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Neonatal Meningitis

Neonatal meningitis is a condition involving inflammation of the meninges, occurring within the first month of life.


Presentation

The clinical features seen in neonatal meningitis are usually indistinguishable from those of neonatal sepsis. The most prevalent clinical signs include temperature instability, irritability or lethargy and poor feeding or vomiting [1]. Neurological manifestations are more commonly seen after a bacterial attack. Meningitis caused by group B streptococci may initially present with features of respiratory distress, accompanying a systemic illness. These findings become less common with an earlier age of onset.

Temperature instability presents either as fever or hypothermia and is the most commonly reported clinical feature.

Neurologic signs may include irritability, lethargy, hypotonia, muscle twitches, tremors and seizures. A more specific feature is paradoxical irritability, wherein consolation by parents irritates rather than comforts the affected neonate. Findings of a full or bulging fontanelle are not uncommon. Some patients may present with nuchal rigidity or hydrocephalus [2]. Cranial nerve lesions, especially involving the oculomotor, abducens and facial nerve may be seen in a few children.

Ventriculitis is seen accompanying neonatal meningitis in a few children, especially in those afflicted with gram negative bacilli [3]. Certain organisms (C. diversus, Cronobacter (previously Enterobacter) sakazakii) responsible for causing vasculitis along with meningitis may lead to brain cysts and abscesses. Brain abscesses may have raised intracranial tension as one of its first manifestations, thereby leading to an increase in head size and non-projectile vomiting.

Fever
  • The symptoms were fever and seizures. The culture of cerebrospinal fluid showed to be positive for Neisseria meningitidis B. culture blood was negative. Antibiotic therapy was started at admission and maintained for 3 weeks.[ncbi.nlm.nih.gov]
  • Symptoms include sepsis, fever, irritability, and dyspnea. It can be caused by Escherichia coli (E. coli), and in rare cases, listeria monocytogenes (listeria).[imedpub.com]
Cerebral Palsy
  • Brain damage Cognitive impairments Cerebral palsy Edema (fluid buildup in the brain) Brain abscesses (pus-filled pockets) Cerebral palsy Developmental delays Seizure disorders Learning disabilities What Are the Signs and Symptoms of Neonatal Sepsis and[michigancerebralpalsyattorneys.com]
  • Complications of cerebral palsy, mental retardation and epilepsy occurred in 3 patients (23%). None of the patients died during the study period.[ncbi.nlm.nih.gov]
  • However, if treatment is delayed or improper, neonatal meningitis can result in serious disabilities such as cerebral palsy , seizure disorders , and developmental issues such as vision and hearing impairments (2).[abclawcenters.com]
Fatigue
  • Pregnant women with listeriosis typically experience only fever and other flu-like symptoms, such as fatigue and aches.[cdc.gov]
  • […] hydrocephalus Pituitary gland insufficiency Treatment : antituberculosis treatment Cryptococcal meningitis Pathogen : Cryptococcus neoformans (a type of yeast ) Etiology: AIDS Exposure to pigeon droppings Clinical course : subacute onset with (low) fever , fatigue[amboss.com]
Hyperthermia
  • […] anterior fontanelle bulging seizures jitteriness dyspnea irritability anorexia vomiting diarrhea abdominal distention (increase in abdominal size) neck rigidity cyanosis jaundice sunset eyes (downward gaze of the eyes) abnormal body temperature (hypo-or hyperthermia[en.wikipedia.org]
  • […] fontanelle bulging seizure jitteriness dyspnea irritability anorexia vomiting diarrhea abdominal distention (increase in abdominal size) neck rigidity cyanosis jaundice and sunset eyes (downward gaze of the eyes) abnormal body temperature ( hypo -or hyperthermia[en.m.wikipedia.org]
Down Syndrome
  • Dhananja Namalie, Streptococcus bovis – unusual etiology of meningitis in a neonate with Down syndrome: a case report, Journal of Medical Case Reports, 10.1186/s13256-018-1634-y, 12, 1, (2018). Lip Nam Loh, Elizabeth M. C.[doi.org]
Aspiration
  • Aspiration revealed a large pus filled cavity and Citrobacter koseri grown from the pus.[ncbi.nlm.nih.gov]
  • Diagnosis is done through blood cultures, tracheal aspirate, chest x-ray and pulse oximetry. Treatment includes initial broad-spectrum antibiotics changed to organism-specific drugs once identified.[abclawcenters.com]
  • A 3-month-old baby in India, who had been exclusively breast-fed since birth, had S. enterica serotype Senftenberg isolated from blood, stool, throat, and gastric aspirate cultures.[jcm.asm.org]
  • […] accompanying intraventricular haemorrhage in very low birth weight neonates, in the presence of a foreign body (a ventriculoperitoneal shunt), or after contamination following neurosurgery or direct entry into the ventricular space (following ventricular fluid aspiration[dx.doi.org]
Abdominal Distension
  • On the fourth day, the baby developed lethargy, refused to feed, and developed abdominal distension. The baby was referred to the neonatal intensive care unit at Sir Ganga Ram Hospital on the sixth day of life.[journals.lww.com]
  • Fever, irritability, seizures and a bulging fontanel were significantly more frequent among newborns whose birth weight was " 2500g, whereas abdominal distension, apnea, jaundice and blood count abnormalities were predominant among low-birth weight newborns[scielo.br]
Projectile Vomiting
  • Brain abscesses may have raised intracranial tension as one of its first manifestations, thereby leading to an increase in head size and non-projectile vomiting.[symptoma.com]
Hypotension
  • […] pathogens include E. coli and Listeria monocytogenes. 1 The cumulative incidence of meningitis is highest in the first month of life and is higher in preterm neonates than term neonates. 2 Patients may present with difficulty feeding, apnea, bradycardia, hypotension[acepnow.com]
  • […] head) Abnormal muscle tone, e.g. nuchal rigidity (inability to flex neck forward) (1) Trouble breathing/ respiratory distress Diarrhea or vomiting Temperature instability (fever or hypothermia) Seizures Irritability or lethargy Apnea or bradycardia Hypotension[abclawcenters.com]
  • The recognition and treatment of hypotension is particularly important to avoid complications such as cerebral ischaemic... Read more...[health.vic.gov.au]
  • Meningococcal meningitis and/or septicaemia may also present with capillary refill time more than two seconds, unusual skin colour and hypotension.[patient.info]
Muscle Twitch
  • Neurologic signs may include irritability, lethargy, hypotonia, muscle twitches, tremors and seizures. A more specific feature is paradoxical irritability, wherein consolation by parents irritates rather than comforts the affected neonate.[symptoma.com]
Stupor
  • Stupor and irritability are common in late-onset meningitis as are neurological complications.[acepnow.com]
  • Symptoms among older children and adults may progress from irritability through confusion, drowsiness, and stupor, possibly leading to coma.[rarediseases.org]
  • […] macular, mucosal) Tachypnea or apnea Jaundice Bulging fontanelle (late) Vomiting or diarrhea Altered sleep pattern PHYSICAL EXAMINATION In the physical examination of a newborn or infant with meningitis, findings may range from completely normal to stupor[aafp.org]
Opisthotonus
  • Signs suggestive of meningeal irritation, including stiff neck, bulging fontanelle, convulsions, and opisthotonus, occur only in a minority of neonates with bacterial meningitis and cannot be relied on solely to identify such patients.[ncbi.nlm.nih.gov]
  • Stiff neck (generally not present in children under the age of one year or in patients with altered mental state), back rigidity, bulging fontanelle (in infants), photophobia, opisthotonus (if severe).[patient.info]
  • Late in the illness, classical features of raised intracranial pressure such as full and tense fontanelles, setting‐sun eye appearance, retrocollis, opisthotonus (when the neck of the infant is twisted backwards) and seizures can occur.[cochranelibrary.com]
Neonatal Seizures
  • For example, if a baby shows signs of neonatal seizures, they may need anticonvulsant medications. Magnetic resonance imaging (MRI) should be performed before antibiotics are discontinued (4).[abclawcenters.com]
Tremor
  • Neurologic signs may include irritability, lethargy, hypotonia, muscle twitches, tremors and seizures. A more specific feature is paradoxical irritability, wherein consolation by parents irritates rather than comforts the affected neonate.[symptoma.com]

Workup

Meningitis is associated with an increased risk of mortality in neonates and hence, there should be no delay in the workup of a neonate suspected of suffering from meningitis. A lumbar puncture is the gold standard test to be done in such neonates, even in the absence of neurological manifestations.

The major findings seen on cerebrospinal fluid (CSF) analysis include an elevated CSF protein, decreased CSF glucose and pleocytosis, with polymorphonuclear leucocytes dominating the picture in both bacterial and viral meningitis. All three parameters need to be normal for a diagnosis of meningitis to be excluded [4]. Symptomatic neonates should also undergo a CSF culture for confirmation of the diagnosis. It has been found though, that 15-30% of CSF-proven cases have negative blood culture results [5].

Another modality with higher sensitivity and specificity rates to detect neonatal meningitis is the polymerase chain reaction (PCR) assay, that is being increasingly used to detect the presence of organisms such as group B streptococci, herpes simplex virus, enterovirus etc [6] [7].

Urinary latex particle agglutination (LGA) is another method designed to rapidly screen neonates for meningitis.

The neuroimaging study of choice is magnetic resonance imaging (MRI) that may help to locate the foci of infection, areas of edema, hemorrhage, infarction or abscesses. Follow-up scans may help evaluate the resolution of infection. Newer MRI techniques such as diffusion-weighted scans and diffusion tensor imaging are being used to note any white matter changes associated with neonatal meningitis [8].

Computed tomography (CT) scans may appear to be beneficial in patients posted for neurosurgery, whilst cranial ultrasonography may be useful to document ventricle size in hydrocephalus. Chest radiography and electroencephalography (EEG) studies may be done in some cases.

Streptococcus Bovis
  • NeonatalSepsis Caused by Streptococcus Bovis Variant (biotype II/2):Report of a Case and Review. Journal of Clinical Microbiology.2003;41:3433–5. Boyer-Mariotte S, Duboc P, Bonacorsi S, Lemeland J F, BingenE, Pinquier D.[revistas.unimilitar.edu.co]
  • Dhananja Namalie, Streptococcus bovis – unusual etiology of meningitis in a neonate with Down syndrome: a case report, Journal of Medical Case Reports, 10.1186/s13256-018-1634-y, 12, 1, (2018). Lip Nam Loh, Elizabeth M. C.[doi.org]
Mycoplasma Hominis
  • Two cases of Mycoplasma hominis meningitis in the newborn are described.[ncbi.nlm.nih.gov]
Lumbar Puncture Abnormal
  • Clinicians frequently use the presence of positive blood cultures to determine whether neonates should undergo lumbar puncture.[ncbi.nlm.nih.gov]
Gliosis
  • We concluded that positive CRP was secondary to aqueduct gliosis; therefore monitoring of serum CRP levels in infants with bacterial meningitis represented useful information, not only in persistent or secondary infection, but also for destructive complications[ncbi.nlm.nih.gov]

Treatment

  • Follow-up MRI was performed in five of the neonates in the patient group after 2 weeks of antibiotic treatment. FA and MD values were compared in patients before and after antibiotic treatment as well as with those in the healthy controls.[ncbi.nlm.nih.gov]
  • The aim for these treatments is to sterilize the cerebrospinal fluid of all pathogens. A repeat spinal tap 24 to 48 hours after treatment has been started should be done to confirm sterilization.[en.wikipedia.org]

Prognosis

  • Patients with the outcomes of death and having sequelae were regarded as having a poor prognosis. Those who were lost to follow-up were excluded from the analysis of outcome.[ncbi.nlm.nih.gov]
  • Early recognition of neonates at risk of poor prognosis would be helpful in providing timely management.[journals.plos.org]

Etiology

  • In this study the main etiological agent identified from CSF culture was S. pneumoniae .[springerplus.springeropen.com]
  • The overall mortality rate was 13% but reached 25% in preterm or small for gestational age infants, regardless of the etiology.[ncbi.nlm.nih.gov]
  • The histologic diagnosis therefore is suppurative meningitis, with culture results necessary to establish the etiologic agent.[labce.com]
  • Coagulase-negative staphylococci were considered to be the etiological agent of meningitis only when they was isolated in CSF and blood cultures at the same time.[scielo.br]

Epidemiology

  • The epidemiological findings suggest that the cases reported from Malaysia were community-acquired in contrast with those from the USA and Thailand.[ncbi.nlm.nih.gov]
Sex distribution
Age distribution

Pathophysiology

  • Over the past few years, major progress has been made in the understanding of the pathophysiology of E. coli O18:K1:H7 neonatal meningitis.[ncbi.nlm.nih.gov]
  • Teixeira, Pathophysiology of neonatal acute bacterial meningitis, Journal of Medical Microbiology, 62, Pt_12, (1781), (2013). Huan-ling Wang, Khalil G.[doi.org]

Prevention

  • It is suggested that the identification and appropriate treatment of any maternal bacterial infection is an important measure in preventing neonatal sepsis and meningitis.[ncbi.nlm.nih.gov]
  • Prevention of neonatal meningitis is primarily intrapartum (during labor) antibiotic prophylaxis (prevention) of pregnant mothers to decrease chance of early-onset meningitis by Streptococcus agalactiae.[en.wikipedia.org]
  • Currently, the best means of neonatal GBS prevention is the use of maternal IAP to prevent early onset GBS disease. However, IAP only prevents early onset GBS disease, 38 and the majority of GBS meningitis cases are of late onset.[dx.doi.org]

References

Article

  1. Volpe JJ. Bacterial and fungal intracranial infections. Neurology of the Newborn. 5th. Philadelphia, Pa: Saunders Elsevier; 2008. 916-56.
  2. Pong A, Bradley JS. Bacterial meningitis and the newborn infant. Infect Dis Clin North Am. 1999 Sep. 13(3):711-33, viii.
  3. Unhanand M, Mustafa MM, McCracken Gh, Nelson JD. Gram-negative enteric bacillary meningitis: a twenty-one year experience. J Pediatr. January 1993. 122:15-21.
  4. Garges HP, Moody MA, Cotten CM, et al. Neonatal meningitis: what is the correlation among cerebrospinal fluid cultures, blood cultures, and cerebrospinal fluid parameters?. Pediatrics. 2006 Apr. 117(4):1094-100.
  5. Malbon K, Mohan R, Nicholl R. Should a neonate with possible late onset infection always have a lumbar puncture?. Arch Dis Child. 2006 Jan. 91(1):75-6.
  6. Tebruegge M, Curtis N. Enterovirus infections in neonates. Semin Fetal Neonatal Med. March 2009. 1-6.
  7. Kimberlin D. Herpes simplex virus, meningitis, and encephalitis in neonates. Herpes. 2004. 11 Supp 2:65A-76A.
  8. Shah DK, Daley AJ, Hunt RW, Volpe JJ, Inder TE. Cerebral white matter injury in the newborn following Escherichia coli meningitis. Eur J Paediatr Neurol. 2005. 9:13-17.

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Last updated: 2019-06-28 11:18