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Four Cases of Meningitis by Streptococci Other Than Pneumoniae

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Four Cases of Meningitis by Streptococci Other Than Pneumoniae Le Infezioni in Medicina, n. 4, 231-234, 2006 Casi clinici Four cases of meningitis by streptococci other than Case reports pneumoniae in adults: clinical and microbiological features Quattro casi di meningite da streptococchi non pneumoniae in adulti: caratteristiche cliniche e microbiologiche Vittorio Attanasio, Pasquale Pagliano, Ugo Fusco, Rosa Zampino1, Francesco Saverio Faella Department of Emergency and Infectious Diseases, D. Cotugno Hospital, Naples, Italy; 1Internal Medicine and Hepatology, Second University of Naples, Italy I INTRODUCTION gone spinal anaesthesia for hemorrhoidec- tomy 8 and 12 hours, respectively, before the treptococci other than pneumoniae are an clinical presentation of meningitis; the patients infrequent cause of community-acquired came from two different hospitals and no in- Smeningitis in adults, but in recent years formation about hygienic and anesthesiologi- they have been responsible for an increasing cal procedures adopted by the medical staff number of hospital-acquired meningitis cases were available. The third patient had had a [1-3]. The wider application of neurosurgical reacutisation of chronic otitis and mastoiditis procedures and the inobservance of measures in the right ear four days before the appear- to prevent infection are considered the most im- ance of meningitis. The fourth patient had un- portant factors in the increased role of these dergone splenectomy for trauma one year be- streptococci in adult meningitis [3-6]. fore and had received dental care two weeks before the appearance of meningitis. One pa- tient (patient 3) had diabetes mellitus while I CASE REPORTS the other three had no underlying chronic sys- temic disease. From 1997 to 2002 at our Division of Infectious Patients 1, 2 and 3 were admitted to our De- Neuropathy, of the Domenico Cotugno Hospi- partment soon after the appearance of symp- tal in Naples, we observed 4 cases of meningitis toms while patient 4 was admitted after two by streptococcus other than pneumoniae in days. On presentation the clinical features of adults. meningitis, namely high fever, neck stiffness A diagnosis of meningitis was made on the clin- and status I or II coma, were clearly present in ical signs and positive culture of CFS and/or all patients. The CSF analysis showed a high blood. CSF was centrifuged and the sediment WBC count, elevated protein concentration and was inoculated on blood agar plates and soy- hypoglycorrhachia. During hospitalisation 3 of bean-casein digest broth (BD BACTECTM, Bec- the 4 patients (75%) presented a diffuse herpes ton, Dickinson and Company Maryland, USA); simplex infection involving the lips, nose and blood was inoculated also on soybean-casein oral cavity and requiring treatment with oral digest broth. Species identification of isolated acyclovir 400 mg q.i.d. for 5 days. bacteria was performed by standard methods From the CSF cultures Streptococcus milleri and [7]. Antibiotic susceptibility was determined Streptococcus mitior were isolated in one case using the E-test (AB Biodisk, Sweden). each and Streptococcus mitis in the other two. All The 4 patients (M/F 3/1) had a median age of strains were susceptible to penicillin, aminogly- 44 years, range 40-57. Two of them had under- cosides, rifampicin, quinolones, carbapenem 231 2006 and macrolides. Empirical treatment consisted prevent the development of a severe disease, of ceftriaxone 3-4 g/die plus rifampicin 300 mg such as S. viridans meningitis, and avoid longer b.i.d. for three patients and meropenem 2 g hospitalisation and supplementary health care t.i.d. plus rifampicin 300 mg b.i.d. for the costs [4]. fourth; rifampicin was discontinued after mi- Infection of CNS by streptococci other than crobiological identification and treatment with pneumoniae can be associated to otolaryngo- the other antibiotic was continued for 2-3 logical infections, infective endocarditis or weeks. Dexamethasone, 12 mg/day, started im- brain abscess; in our observations meningitis mediately before the first dose of antibiotics, caused by streptococci other than pneumoniae was given for 6 days and slowly tapered. was observed after an otolaryngological infec- No patient showed seizure and all recovered; tion, dental care and spinal anaesthesia [3]. only patient 4 presented a permanent and se- The central role of the spleen in bacterial clear- vere neurosensorial bilateral hearing loss con- ance by macrophage killing and antibody re- firmed by audiological examination. The hear- sponse is well known. In splenectomised pa- ing loss started early and was already present tients the risk of sepsis and other severe infec- on admission to our Division; no ear lesions tions is associated to S. pneumoniae in about were seen on a cranial CT scan. 80% of cases [8]. The fact that S. milleri was re- The general and microbiological characteristics sponsible for meningitis after dental treatment of the patients are shown in Table 1. in one patient (patient 4) might indicate the role of streptococci other than pneumoniae in causing severe infection, with possible perma- I DISCUSSION nent complications for splenectomised pa- tients. Particular attention should be devoted In our Department we observed 4 cases of adult to asplenic patients as regards sepsis and meningitis caused by streptococci other than meningitis by streptococci other than pneumo- pneumoniae in 6 years. Two of the 4 patients niae, and a specific prophylaxis before inva- observed developed meningitis after spinal sive treatment of the oral cavity should be ad- anaesthesia for a simple surgical procedure and ministered. it is possible that the hygiene guidelines may Reactivation of latent HSV during severe bacte- not have been properly observed. Infact, Strep- rial infections, as has already been described, is tococcus viridans is part of the normal flora of the so common that it is generally not mentioned in mouth and transmission from hospital person- this context [9, 10]. However, diffuse herpes nel can occur if the guidelines for the control of simplex lesions increase the discomfort of the infection are not strictly observed. The use of patient and need to be treated. masks and sterile gloves is mandatory. It has Streptococci other than pneumoniae are gener- been shown that these simple precautions can ally susceptible to penicillin, but resistant Tabella 1 - General and microbiological characteristics of patients. CSF Patient Sex/Age Associated CSF isolated Blood Penicillin WBC count Glucose Protein Treatment Year of condition pathogen isolated resistance (mm3) (mg/dl) (g/L) diagnosis pathogen [% PMN]° 1 F/42 Spinal S. mitis - No 17000 [80] 10 4.0 Ceftriaxone 2001 anaesthesia *Rifampicin 2 M/40 Spinal S. mitis - No 14000 [95] 5 7.1 Meropenem 2000 anaesthesia *Rifampicin 3 M/57 Chronic otitis S. mitior - No 1200 [76] 21 2.0 Ceftriaxone 1997 and mastoiditis *Rifampicin 4 M/46 Splenectomy S. milleri S. milleri No 1800 [69] 3 8.7 Ceftriaxone 2002 Dental care *Rifampicin °[% PMN] = polymorphonuclear cell; *discontinued after microbiological identification. 232 2006 strains to penicillin and macrolides have been essary to establish the efficacy of dexametha- reported [11-13]. All S. viridans isolated in our sone in adults with meningitis from strepto- Division were sensitive to all the antibiotics cocci other than pneumoniae. tested, thus indicating the low circulation of re- Meningitis due to streptococci other than pneu- sistant strains in our geographical area. moniae in adults is associated with low mortality Although there is no conclusive evidence to and morbidity, although a fulminant clinical support the use of dexamethasone in adult course has been described [16]. Preventive mea- meningitis, we found the 6-day administration sures must be implemented to decrease the risk useful in improving the general condition of the of meningitis; early diagnosis and appropriate patients and in reducing sequelae [14, 15]. Pa- treatment are necessary for a favourable outcome tient 4, who presented hearing loss, started cor- for the patient, particularly after spinal anaesthe- tisone and antibiotic treatment two days after sia, when the onset of symptoms is rapid. the onset of symptoms. However, the small number of patients does not allow any conclu- Key words: meningitis, streptococci other than sions to be drawn and further studies are nec- pneumoniae, adults SUMMARY Meningitis sustained by streptococci other than describe four cases of meningitis caused by strep- pneumoniae, infrequent in community medicine, tococci other than pneumoniae in adults. is emerging as a hospital-acquired infection. We RIASSUNTO La meningite da streptococco non pneumo- daliera. Descriviamo quattro casi di menin- niae, è infrequentemente acquisita in comu- gite da streptococco non pneumoniae nel- nità, ma sta emergendo come infezione ospe- l’adulto. I REFERENCES increasing role for resistant viridans streptococci? Case report and review of the last 20 years. Scand. J. [1] Durand M.L., Calderwood S.B., Weber D.J., et al. Infect. Dis. 32, 693-696, 2000. Acute bacterial meningitis in adults. A review of 493 [7] Facklam R.R., Washington J.A. II. Streptococcus episodes. N. Engl. J. Med. 328, 21-28, 1993. and related catalase-negative gram positive cocci. [2] Schuchat A., Robinson K., Wenger J.D., et al. Bac- In:Balows A, Herrmann KL, Isenberg HD, Shadomy terial meningitis in the United States in 1995. Active HJ, eds. Manual of clinical microbiology. 5th ed. Wash- Surveillance Team. N. Engl. J. Med. 337, 970-976, 1997. ington DC: American Society for Microbiology 238- [3] Cabellos C., Viladrich P.F., Corredoira J., Verda- 257, 1991. guer R., Ariza J., Gudiol F. Streptococcal meningitis [8] Altamura M., Caradonna L., Amati L., Pellegrino in adult patients: current epidemiology and clinical M., Urgesi G., Miniello S. Splenectomy and sepsis: spectrum. Clin. Infect. Dis. 28, 1104-1108, 1999. the role of the spleen in the immune-mediated bacte- [4] Schneeberger P.M., Janssen M., Voss A. Alpha-he- rial clearance. Immunopharmacology and immunotoxi- molytic streptococci: a major pathogen of iatrogenic cology 23, 153-161, 2001. meningitis following lumbar puncture.
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