Mumps meningoencephalitis; a clinical review of 119 cases with one death

Mumps is one of the most common viruses to affect the central nervous system and should be given primary consideration in the differential diagnosis of aseptic meningitis. Many cases of numps infection do not involve the salivary glands. The course of numps meningoencephalitis is usually benign, with fever and signs of meningeal irritation lasting less than five days. The findings in the cerebrospinal fluid are usually distinctive, with leukocyte content greater than 200 per milliliter, of which 80 per cent or more are lymphocytes. Sequelae, even of a minor nature, are rare. Death is extremely rare in recorded literature. A fatal case of numps meningoencephalitis is described herein.     

Bloodstream Infection among Children Presenting to a General Hospital Outpatient Clinic in Urban Nepal

Background

There are limited data on the etiology and characteristics of bloodstream infections in children presenting in hospital outpatient settings in South Asia. Previous studies in Nepal have highlighted the importance of murine typhus as a cause of febrile illness in adults and enteric fever as a leading bacterial cause of fever among children admitted to hospital.

Methods

We prospectively studied a total of 1084 febrile children aged between 2 months and 14 years presenting to a general hospital outpatient department in Kathmandu Valley, Nepal, over two study periods (summer and winter). Blood from all patients was tested by conventional culture and by real-time PCR for Rickettsia typhi.

Results

Putative etiological agents for fever were identified in 164 (15%) patients. Salmonella enterica serovar Typhi (S. Typhi) was identified in 107 (10%), S. enterica serovar Paratyphi A (S. Paratyphi) in 30 (3%), Streptococcus pneumoniae in 6 (0.6%), S. enterica serovar Typhimurium in 2 (0.2%), Haemophilus influenzae type b in 1 (0.1%), and Escherichia coli in 1 (0.1%) patient. S. Typhi was the most common organism isolated from blood during both summer and winter. Twenty-two (2%) patients were PCR positive for R. typhi. No significant demographic, clinical and laboratory features distinguished culture positive enteric fever and murine typhus.

Conclusions

Salmonella infections are the leading cause of bloodstream infection among pediatric outpatients with fever in Kathmandu Valley. Extension of immunization programs against invasive bacterial disease to include the agents of enteric fever and pneumococcus could improve the health of children in Nepal.     

Bacterial Meningitis in Washington State

During 1977 the state of Washington maintained a surveillance system for reporting cases of bacterial meningitis. Hemophilus influenzae meningitis was the most common etiologic agent causing bacterial meningitis. A high incidence rate for H. influenzae meningitis was found among American Indians less than five years ago. A focus of ampicillin-resistant H. influenzae meningitis was found in Pierce County among military dependents or persons who had family members or relatives working or attending school with Fort Lewis Army Base personnel. Although relationships between the individual cases were not detected, the surveillance system continues to seek some association.     

Listeria monocytogenes infections in Canada

Between 1951 and January 1972 listeriosis was diagnosed bacteriologically in 101 Canadian patients. This study adds 80 cases to the 21 reported from Metropolitan Toronto by Sepp and Roy in 1963. The Laboratory Centre for Disease Control, Ottawa, collated epidemiological and clinical data. Serotypes of Listeria monocytogenes included 4b (53), 1 (15), 1b (6), 1a (2), 2 and 3. Clinically, 54 patients had meningitis and 23 septicemia. The mortality rate was 30%.Between 1954 and January 1972 listeriosis affected 15 British Columbian patients: nine were male and six female; 12 were less than 1 or more than 45 years old. Among the patients were a pregnant mother and the son to whom she gave premature birth. A day-old infant and an elderly man died.     

Haemophilus influenzae meningitis in Manitoba and the Keewatin District,NWT: potential for mass vaccination.

A community-based surveillance study of all central nervous system infections was carried out in Manitoba and the Keewatin District, NWT, between Apr. 1, 1981, and Mar. 31, 1984. There were 201 cases of bacterial meningitis in Manitoba over the study period, 81 (40%) caused by Haemophilus influenzae; all but one isolate tested were type b (Hib). There were nine cases of H. influenzae meningitis in the Keewatin District. The overall annual incidence rate of H. influenzae meningitis in Manitoba was 2.5/100,000; for children under 5 years the rate was 32.1/100,000. For the Keewatin District the corresponding rates were 69.6/100,000 and 530/100,000. A total of 85% and 100% of the cases of H. influenzae meningitis occurred by 24 months of age in Manitoba and the Keewatin District respectively. The age at onset was earlier in native Indian children (22 cases) and Inuit children (9 cases) than in non-native children (59 cases) (p less than 0.005); thus, vaccine prevention of Hib meningitis will likely be more difficult in native Indian and Métis children. Without evaluating the increased potential of H. influenzae vaccines to prevent nonmeningitic forms of disease, we concluded that mass childhood vaccination with polyribosylribitolphosphate (PRP) vaccine is not warranted in Manitoba or the Keewatin District. Immunogenicity studies suggest that administration of conjugated Hib vaccines such as PRP-D in infancy may prevent approximately one-third to two-thirds of cases of H. influenzae meningitis; these vaccines warrant consideration for use in mass childhood vaccination programs.     

Septicemia due to Yersinia enterocolitica

Despite the increasing number of reports of Yersinia enterocolitica infection in humans, septicemia with this organism has remained a rare complication. A 73-year-old woman presented with fever, jaundice, hepatomegaly and cellulitis. Microorganisms isolated from both skin lesion and blood were biochemically and serologically identified as Yersinia enterocolitica, biotype 4, serotype 3 and lysotype 9b. High agglutinating titres against this organism were demonstrated in the patient''s serum. Complete recovery followed a course of gentamicin sulfate. A household pet was considered, but not proved, to be the source of this infection.     

Lassa Fever in Post-Conflict Sierra Leone

Background

Lassa fever (LF), an often-fatal hemorrhagic disease caused by Lassa virus (LASV), is a major public health threat in West Africa. When the violent civil conflict in Sierra Leone (1991 to 2002) ended, an international consortium assisted in restoration of the LF program at Kenema Government Hospital (KGH) in an area with the world''s highest incidence of the disease.

Methodology/Principal Findings

Clinical and laboratory records of patients presenting to the KGH Lassa Ward in the post-conflict period were organized electronically. Recombinant antigen-based LF immunoassays were used to assess LASV antigenemia and LASV-specific antibodies in patients who met criteria for suspected LF. KGH has been reestablished as a center for LF treatment and research, with over 500 suspected cases now presenting yearly. Higher case fatality rates (CFRs) in LF patients were observed compared to studies conducted prior to the civil conflict. Different criteria for defining LF stages and differences in sensitivity of assays likely account for these differences. The highest incidence of LF in Sierra Leone was observed during the dry season. LF cases were observed in ten of Sierra Leone''s thirteen districts, with numerous cases from outside the traditional endemic zone. Deaths in patients presenting with LASV antigenemia were skewed towards individuals less than 29 years of age. Women self-reporting as pregnant were significantly overrepresented among LASV antigenemic patients. The CFR of ribavirin-treated patients presenting early in acute infection was lower than in untreated subjects.

Conclusions/Significance

Lassa fever remains a major public health threat in Sierra Leone. Outreach activities should expand because LF may be more widespread in Sierra Leone than previously recognized. Enhanced case finding to ensure rapid diagnosis and treatment is imperative to reduce mortality. Even with ribavirin treatment, there was a high rate of fatalities underscoring the need to develop more effective and/or supplemental treatments for LF.     

Haemophilus influenzae Meningitis in Adults

Haemophilus influenzae meningitis though common in childhood is rarely seen in the adult. During the past four years eight cases of H. influenzae meningitis have been seen in St. Thomas''s Hospital and four of these were in patients over 20 years old. There was a possible predisposing condition in two patients. In each case there was difficulty in identification of the organism in the Gram-stained film of the cerebrospinal fluid deposit.     

Analysing spatio-temporal clustering of meningococcal meningitis outbreaks in Niger reveals opportunities for improved disease control

Background

Meningococcal meningitis is a major health problem in the “African Meningitis Belt” where recurrent epidemics occur during the hot, dry season. In Niger, a central country belonging to the Meningitis Belt, reported meningitis cases varied between 1,000 and 13,000 from 2003 to 2009, with a case-fatality rate of 5–15%.

Methodology/Principal Findings

In order to gain insight in the epidemiology of meningococcal meningitis in Niger and to improve control strategies, the emergence of the epidemics and their diffusion patterns at a fine spatial scale have been investigated. A statistical analysis of the spatio-temporal distribution of confirmed meningococcal meningitis cases was performed between 2002 and 2009, based on health centre catchment areas (HCCAs) as spatial units. Anselin''s local Moran''s I test for spatial autocorrelation and Kulldorff''s spatial scan statistic were used to identify spatial and spatio-temporal clusters of cases. Spatial clusters were detected every year and most frequently occurred within nine southern districts. Clusters most often encompassed few HCCAs within a district, without expanding to the entire district. Besides, strong intra-district heterogeneity and inter-annual variability in the spatio-temporal epidemic patterns were observed. To further investigate the benefit of using a finer spatial scale for surveillance and disease control, we compared timeliness of epidemic detection at the HCCA level versus district level and showed that a decision based on threshold estimated at the HCCA level may lead to earlier detection of outbreaks.

Conclusions/Significance

Our findings provide an evidence-based approach to improve control of meningitis in sub-Saharan Africa. First, they can assist public health authorities in Niger to better adjust allocation of resources (antibiotics, rapid diagnostic tests and medical staff). Then, this spatio-temporal analysis showed that surveillance at a finer spatial scale (HCCA) would be more efficient for public health response: outbreaks would be detected earlier and reactive vaccination would be better targeted.     

Aseptic meningitis,Montreal, 1969: A Clinical and Laboratory Study

During the summer and fall of 1969 an outbreak of aseptic meningitis occurred in Montreal and its environs. Forty-four patients were admitted to the infectious disease ward of The Montreal Children''s Hospital in August, September and October. Half of the patients were in the age group 6 to 10 years. The ratio of males to females was two to one. Patients showed the typical signs and symptoms of aseptic meningitis, namely fever, vomiting, headache, neck stiffness and pleocytosis of the cerebrospinal fluid.Viruses were recovered from 19 (43%) of the 44 cases. The predominant virus in the outbreak was a non-hemagglutinating strain of echovirus 6. Other virus types isolated in the outbreak were echovirus 7, coxsackievirus A9 and coxsackievirus B4. Serological investigations confirmed the validity of the echovirus isolations and identified additional cases.     

The Effect of a Yeast Probiotic on Acute Diarrhea in Children

A probiotic is a living micro-organism administered to promote the health of the host by treating or preventing infections owing to strains of pathogens. Saccharomyces boulardii is a nonpathogen yeast that has a direct inhibitory effect on the growth of many pathogens, an anti-secretory effect and a trophic effect on enterocytes. The aim of this study was to determine the effect of S. boulardii on diarrhea in children. The children from 6 months to 6 years of age with acute watery diarrhea admitted in pediatric clinic in Kashan in 2012 were included in this trial. Exclusion criteria were high fever (T > 38.5 °C), severe dehydration, bloody diarrhea, severe malnutrition, using of antibiotics, anti-diarrheal or antifungal drugs and children with more than one complain. Two hundred patients were assigned into two groups: A total of 100 patients were treated with S. boulardii in addition to ORS (case group) and 100 patients were given placebo in addition to ORS (control group). The duration of diarrhea and frequency of stools were recorded by asking the mothers of the children every day. The results showed that the defecation frequency after second day of treatment in the case group was significantly less than the control group (P = 0.001) and the mean numbers of days of diarrhea was significantly lower in the case group (P = 0.001). The result of this study confirms that S. boulardii reduces the frequency of stool and duration of illness in children.     

Completeness of statutory notification for acute bacterial meningitis.

Several different sources of data, including statutory notifications, were used to identify cases of acute bacterial meningitis in childhood in a defined population. Only half the cases of meningococcal meningitis and less than one quarter of ofther types of bacterial meningitis had been notified. Notified cases differed from the remainder with respect to causative organism, age, outcome, and type of hospital of admission. Thus notifications are an unreliable measure of incidence for this disease, and studies of infectious disease based on notified cases alone should be interpreted with considerable reserve. It is suggested that infectious-disease surveillance should be both clinical and microbiological and that data from different sources need to co-ordinated. The reason for reporting each disease (or organism) should be specified and and reviewed periodically.     

Pneumococcal bacteraemia: 325 episodes diagnosed at St Thomas's Hospital.

Three hundred and twenty five episodes of pneumococcal bacteraemia occurred at St Thomas''s Hospital during 1970-84, accounting for 13.3% of all episodes of bacteraemia. Twice as many cases occurred in male as in female patients, and common predisposing factors included chronic chest disease, alcoholism, haematological malignancies, cirrhosis, and sickle cell anaemia. Mortality was 28.6% overall but only 11.8% among patients who received antibiotic treatment for at least 24 hours. Most patients (261) had pneumonia, 26 had meningitis, and eight were children with occult bacteraemia. The commonest serotype of pneumococcus in adults was type 3 (39 episodes), and these strains were associated with a high mortality. Other factors determining a fatal outcome included underlying disease (such as cirrhosis, malignancy, and chronic chest disease) and extrapulmonary infection. Almost half the survivors were treated for 10 days or less and became afebrile within 48 hours.     

Innate immune recognition of,and response to,Clostridium sordellii

Clostridium sordellii, an anaerobic pathogen, has recently been associated with rapidly fatal infections following medically induced abortions and injecting drug use. Patients with C. sordellii infection display few signs of inflammation such as fever, or redness and pain at the site of infection. We hypothesized that this could be due to reduced recognition of the organism by Toll-like receptors (TLRs) of the innate immune system. An ELAM-NF-κB luciferase reporter system in TLR-transfected HEK cells was used to measure TLR-dependent recognition of washed, heat-killed C. sordellii and other pathogenic clostridial species. Results demonstrated that all clostridia were well recognized by TLR2 alone and that responses were greatest when TLR2 was co-expressed with TLR6. Further, isolated human monocytes produced the pro-inflammatory cytokine TNFα and the immunoregulator IL-10 in response to C. sordellii. In addition, C. sordellii-stimulated monocytes produced 30% less TNFα following treatment with an anti-TLR2 blocking antibody. These data demonstrate that innate immune recognition of, and response to, cell-associated components of C. sordellii and other clostridial pathogens are mediated by TLR2 in combination with TLR6. We conclude that the characteristic absence of inflammatory signs and symptoms in C. sordellii infection is not related to inadequate immune detection of the organism, but rather is attributable to a species-specific immune system dysfunction that remains to be elucidated.     

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

ObjectiveTo 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.DesignFollow 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.SettingEngland and Wales.ParticipantsGeneral practitioners and parents of children who had had meningitis before the age of 1 year and of matched controls.ResultsAltogether, 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.ConclusionThe 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.

What is already known on this topic

Meningitis in infancy is associated with important long term consequencesThere is considerable variation in outcome depending on which organism caused the infection

What this study adds

This follow up study of 1717 children who had meningitis in infancy found that they had a 10-fold increase in risk of severe or moderate disabilities at age 5 years compared with children in the control groupThe outcome of having meningitis was associated with the age at infection, and children who had meningitis in the neonatal period were more likely to have health and development problems than those older than 1 monthSubtle deficits, such as middle ear disease and visual and behavioural problems, were more prevalent among children who had had meningitis in infancy     

Epidemic Listeriosis in the Newborn

Within a three-month period 13 cases of listeriosis in the newborn were seen at the National Women''s Hospital, Auckland. Eleven presented in the first 24 hours of life, the most common feature being respiratory difficulty in low birth weight infants. Meconium-stained liquor was noted in nine cases. The constant finding in all cases was an aspiration pneumonia which appeared to be of intrauterine origin from an infected amniotic cavity. There was also evidence of septicaemia in nine cases, and two infants survived meningitis which developed at 1 week. Maternal symptoms were mild and variable, and in only one case were they proved to be due to listerial infection. The mothers came from different suburbs of Auckland and no common source of infection was found.     

Recurrent aseptic meningitis for 24 years: diagnosis and treatment of an associated lesion

Recurrent meningitis in the absence of an identifiable causative organism or anatomical source is a difficult diagnostic challenge for any infectious disease consultant. We evaluated a 49-year-old woman with episodes of meningitis which occurred on at least nine separate occasions for over 24 years. No causative organism, physical agent, or underlying disease process was identified as the source of this patient's recurrent lymphocytic meningitis. When computerized tomographic head scanning was first performed in 1977, a prominence of the left lateral ventricle was evident. It was not until the area was subsequently evaluated with magnetic resonance imaging techniques 13 years later that a lesion could be clearly identified, removed, and evaluated at pathology. Time alone will tell whether the lesion, a cavernous hemangioma, was truly the cause of this patient's recurrent aseptic meningitis for 24 years.     

Haemophilus influenzae type B meningitis: a contagious disease of children.

The families of 126 consecutive patients with Haemophilus influenzae type B meningitis were surveyed for secondary invasive H influenzae disease among household contacts. A total of 120 of the families were contacted. In six cases no contact was possible and the medical record was reviewed. Some 555 household contacts were found; 31% (171) were under 5 years of age. A secondary case was defined as a household contact with H influenzae type B isolated from blood or cerebrospinal fluid more than 24 hours, but less than 30 days, after admission to hospital of the index case. Four secondary cases were identified, all in children aged under 5 years. The secondary attack rate in children under 5 years or less in the month after exposure to an index case was thus 2.3%, 800 times the endemic attack rate for H influenzae meningitis. This is a conservative estimate since five additional contact cases were documented, but not included in the secondary attack rate. Young contacts of a child with H influenzae meningitis are thus at significant risk of life-threatening secondary disease.