Cases reported "Meningitis, Pneumococcal"

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1/10. Flaccid quadriplegia from tonsillar herniation in pneumococcal meningitis.

    A young woman with fulminant pyogenic meningitis became quadriplegic, areflexic and flaccid due to herniation of the cerebellar tonsils and compression of the upper cervical cord. This state of spinal shock was associated with absent F-waves. intracranial pressure was greatly elevated and there was an uncertain relationship of tonsillar descent to a preceding lumbar puncture. Partial recovery occurred over 2 years. Tonsillar herniation can cause flaccid quadriplegia that may be mistaken for critical illness polyneuropathy. This case demonstrates cervicomedullary infarction from compression, a mechanism that is more likely than the sometimes proposed infectious vasculitis of the upper cord.
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2/10. Pneumococcal meningitis masquerading as subarachnoid haemorrhage.

    A 43-year-old woman taking warfarin for past venous thrombosis presented with 4 days of flu-like symptoms and deterioration in level of consciousness. Computed tomography suggested subarachnoid haemorrhage, and magnetic resonance imaging showed widespread cerebral infarcts. However, these seemed out of proportion to the amount of haemorrhage, and lumbar puncture revealed meningitis caused by streptococcus pneumoniae.
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3/10. Fulminant bacterial meningitis without meningeal signs.

    Common clinical practice relies on the absence of neck stiffness or other meningeal signs to rule out meningitis in the alert, healthy adult. The literature does not address this specifically but implies that meningeal signs are reliable and usually present in awake patients, except infants, the elderly, and the immunosuppressed. In the following three cases two adults and a 4-year-old child, none of them immunosuppressed, presented with bacterial meningitis with no meningeal signs. In the first case, mental status was completely normal; in the second, there was only minor lethargy attributed to pain medication. In the third, lethargy was attributed to head trauma. In all three the diagnosis of meningitis was delayed up to 19 hours; lumbar puncture was performed while meningeal signs were still absent and cerebrospinal fluid analysis was grossly abnormal. All three patients had streptococcus pneumoniae meningitis, and all three suffered massive brain damage within 24 hours of presentation and eventually died. Although the true incidence of absent meningeal signs in meningitis is unknown, the condition is rare. Clinicians cannot rely on the absence of neck stiffness to rule out meningitis, even in healthy and awake adults, and lumbar puncture should be performed whenever there is serious consideration of that diagnosis.
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4/10. Recurrent bacterial meningitis. Secondary to malformation of the inner ear.

    A 5-year-old girl with congenital sensorial deafness experienced four episodes of bacterial meningitis in a 13-month period. On the fourth episode, an extensive search for the cause of recurrent meningitis was conducted. Complete immunologic studies, humoral, cellular, and phagocytic, yielded negative results. Precise otological examination, i.e., skull roentgenograms, an inner ear target CT scan, and puncture of the eardrum, was attempted, which disclosed the inner ear malformation (Mondini's anomaly) and a cerebrospinal fluid (CSF) fistula. CSF discharge from the oval window was repaired surgically. Extensive otologic evaluation should be conducted in patients with recurrent bacterial meningitis.
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5/10. spinal cord dysfunction with quadriplegia complicating pneumococcal meningitis.

    A case of pneumococcal meningitis complicated by brain-stem herniation and flaccid quadriplegia is described, from which the patient, an 11 year old boy, made a partial recovery. The patient had suffered a head injury with skull fracture some years previously; this was his third episode of meningitis. The aetiology of the quadriplegia has not been fully established, but is presumed to be of vascular nature at spinal cord level, associated with an acute hypotensive episode. Preventative aspects of recurrent bacterial meningitis and brain-stem herniation following lumbar puncture are stressed.
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6/10. Apurulent bacterial meningitis (compartmental leucopenia in purulent meningitis).

    Meningococci and haemophilus influenzae may invade the subarachnoid space during the bacteriaemic phase without impairment of the blood-CSF barrier and in the absence of any leucocyte reaction. In pneumococcal meningitis the CSF may also contain less than 100 cells/microliter despite the presence of "pure bacterial cultures", but the barrier is completely broken when the serum/CSF concentration ratio is below 10. A clinical analysis of eight patients with fewer than 100 cells/microliter revealed that the first symptoms of meningitis appeared at least 3 days prior to the diagnostic lumbar puncture. There was a strong neutrophilic reaction in the blood with a prevalence of juvenile forms in most cases, indicating intact antibacterial defence mechanisms. Within 24 h after the start of antibiotic therapy the cell number rose above 2000/microliter accompanied by disappearance of pneumococci. Six of the eight patients died. In three cases autopsy revealed thick layers of pus over the convexities, indicating a compartmental separation of the ventricles and the spinal subarachnoid space. In one case of late diagnosed bacterial meningitis with a pleocytosis of 430/microliter the CSF lysozyme level was seven times higher than compatible with this cell number. Hyperphagocytosis and cellular disintegration is thought to cause the leucopenia within the spinal CSF compartment. "Apurulent bacterial meningitis" can be seen as a disease entity that is a diagnostic pitfall and also a prognostic sign.
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7/10. Appearance of resistance to beta-lactam antibiotics during therapy for streptococcus pneumoniae meningitis.

    A young boy had meningitis caused by streptococcus pneumoniae that was relatively resistant to penicillin and susceptible to cefotaxime. After 10 days of therapy with penicillin and cefotaxime, fever recurred and a second lumbar puncture revealed a pneumococcus that was resistant to all beta-lactam antibiotics. We now add vancomycin to empiric third-generation cephalosporin therapy for meningitis in children when gram-positive cocci are seen on the cerebrospinal fluid smear.
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8/10. adult pneumococcal meningitis with no inflammatory cells in the CSF.

    An 18 year old male patient was admitted to the Medical intensive care Unit of the Tikur Anbessa Hospital in October 1988. He was in deep coma and had findings consistent with a left lobar pneumonia. Lumbar puncture revealed a turbid CSF. Gram stain on both centrifuged and uncentrifuged specimens revealed plenty of gram positive diplococci with no single inflammatory cell. CSF culture proved the organism to be streptococcus pneumoniae. The patient was put on combination of high doses of intravenous sodium-penicillin and chloramphenicol with all appropriate supportive management. However, the patient died only after three hours of stay in the hospital. The condition of diminished to absent inflammatory response in the CSF associated with pneumococcal meningitis in adults is discussed with a review of the literature.
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9/10. Hemorrhagic stroke as a complication of bacterial meningitis in adults: report of three cases and review.

    We describe three adults who had hemorrhagic strokes during the acute phase of bacterial meningitis (BM). We also report the results of a literature review and a review of the charts of 296 adults treated at our hospital for acute BM. The diagnosis of hemorrhagic stroke was made based on the results of cerebral computed tomography (CT) for two of 92 patients with BM who had CT performed and by means of lumbar puncture and a postmortem study in one other case. Two patients died of cerebral bleeding. Although the frequency of hemorrhagic stroke was only 2.1% among adults with acute BM, it is a major determinant of prognosis for such patients.
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10/10. role of MRI in the diagnosis of otitic hydrocephalus.

    The pathogenesis of otitic hydrocephalus still remains doubtful. magnetic resonance imaging (MRI) demonstrated sigmoid and transverse sinus thrombosis in two consecutive patients. The role of MRI in the diagnosis and pathogenesis of this complication, together with literature findings, is discussed. Until now, lumbar puncture, which is a minimally invasive technique, was the only diagnostic measure. MRI, however, can be used to establish the diagnosis of otitic hydrocephalus by showing the thrombosis in the sigmoid and transverse sinus.
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