Recurrent neonatal sepsis and progressive white matter injury in a premature newborn culture-positive for group B Streptococcus: A case report

RATIONALE

Group B Streptococcus (GBS) remains a principal pathogen causing neonatal sepsis and meningitis, particularly in premature infants with relatively insufficient immunity. Recurrence may occur uncommonly, largely associated with subclinical mucosal persistence or repetitive exposure to exogenous sources. White matter injury (WMI) including cystic periventricular leukomalacia (PVL) has been associated with intrauterine infection/inflammation, and neonatal infection as a more significant predictor including postnatal sepsis and recurrent infection, even without microbial neuroinvasion. Furthermore, clinical and experimental evidence of WMI by some bacteria other than GBS without central nervous system invasion has been reported. However, there is little evidence of WMI associated with neonatal GBS sepsis in the absence of meningitis in the literature.

PATIENT CONCERNS

A newborn at 30+4 weeks' gestation with low birthweight presented with 2 episodes (with a 13-day interval with no antibiotic therapy) of neonatal sepsis culture-proven for GBS with early-onset presentation after clinical chorioamnionitis via vertical GBS transmission and the associated conditions including prematurity-related neonatal immunodeficiency and persistent mucosal GBS carriage after the first antibiotic treatment. The perinatal GBS infection was complicated by progressive WMI presenting with ventriculomegaly and cystic PVL without a definite evidence of meningitis, intraventricular hemorrhage, and documented cerebral hypoxia or hypoperfusion conditions including septic shock.

DIAGNOSES

Recurrent group B streptococcal sepsis and cystic PVL with ventriculomegaly.

INTERVENTIONS

Two episodes of GBS sepsis were treated with 15-day parenteral antibiotic therapy, respectively.

OUTCOMES

Resolution of the recurrent GBS sepsis without further relapses, however, complicated by WMI and subsequent about 6 months delay in motor development at 12 months' corrected age.

LESSONS

This case suggests WMI associated with GBS bacteremia without central nervous system entry by viable GBS and also shows that in premature infants, intrauterine GBS infection with no interventions may lead to extensive and persistent GBS colonization, early-onset and recurrent GBS disease, and WMI. Postnatal as well as intrauterine infection/inflammation controls with maternal prophylaxis may be pivotal for prevention and limiting the magnitude of neurologic injury.

Psychiatric Disabilities and Other Long-term Consequences of Childhood Bacterial Meningitis

BACKGROUND

Bacterial meningitis is known to cause hearing impairments and neurologic deficits; however, less is known regarding psychiatric disabilities. In this study, we assessed psychiatric disabilities and other long-term consequences of childhood bacterial meningitis.

METHODS

From a previously validated dataset, we selected children having had bacterial meningitis. We then reviewed medical records and child health records from discharge onwards to identify disabilities. We calculated the occurrence of disabilities with a 95% confidence interval (CI), and we used a χ test to assess possible individual risk factors associated with occurrence of disabilities.

RESULTS

Of the 80 children included in this study, permanent disabilities not attributed to preexisting diseases were noted in 56% (CI: 45-67) during the mean observation period of 19 years and 2 months. Psychiatric disease was diagnosed in 30% (CI: 21-41), and another 5% (CI: 2-13) were under ongoing investigations for symptoms of psychiatric disease. Hearing impairments affected at least 30% (CI: 20-40), and neurologic deficits affected at least 23% (CI: 15-34). While other disabilities were often detected within the first year, psychiatric disabilities were detected after a mean time period of 14 years (CI: 11:1-16:11). Although some associations were noted, no individual risk factor was able to predict the occurrence of disabilities.

CONCLUSIONS

Psychiatric disabilities affect more than one-third of survivors and are among the most common long-term consequence of childhood bacterial meningitis. Late discovery and predictive difficulties call for a revision of current guidelines to include a specific long-term strategy for detecting psychiatric disabilities.

Neurodevelopmental Impairment in Children After Group B Streptococcal Disease Worldwide: Systematic Review and Meta-analyses

BACKGROUND

Survivors of infant group B streptococcal (GBS) disease are at risk of neurodevelopmental impairment (NDI), a burden not previously systematically quantified. This is the 10th of 11 articles estimating the burden of GBS disease. Here we aimed to estimate NDI in survivors of infant GBS disease.

METHODS

We conducted systematic literature reviews (PubMed/Medline, Embase, Latin American and Caribbean Health Sciences Literature [LILACS], World Health Organization Library Information System [WHOLIS], and Scopus) and sought unpublished data on the risk of NDI after invasive GBS disease in infants <90 days of age. We did meta-analyses to derive pooled estimates of the percentage of infants with NDI following GBS meningitis.

RESULTS

We identified 6127 studies, of which 18 met eligibility criteria, all from middle- or high-income contexts. All 18 studies followed up survivors of GBS meningitis; only 5 of these studies also followed up survivors of GBS sepsis and were too few to pool in a meta-analysis. Of meningitis survivors, 32% (95% CI, 25%-38%) had NDI at 18 months of follow-up, including 18% (95% CI, 13%-22%) with moderate to severe NDI.

CONCLUSIONS

GBS meningitis is an important risk factor for moderate to severe NDI, affecting around 1 in 5 survivors. However, data are limited, and we were unable to estimate NDI after GBS sepsis. Comparability of studies is difficult due to methodological differences including variability in timing of clinical reviews and assessment tools. Follow-up of clinical cases and standardization of methods are essential to fully quantify the total burden of NDI associated with GBS disease, and inform program priorities.

Group A streptococcal meningitis as a complication of an infected capillary haemangioma

We report a case of group A streptococcal meningitis in an infant resulting from an infected capillary haemangioma. The child suffered significant morbidity including cerebral infarction, epilepsy, and developmental delay. Treatment of infected capillary haemangiomas remains controversial and inconsistent.

CONCLUSION

Our experience of this infant, resulting in profound neurological morbidity suggests that group A Streptococcus can be a virulent organism in the young child and that capillary haemangiomas must be treated aggressively at the first sign of infection.

Perinatal infections and brain injury: current treatment options

Antimicrobial therapy can ameliorate infection and prevent long-term morbidity caused by several pathogens that infect the fetus and neonate. Ultimately, however, preventive strategies need to be developed and incorporated into routine preconceptional care. The future of prevention lies in immunizations, and if past and current successes with smallpox, polio, rubella, and measles vaccination programs are any indication, the future is bright for the developing fetus.

[Obsessive-compulsive disorders in children. Subtypes of OCD and their relation to infection with group A streptococci]

The present review describes the theory of a spectrum of obsessive-compulsive disorders (OCD). This spectrum includes such disorders as trichotillomania, eating disorders, body dysmorphic disorder, and possibly pervasive developmental disorders. OCD with an onset in childhood is presented as a specific subtype, with more boys affected and frequently co-morbid with tics and Tourette's syndrome. Furthermore, it seems to be more genetically determined and have more significant deviations, as measured by neuro-imaging studies, than has OCD with an adult onset. The PANDAS theory (paediatric autoimmune neuropsychiatric disorder associated with streptococcal infections) is described. This subtype of OCD is, still on a speculative basis, connected to infections with beta-haemolytic streptococci. The obsessive-compulsive symptoms are characterised by a sudden onset, "sawtoothed" course with relapses and remissions, and are associated with neurological abnormalities. There are still no clinical consequences in terms of penicillin treatment of this PANDAS subtype of OCD.

Long-term outcomes of childhood meningitis

Meningitis and meningococcal disease remain a major source of anxiety to paediatricians and parents alike. Survival rates have improved with rapid diagnosis and appropriate management. However, survivors remain at risk of long-term neurodevelopmental sequelae.

Neurological soft signs in mainstream pupils

AIMS

(1) To examine the relation between neurological soft signs and measures of cognition, coordination, and behaviour in mainstream schoolchildren. (2) To determine whether high soft sign scores may predict children with significant problems in other areas.

METHODS

A total of 169 children aged between 8 and 13 years from mainstream schools were assessed. They form part of a larger study into the outcome of meningococcal disease in childhood. Half had previous meningococcal disease and half were controls. Assessment involved measurement of six soft signs followed by assessment of motor skills (movement ABC), cognitive function (WISC-III), and behaviour (Conners' Rating Scales).

RESULTS

Children having an age corrected soft sign score above the 90th centile were considered to have an excess of soft signs. When compared to the other children they had significantly worse scores on the other three measures. Median movement ABC score was 15.3 v 7. Mean total IQ scores were lower by 10.3 points. Median behaviour scores were significantly higher on both parental and teacher questionnaires. A soft sign score above the 90th centile had a sensitivity of 38% for detecting cognitive impairment, 42% for detecting coordination problems, and 25% for detecting possible attention deficit hyperactivity disorder.

CONCLUSION

In this group of children higher scores on the soft sign battery were related to significantly worse performance on measures of cognition, coordination, and behaviour. However, although soft sign assessment may be of interest it cannot accurately predict which children are likely to have impairment in other areas.

Meningitis in infancy in England and Wales: follow up at age 5 years

OBJECTIVE

To describe important sequelae occurring among a cohort of children aged 5 years who had had meningitis during the first year of life and who had been identified by a prospective national study of meningitis in infancy in England and Wales between 1985 and 1987.

DESIGN

Follow up questionnaires asking about the children's health and development were sent to general practitioners and parents of the children and to parents of matched controls. The organism that caused the infection and age at infection were also recorded.

SETTING

England and Wales.

PARTICIPANTS

General practitioners and parents of children who had had meningitis before the age of 1 year and of matched controls.

MAIN OUTCOME MEASURES

The prevalence of health and developmental problems and overall disability among children who had had meningitis compared with controls.

RESULTS

Altogether, 1584 of 1717 (92.2%) children who had had meningitis and 1391 of 1485 (93.6%) controls were successfully followed up. Among children who survived to age 5 years 247 of 1584 (15.6%) had a disability; there was a 10-fold increase in the risk of severe or moderate disability at 5 years of age among children who had had meningitis (relative risk 10.3, 95% confidence interval 6.7 to 16.0, P<0.001). There was considerable variation in the rates of severe or moderate disability in children infected with different organisms.

CONCLUSION

The long term consequences of having meningitis during the first year of life are significant: 32 of 1717 (1.8%) children died within five years. Not only did almost a fifth of children with meningitis have a permanent, severe or moderately severe disability, but subtle deficits were also more prevalent.