A Very Rare Form of Bacterial Meningitis: Case Report

 

1-Prof.MohammadHossein Soltanzadeh MD,ID

2- Prof. Ahmad Siadati MD,ID

3- Dr. Fatemah Ashrafi , MD

Introduction:

 

Bacterial meningitis is a very serious fatal disease that is caused by various microorganisms including bacterial agents. Bacterial meningitis is associated with a very high rate of mortality and morbidity in children and infants. Early prompt diagnosis decreases this rate to about 2-5%. Most fatalities occur in pneumoccal meningitis. Severe neurological disabilities occur in 10-20% of the cases. Deafness is seen in 50% of the patients (30% pneumoccal meningitis, 10% meningococcal and 5-20% in H.influenza -type b- meningitis). Unfortunately 30% of newborn  succumb to death as a result of this disease. (Ref. 1,2,3,5 )

1-        Professor of Pediatrics Shahid Beheshti University of Medical  Science,   Tehran .IRAN, ID from Mayo Clinic USA

2-        Professor of Pediatrics, Tehran University of Medical Science, Tehran , IRAN, Research center of pediatrics ID ,Central Children Hospital

3-        Clinical Laboratory Specialist , Tehran Rsalat Hospital , Tehran , IRAN

 

Case Presentation:

 

The infant was an 11 months old girl weighing 9.2 kg. She was admitted with the chief complaint of fever (39 °C) that had started 5 days prior to admission. There was history of a minor head trauma. 10 days before the admission.

 

On admission, CBC was sent to the laboratory; the results of which are:

 

WBC=8800/mm³ (42% poly, 58% lymph)

Hb= 10.9 g/dl,  ESR=121,  CRP=1+

Ca= 8.8 mg/dl

Blood sugar=151 mg/dl

Platelets 230000/ mm³

U/A= Normal

BUN=20 mg/dl

Creatinine= 0.5 mg/dl

 

Figure (1)

 

 

However because of the high fever and ESR level, LP was performed. The laboratory report of the CSF was as:

 

Sugar=25mg/dl

Protein=52mg/dl

WBC=62000(90% poly, 10% lymph)

RBC=300

CSF smear= Gram positive

CSF culture=Pneumococcus

 

Blood Culture= Negative

U/C = Negative

 

Diagnosis:

This was a very rare and possibly a one-of-a-kind form of Bacterial Meningitis with WBC in CSF of  62000 .

 

Treatment was initiated with Ceftriaxone ( 50 mg/kg/dose every 12 hrs), Vancomycin ( 15 mg/kg/dose) and Dexamethasone.

 

The patient underwent brain CT scan on the third day of operation. The report was:

Subdural effusion with few isodense areas in both frontal lobes.

 

Figure (2)

Four days after admission another CBC was done which showed:

WBC=19600( 73% poly, 26% lymph)

Platelet= 507000/mm³

ESR=82

 

-          Ninth day of admission, LP was done which showed:

 

WBC=100

Protein=25

Sugar=45

 

-          Twelfth day CBC showed:

 

WBC=20700/mm³ (80% poly, 18% lymph, 2% band)

Hb= 9.4 g/dl,

 ESR=135,

 CRP=2++

 

The patient underwent a second brain CT scan on day 14 of treatment. Brain scan reported: There is evidence of abnormal frontal lobe bilaterally more prominent on the left side. Fluid collection with mild mass effect in left frontal area (epidural empyema).

 

Figure (3)

 

 

 

 

Figure(4)

 

Therefore considering the hyperleucocytosis polynucleosis, ESR 135 and CSF cell count =100, Atypical Kawasaki's Disease-a form of vasculitis-was considered as diagnosis for the patient; as a result of which she was put on IVIG( 2gr/kg) and Aspirin (100mg/kg) for two weeks.

 

Meanwhile ABR was done: for left ear 20 dbH

Figure (5)

 

 

 

l and right ear 110dbHl was recorded. All other investigations including abdominal sonography, echocardiography and opthalamoscopy were normal.

 

 

After two weeks of aspirin consumption the dose was reduce to 100 mg/day and continued for 3 months.

 

-Thirty six days after treatment, CBC was:

 

WBC= 8100/mm³ (31% poly, 66% lymph)

Platelet=370000

Hb=11.9gr/dl

ESR=44

CRP=Negative

 

-Forty seven days after treatment, CBC was:

  WBC=8500 (31% poly, 67% lymph)

ESR=13

Platelet=340000

CRP=Negative

 

Figure (6)

 

 

 

 

Figure (7)

 

 

 

 

 

Figure (8)

 

After 4.5 months of treatment: laboratory findings and brain CTscan had become normal.

 

 

Figure(9)

 

 

  

Figure (10)

 

 

Figure (11)

 

 

Figure ( 12 )

 

 

Discussion

Streptococcus  pneumoniae has been dramatically altered by the use of vaccine in February 2000  risk factors include  : otitis media , sinusitis , pneumonia . ( Ref. 3,4 )

Diagnosis of acute bacterial meningitis is confirm by analysis of the CSF

Complications include seizure , increased ICP , cranial nerve palsies , stroke , cerebral herniation and thrombosis . (Ref. 1,5 )

Collections of fluid in the subdural space develop in 10-30 % of patients  . CT and MRI scanning confirms the presence of a subdural effusion that should be treated by aspiration .

Fever usually resolved within 5-7 days of the onset of therapy . prolonged fever > 10 days is noted in about 10% of patients due to Nosocomial or secondary infection. ( Ref. 2 )

Kawasaki Disease (KD) is a systemic vasculitis that occurs most commonly in children less than 5 years . ( Ref. 5 )  Most cases of KD occur in children younger than 12 years of age.   in 1967 Tomisaku Kawasaki developed diagnostic criteria for an apparently new illness .The illness is characterized by fever and the following clinical feature (1) bilateral bulbar conjunctival injection without exudates (2) erythematous mouth and pharynx, strawberry tongue ,and red ,cracked lips  (3) a polymorphous , generalized , erythematous rash that can be morbilliform , maculopapular or scarlatiniform or may resemble erythema multiform (4) changes in the peripheral extremities consisting of induration of the hands and feet with erythematous palms and  soles, often with later priunguinal desquqmation and (5) acute , nonsupurative , usually unilateral, cervical lymph – adenopathy with at least one node 1.5 cm in diameter. For diagnosis of classic KD patient should have fever at least 4 days and at least 4 of these 5 features without alternative explanation for the findings .other finding 10%-20% meningismus with CSF pleocytosis . ( Ref. 5,6,7 )

Incomplete KD can be diagnosed  . Incomplete KD is mor common in infants younger than 12 months of age than in older children ( Ref . 8 )

 

 

REFERENCES       

1 – Bonsu BK ,Harper MB: fever interval before diagnosis ,prior antibiotic treatment , clinical outcome for young children with bacterial meningitis , clin infect Dis 2001;32.566-572

2  - Kilpi T , Anttila M,Kallio MJ ,et al ; Lent of prediagnostic history related to the course and sequelae of childhood bacterial meningitis .pediatr infect Dis j 1993;12;184-188

3 – McIntyre PB ,Macintyre CR ,Gilmour R, et al; A population based study of the impact of corticosteroid therapy and delayed diagnosis on the outcome of childhood pneumococcal meningitis . Arch Dis Child 2005;90;391-396.

4 – Tunkel AR , Hartman BJ ,Kaplan SL,et al; practice guideline for the management of bacterial meningitis. Clin infect Dis 2004;39;1267 – 1284

5- Larry K Pickering ,MD, FAAP, Associate Editor- David W ,Kimberlin , MD, FAAP ,Associate Editor – Sarah  S, Long ,MD , FAAP, Associate Editor , Report of the Committee on Infectious Diseases 2009

6- Anderson MS Todd JK ,Glode ,MP ,Delayed diagnosis  of Kawasaki Syndrome , An analysis of the problem , Pediatrics 2005

7- Muta H,Ishii ,M, Egami K, et al , Early intravenous gamma – globulin treatment for Kawasaki Disease; The The nationwide surveys in Japan ,J Pediatr 2004

7- Newburger , JW , M , Gerber MA , et al :  Diagnosis , Treatment  and long-term management of Kawasaki Disease : Pediatrics 2004

8 – Shulman ST , Rowley AH , Advance in Kawasaki Disease , Eur J Pediatr , 2004