) pneumococcal meningitis cases and 548.86 (95% CI: 474.80-627.62) deaths occurred among under-fives in China in 2020. Streptococcus pneumoniae played an important role in the etiology of confirmed bacterial meningitis cases, with a pooled proportion of 22.05% (95% CI: 17.83-26.27%). The most prevalent serotypes were 6B, 14, 19F, 19A, and 23F, which were preventable with a vaccine.

CONCLUSIONS

Pneumococcal meningitis remains one of the most important health problems among children younger than 5 years in China. Immunization programs should be promoted to avoid preventable cases and deaths.

Surgical Indications and Outcomes of Postmeningitis Subdural Collection in Infants: Single Tertiary Care Center Experience

BACKGROUND

 Postmeningitis subdural collection (PMSC) is a complication in infants with bacterial meningitis. Clinical and radiologic findings enable treating teams to gain more insights into diagnosing and managing PMSC. This study aims to establish the indications for surgical management of PMSC in infants based on a single pediatric tertiary care center experience.

METHODS

 We reviewed the hospital records of infants diagnosed with PMSC between January 2015 and December 2021. They were diagnosed based on clinical suspicion that was confirmed through imaging using computed tomography (CT) scanning or magnetic resonance imaging (MRI). All patients received antibiotic treatment, and surgical interventions using subdural drain placement or craniotomy were performed. The patients were followed up for outcomes and prognosis for 1 to 5 years.

RESULTS

 A total of 17 infants were included in the study. Infants younger than 4 months represented most cases of PMSC (64.7%). Initially, bacterial growth was seen in the cerebrospinal fluid (CSF) of 15 (88.2%) patients. The causative agents included Streptococcus pneumoniae (58.8%), Salmonella spp. (11.7%), Streptococcus agalactiae (5.9%), Escherichia coli (5.9%), and Micrococcus luteus (5.9%). Growth in subdural fluid revealed the presence of E. coli (5.9%) and Staphylococcus hominis (5.9%). All the patients received treatments including combinations of antibiotics regimens. Major indications predisposing patients with PMSC to surgery included persistent fever, seizures, and bulging fontanel in the presence of PMSC on CT or MRI. All the patients underwent surgical operations, including subdural drain placement (76.5%) and craniotomy (23.5%).

CONCLUSIONS

 Persistent fever, seizures, and bulging fontanel, in the presence of PMSC, were found to be the indications for surgical intervention in PMSC. Drainage of PMSC and continuation of antibiotics is a safe and effective modality for treatment in PMSC, with a reasonable outcome and acceptable rate of morbidity and mortality. Craniotomy should be reserved for those with thick pus collection, as burr hole surgery can be used to achieve the goal in the majority of patients.

A Multicenter Epidemiological and Pathogenic Characteristics Study of Community-Acquired Bacterial Meningitis Children in China: Results from the Chinese Pediatric Bacterial Meningitis Surveillance (CPBMS) 2019-2020

Objective

To explore the epidemiological and pathogenic characteristics of children with community-acquired bacterial meningitis.

Methods

A multicenter, retrospective study was conducted among CABM patients under 15 years old from 33 hospitals in China from 2019 to 2020. The medical record, laboratory, and microbiological data were collected and analyzed.

Results

A total of 1610 children with CABM were identified and presented at a median onset age of 45 days of whom 955 (59.3%) were males. CABM occurred mostly in infants <1 year of age (84.0%, 1352/1610). In etiology-confirmed cases, the pathogens were isolated from CSF culture in 515 (32.0%), 400 (24.8%) in blood culture, and 186 (11.6%) both in CSF and blood culture. In total, 126 pathogens were identified through CSF mNGS in 330 CABM cases; 21 S. pneumoniae isolates were detected in 83 CABM cases by antigen detection method. Major pathogens were E. coli (195, 24.7%), GBS (170, 21.5%), and S. pneumoniae (157, 19.9%). GBS (29.3%, 22/75) was the first pathogen of CABM in neonates aged 0-6 days old, while E. coli (44.7%, 76/170) in 7 to 28 days of age; S. pneumoniae (96.2%, 151/157) was the most common pathogen in >3 months old cases. About 9.7% (19/195) strains of E. coli produced ultra‑broad‑spectrum β‑lactamases. The common intracranial imaging complications were subdural effusion and (or) empyema in 349 (21.7%), hydrocephalus in 233 (14.5%), and cerebral abscess in 178 (11.1%). A total of 389 (24.2%) cases were completely cured and 1088 (67.6%) cases improved. Among 166 patients (10.3%) with adverse outcomes, 32 cases (2.0%) died, and 37 cases (2.3%) relapsed.

Conclusion

The onset age of CABM in children is usually within 1 year of age, especially <3 months. The primary pathogens in infants less than 3 months old are E. coli and GBS, and the dominant pathogen in children older than 3 months old is S. pneumoniae. Subdural effusion and (or) empyema and hydrocephalus are common complications. CABM should not be excluded even if CSF leukocyte counts are within normal range. Due to the low detection rate of pathogens in children with CABM, standardized CSF bacteriological examination should be paid more attention to increase the pathogen detection rate. Non‑culture CSF detection methods may facilitate pathogenic diagnosis.

Immunologic biomarkers for bacterial meningitis

Meningitis is defined as the inflammation of the meninges that is most often caused by various bacterial and viral pathogens, and is associated with high rates of mortality and morbidity. Early detection of bacterial meningitis is essential to appropriate antibiotic therapy. Alterations in immunologic biomarkers levels have been considered the diagnostic approach in medical laboratories for the identifying of infections. The early increasing immunologic mediators such as cytokines and acute phase proteins (APPs) during bacterial meningitis have made they significant indicators for laboratory diagnosis. Immunology biomarkers showed wide variable sensitivity and specificity values that influenced by different reference values, selected a certain cutoff point, methods of detection, patient characterization and inclusion criteria, as well as etiology of meningitis and time of CSF or blood specimens' collection. This study provides an overview of different immunologic biomarkers as diagnostic markers for the identification of bacterial meningitis and their efficiencies in the differentiating of bacterial from viral meningitis.

Clinical Features and a Prediction Nomogram for Prognosis in Children with Escherichia coli Meningitis

BACKGROUND

We aimed to build a prediction nomogram for early prediction of poor prognosis in children with Escherichia coli meningitis and analyzed the course of treatment and discharge criteria.

METHODS

Eighty-seven pediatric patients with E coli meningitis were retrospectively recruited from the Children's Hospital of Chongqing Medical University between June 2012 and November 2021. Univariate analysis and binary logistic analysis were used to evaluate the risk factors, and the prediction model was built.

RESULTS

E coli meningitis is more common in children <3 months old in our study (86.2%). Common complications were subdural effusion (39.1%), followed by hydrocephalus (13.8%) and repeated convulsions (12.6%). The mortality rate and sequelae rate of E coli meningitis in children was ∼10.9% and ∼6.3%, respectively. Univariate analysis showed that 13 clinical indicators were associated with poor prognosis of E coli meningitis in children. In binary logistic analysis, risk factors were seizures (P = .032) and the last cerebrospinal fluid glucose content before discharge (P = .002). A graphical nomogram was designed. The area under the receiver operating characteristic curve was 0.913. The Hosmer-Lemeshow test showed that the model was a good fit (P = .648). Internal validation proved the reliability of the prediction nomogram.

CONCLUSIONS

E coli meningitis is more common in children <3 months old in our study. The rate of complications and sequelae are high. The prediction nomogram could be used to assess the risk of poor prognosis in children with E coli meningitis by clinicians.

Phage Targeting Neonatal Meningitis E. coli K1 In Vitro in the Intestinal Microbiota of Pregnant Donors and Impact on Bacterial Populations

Escherichia coli K1 is a leading cause of neonatal meningitis. The asymptomatic carriage of these strains in the maternal intestinal microbiota constitutes a risk of vertical transmission to the infant at birth. The aim of this work was to evaluate the efficacy of phage therapy against E. coli K1 in an intestinal environment and its impact on the intestinal microbiota. For this purpose, three independent experiments were conducted on the SHIME® system, the first one with only the phage vB_EcoP_K1_ULINTec4, the second experiment with only E. coli K1 and the last experiment with both E. coli K1 and the phage. Microbiota monitoring was performed using metagenetics, qPCR, SCFA analysis and the induction of AhR. The results showed that phage vB_EcoP_K1_ULINTec4, inoculated alone, was progressively cleared by the system and replicates in the presence of its host. E. coli K1 persisted in the microbiota but decreased in the presence of the phage. The impact on the microbiota was revealed to be donor dependent, and the bacterial populations were not dramatically affected by vB_K1_ULINTec4, either alone or with its host. In conclusion, these experiments showed that the phage was able to infect the E. coli K1 in the system but did not completely eliminate the bacterial load.

High-risk factors associated with refractory childhood bacterial meningitis in Southwest China

BACKGROUND

Refractory bacterial meningitis is acute, develops rapidly, and has higher mortality and morbidity than common bacterial meningitis. This study was undertaken to investigate the high-risk factors related to refractory bacterial meningitis in children with positive pathogens.

METHODS

We retrospectively analyzed the clinical data of 109 patients who had bacterial meningitis. The patients were divided into a refractory group (96 patients) and nonrefractory group (13 patients) based on the classification criteria. Seventeen clinical variables on risk factors were extracted and evaluated by univariate and multivariate logistic regression analyses.

RESULTS

There were 64 males and 45 females. The onset age ranged from 1 month old to 12 years old, and the median age was 181 days old. The pathogenic bacteria included 67 cases of gram-positive (G+) bacteria (61.5%) and 42 cases of gram-negative (G-) bacteria. In patients who were 1 to 3 months old, E. coli was the most common (47.5%), followed by Streptococcus agalactiae and Staphylococcus hemolyticus (10.0%); in patients > 3 months old, S. pneumoniae was the most common (55.1%), followed by E. coli (8.7%). The multivariate analysis indicated that consciousness disorder (odds ratio [OR] = 13.050), peripheral blood C-reactive protein (CRP) ≥ 50 mg/L (OR = 29.436), and the isolate bacteria being gram-positive bacteria (OR = 8.227) were independent risk factors for predicting who would progress to refractory bacterial meningitis in this group.

CONCLUSION

For patients who have pathogenic positive bacterial meningitis along with consciousness disorder, CRP ≥ 50 mg/L, and/or have an isolate bacteria that is a G + bacteria, it is important to be alert to the potential for progression to refractory bacterial meningitis, which demands the physicians' significant attention.

Cerebrospinal fluid cytokines and chemokines exhibit distinct profiles in bacterial meningitis and viral meningitis

Differential diagnosis of bacterial meningitis (BM) and viral meningitis (VM) is a critical clinical challenge, as the early and accurate identification of the causative agent determines the appropriate treatment regimen and markedly improves patient outcomes. Clinical and experimental studies have demonstrated that the pathogen and the host immune response contribute to mortality and neurological sequelae. As BM is associated with the activation of an inflammatory cascade, the patterns of pro- and anti-inflammatory cytokines/chemokines (CTs/CKs) present in the cerebrospinal fluid (CSF) in response to the immune assault may be useful as sensitive markers for differentiating BM from VM. In the present study, the ability of CTs/CKs in the CSF to differentiate between BM and VM was investigated. For this, biochemical markers and CT/CK profiles were analysed in 145 CSF samples, divided into three groups: BM (n=61), VM (n=58) and the control group (C; n=26) comprising patients with meningism. The CSF concentrations of monocyte chemoattractant protein-1, interleukin (IL)-8, IL-1β, IL-6, macrophage inflammatory protein-1α (MIP-1α), epithelial-neutrophil activating peptide, IL-10, tumour necrosis factor-α (TNF-α), proteins and white blood cells were significantly higher and the CSF glucose level was significantly lower in the BM group compared with the VM and C groups (P<0.01). Correlation analysis identified 28 significant correlations between various CTs/CKs in the BM group (P<0.01), with the strongest positive correlations being for TNF-α/IL-6 (r=0.75), TNF-α/MIP-1α (r=0.69), TNF-α/IL-1β (r=0.64) and IL-1β/MIP-1α (r=0.64). To identify the optimum CT/CK patterns for predicting and classifying BM and VM, a dataset of 119 BM and VM samples was divided into training (n=90) and testing (n=29) subsets for use as input for a Random Forest (RF) machine learning algorithm. For the 29 test samples (15 BM and 14 VM), the RF algorithm correctly classified 28 samples, with 92% sensitivity and 93% specificity. The results show that the patterns of CT/CK levels in the CSF can be used to aid discrimination of BM and VM.

Post-tuberculosis sequelae in children and adolescents: a systematic review

In 2020, an estimated total of 155 million people had survived tuberculosis. Among this number, a sizable proportion have considerable post-tuberculosis morbidity, as shown for the adult population. This systematic review aims to identify the spectrum and prevalence of post-tuberculosis sequelae in children and adolescents. Four databases were systematically searched from database inception to Feb 7, 2022, for literature on post-treatment outcomes of tuberculosis acquired during childhood. Of the 4613 identified publications, 71 studies were included in this systematic review. Studies on cohorts with comparably rare (most of which were extrapulmonary) tuberculosis presentations, such as spinal tuberculosis and tuberculous meningitis were over-represented; however, no study assessed long-term sequelae in a cohort with an average childhood tuberculosis spectrum. The descriptive analysis includes long-term outcomes of 3529 paediatric patients 1 month to 36 years after confirmed (47%) or clinical (53%) tuberculosis. In a considerable proportion of children, a broad spectrum of post-tuberculosis sequelae were identified, ranging from radiological residua after pulmonary tuberculosis, to disabling deformities after musculoskeletal and cutaneous tuberculosis, to somatic and psychosocial impairment after tuberculous meningitis. A better understanding and comprehensive assessment of post-tuberculosis sequelae in children are needed to improve tuberculosis care beyond antituberculous treatment.

Escherichia coli extended spectrum beta-lactamase meningitis in 3 months infant with subdural abscess and communicating hydrocephalus: A case report

INTRODUCTION AND IMPORTANCE

Escherichia coli ESBL as the etiology of meningitis is rarely found and frequently missed in infants. Escherichia coli found in the environment is an indication of fecal contamination.

CASE PRESENTATION

A 3-month-old infant presented with focal seizures without fever, accompanied by positive meningeal sign and bulging large fontanelle. Laboratory examination found an increase in inflammation marker. A head CT scan showed hydrocephalus and subdural cysts.

CLINICAL DISCUSSION

The patient underwent a burr hole drainage. Subdural abscesses with yellowish pus and hydrocephalus were found during the operation. Escherichia coli ESBL growth from the pus culture. This patient diagnosed as meningitis, subdural abscess and communicating hydrocephalus. Evacuation of the subdural abscess by burr hole drainage, meropenem treatment, and shunt was placed in this case.

CONCLUSION

We suggest the source of infection in this patient related to poor hygiene practices prior to formula preparation. Early diagnosis and treatment are essential to prevent morbidity and mortality.

High Concentration of Protein Oxidation Biomarker O-Tyr/Phe Predicts Better Outcome in Childhood Bacterial Meningitis

Neuronal damage in bacterial meningitis (BM) partly stems from the host´s inflammatory response and induced oxidative stress (OS). We studied the association of cerebrospinal fluid (CSF) biomarkers indicating oxidative damage to proteins with course of illness and outcome in childhood BM in Angola. Ortho-tyrosine/phenylalanine (o-Tyr/Phe), 3-chlorotyrosine/para-tyrosine (3Cl-Tyr/p-Tyr), and 3-nitrotyrosine/para-tyrosine (3NO2-Tyr/p-Tyr) concentration ratios were measured in 79 BM admission CSF samples, employing liquid chromatography coupled to tandem mass spectrometry. Besides death, disease outcomes were registered on Day 7 of treatment and one month after discharge (control visit). The outcome was graded according to the modified Glasgow Outcome Scale (GOS), which considers neurological and audiological sequelae. Children with a o-Tyr/Phe ratio below the median were more likely to present focal convulsions and secondary fever during recovery and suboptimal outcome (GOS < 5) on Day 7 and at control visit (odds ratio (OR) 2.85; 95% CI 1.14–7.14 and OR 5.23; 95% CI 1.66–16.52, respectively). Their most common sequela was ataxia on Day 7 and at control visit (OR 8.55; 95% CI 2.27–32.22 and OR 5.83; 95% CI 1.12–30.4, respectively). The association of a higher admission CSF o-Tyr/Phe ratio with a better course and outcome for pediatric BM points to a beneficial effect of OS.

Diagnosis of Pediatric Stroke in Resource Limited Settings

Global awareness of stroke as a significant cause of neurologic sequelae and death in children has increased over the years as more data in this field becomes available. However, most published literature on pediatric stroke have limited geographic representation. Data on childhood stroke from developing countries remains limited. Thus, this paper reviewed geographic/ethnic differences in pediatric stroke risk factors highlighting those reported in low- and middle-income countries, and proposes a childhood arterial ischemic stroke diagnostic algorithm for resource limited settings. Stroke risk factors include cardiac disorders, infectious diseases, cerebral arteriopathies, hematologic disorders, inflammatory diseases, thrombophilia and genetic conditions. Infection of the central nervous system particularly tuberculous meningitis, is a leading cause of pediatric arterial ischemic stroke in developing countries. Stroke should be considered in children with acute focal neurologic deficit especially in the presence of aforementioned risk factors. Cranial magnetic resonance imaging with angiography is the neuroimaging modality of choice but if unavailable, cranial computed tomography with angiography may be performed as an alternative. If both are not available, transcranial doppler together with neurologic exam may be used to screen children for arterial ischemic stroke. Etiological diagnosis follows with the aid of appropriate laboratory tests that are available in each level of care. International collaborative research on stroke risk factors that are prevalent in low and middle income countries will provide information for drafting of stroke care guidelines that are universal yet inclusive taking into consideration regional differences in available resources with the goal of reducing global stroke burden.

Streptococcus intermedius Acute Meningitis in an Immunocompetent Child

Streptococcus intermedius is a commensal bacterium increasingly associated with brain abscesses. It can infect the brain through a direct extension of an inflammatory process or a hematogenous route. Meningitis due to this pathogen is sporadic and has not been described in children before. We report a case of an immunocompetent 6-year-old boy who developed bacterial meningitis due to S. intermedius .

Back to School: Academic Functioning and Educational Needs among Youth with Acquired Brain Injury

Youth with a history of traumatic or non-traumatic acquired brain injury are at increased risk for long-lasting cognitive, emotional, behavioral, social, and physical sequelae post-injury. Such sequelae have great potential to negatively impact this population’s academic functioning. Consistently, poorer academic achievement and elevated need for educational supports have been well-documented among youth with a history of acquired brain injury. The current paper reviews the literature on neuropsychological, psychiatric, and academic outcomes of pediatric acquired brain injury. A discussion of special education law as it applies to this patient population, ongoing limitations within the field, and a proposal of solutions are also included.

Quantitative proteomics on the cerebrospinal fluid of hydrocephalus in neonatal bacterial meningitis

Objective

Hydrocephalus in bacterial meningitis (BM) is a devastating infectious neurological disease and the proteins and pathways involved in its pathophysiology are not fully understood.

Materials and methods

Label-free quantitative (LFQ) proteomics analyses was used to identify differentially expressed proteins (DEPs) in cerebrospinal fluid (CSF) samples from infants with hydrocephalus and bacterial meningitis (HBM group, N = 8), infants with bacterial meningitis (BM group, N = 9); and healthy infants (N group, N = 11). Bioinformatics analysis was subsequently performed to investigate Gene Ontology (GO) functional annotation and Kyoto Encyclopedia of Genes and Genomes (KEGG) enriched signaling pathways of these DEPs. Six proteins (AZU1, COX4I1, EDF1, KRT31, MMP12, and PRG2) were selected for further validation via enzyme-linked immunosorbent assay (ELISA).

Results

Compared with BM group and N group, HBM group had a higher whole CSF protein level (5.6 ± 2.7 vs. 1.7 ± 1.0 vs. 1.2 ± 0.5 g/l) and lower whole CSF glucose level (0.8 ± 0.6 vs. 1.8 ± 0.7 vs. 3.3 ± 0.8 mmol/l) (both P < 0.05). Over 300 DEPs were differentially expressed in HBM group compared with BM group and BM compared with N group, of which 78% were common to both. Cluster analysis indicated that the levels of 226 proteins were increased in BM group compared with N group and were decreased in HBM group compared with BM group. Bioinformatics analysis indicated the involvement of the cell adhesion, immune response and extracellular exosome signaling were significantly enriched in HBM compared with BM group and BM compared with N group. 267 DEPs were identified between HBM group with N group, KEGG analysis indicated that DEPs mainly involved in filament cytoskeleton and immune response. The ELISA results further verified that the expression levels of AZU1 were significantly different from among three groups (both P < 0.05).

Conclusion

This is the first reported characterization of quantitative proteomics from the CSF of infants with HBM. Our study also demonstrated that AZU1 could be a potential biomarker for the diagnosis of hydrocephalus in bacterial meningitis.

Amplitude-Integrated EEG Monitoring in Pediatric Intensive Care: Prognostic Value in Meningitis before One Year of Age

Pediatric morbidity from meningitis remains considerable. Preventing complications is a major challenge to improve neurological outcome. Seizures may reveal the meningitis itself or some complications of this disease. Amplitude-integrated electroencephalography (aEEG) is gaining interest for the management of patients with acute neurological distress, beyond the neonatal age. This study aimed at evaluating the predictive value of aEEG monitoring during the acute phase in meningitis among a population of infants hospitalized in the pediatric intensive care unit (PICU), and at assessing the practicability of the technique. AEEG records of 25 infants younger than one year of age hospitalized for meningitis were retrospectively analyzed and correlated to clinical data and outcome. Recording was initiated, on average, within the first six hours for n = 18 (72%) patients, and overall quality was considered as good. Occurrence of seizure, of status epilepticus, and the background pattern were significantly associated with unfavorable neurological outcomes. AEEG may help in the management and prognostic assessment of pediatric meningitis. It is an easily achievable, reliable technique, and allows detection of subclinical seizures with minimal training. However, it is important to consider the limitations of aEEG, and combinate it with conventional EEG for the best accuracy.

A Novel Splice-Site Deletion in the POU1F1 Gene Causes Combined Pituitary Hormone Deficiency in Multiple Sudanese Pedigrees

Pathogenic variants within the gene encoding the pituitary-specific transcription factor, POU class 1 homeobox 1 (POU1F1), are associated with combined pituitary hormone deficiency (CPHD), including growth hormone, prolactin, and thyrotropin stimulating hormone deficiencies. The aim of the study was to identify genetic aetiology in 10 subjects with CPHD from four consanguineous Sudanese families. Medical history, as well as hormonal and radiological information, was obtained from participants’ medical records. Targeted genetic analysis of the POU1F1 gene was performed in two pedigrees with a typical combination of pituitary deficiencies, using Sanger sequencing, and whole-exome sequencing was performed in the other two pedigrees, where hypocortisolism and additional neurologic phenotypes were also initially diagnosed. In POU1F1 gene (NM_001122757.2) a novel homozygous splice-site deletion—namely, c.744-5_749del—was identified in all 10 tested affected family members as a cause of CPHD. Apart from typical pituitary hormonal deficiencies, most patients had delayed but spontaneous puberty; however, one female had precocious puberty. Severe post-meningitis neurologic impairment was observed in three patients, of whom two siblings had Dyke–Davidoff–Masson syndrome, and an additional distantly related patient suffered from cerebral infarction. Our report adds to the previously reported POU1F1 gene variants causing CPHD and emphasises the importance of genetic testing in countries with high rates of consanguineous marriage such as Sudan. Genetic diagnostics elucidated that the aetiologies of hypopituitarism and brain abnormalities, identified in a subset of affected members, were separate. Additionally, as central hypocortisolism is not characteristic of POU1F1 deficiency, hydrocortisone replacement therapy could be discontinued. Elucidation of a genetic cause, therefore, contributed to the more rational clinical management of hypopituitarism in affected family members.

Decreasing Trend in Incidence of Late Onset Culture Positive Bloodstream Infections but Not Late Onset Meningitis in Preterm Infants <33 Weeks Gestation in Canadian Neonatal Intensive Care Unit

INTRODUCTION

Recent studies reported decreased incidence of late onset sepsis in the neonatal intensive care unit (NICU), but it is unclear whether this is also true for late onset meningitis. Recent reports that both meningitis and intraventricular hemorrhage (IVH) are associated with systemic inflammation also raise questions about an association between the 2.

METHODS

All preterm infants <33 weeks gestational age admitted to CNN NICUs from 2010 to 2018 were included. We compared incidence trends of late onset culture positive bloodstream infection (CPBSI) and late onset meningitis, and examined the association of meningitis and IVH (exposure), after adjustment for potential confounders.

RESULTS

Of 36,573 infants included, 32,198 had no infection, 3,977 had only late onset CPBSI and 398 had late onset meningitis. There was significant decrease in incidence of late onset CPBSI (14%-10%; adjusted odds ratio (AOR) = 0.93; 95% confidence interval [CI] 0.92, 0.95) but not late onset meningitis (1.6%-1.2%; AOR = 0.98; 95% CI 0.94, 1.01). Compared to infants with no IVH grade 3 or above, infants with IVH grade 3, or above had higher odds of late onset meningitis versus no infection (AOR 4.16; 95% CI 3.17, 5.44), and higher odds of late onset meningitis versus late onset CPBSI (AOR 4.11; 95% CI 3.08, 5.50).

CONCLUSIONS

There was a decreasing trend of late onset CPBSI but not late onset meningitis. An association between late onset meningitis and IVH grade 3 or above was observed. Late onset CPBSI and meningitis may have different risk factors and require different prevention strategies.

Endogenous α7 nAChR Agonist SLURP1 Facilitates Escherichia coli K1 Crossing the Blood-Brain Barrier

Alpha 7 nicotinic acetylcholine receptor (α7 nAChR) is critical for the pathogenesis of Escherichia coli (E. coli) K1 meningitis, a severe central nervous system infection of the neonates. However, little is known about how E. coli K1 manipulates α7 nAChR signaling. Here, through employing immortalized cell lines, animal models, and human transcriptional analysis, we showed that E. coli K1 infection triggers releasing of secreted Ly6/Plaur domain containing 1 (SLURP1), an endogenous α7 nAChR ligand. Exogenous supplement of SLURP1, combined with SLURP1 knockdown or overexpression cell lines, showed that SLURP1 is required for E. coli K1 invasion and neutrophils migrating across the blood-brain barrier (BBB). Furthermore, we found that SLURP1 is required for E. coli K1-induced α7 nAChR activation. Finally, the promoting effects of SLURP1 on the pathogenesis of E. coli K1 meningitis was significantly abolished in the α7 nAChR knockout mice. These results reveal that E. coli K1 exploits SLURP1 to activate α7 nAChR and facilitate its pathogenesis, and blocking SLURP1-α7 nAChR interaction might represent a novel therapeutic strategy for E. coli K1 meningitis.