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Pneumococcal Meningitis

Pneumococcal meningitis is a bacterial inflammation of the meninges. It is potentially fatal with increased incidence of mortality in the very young and in the elderly. Individuals who survive this infection are at risk of developing sequelae like deafness, neurological deficits and growth retardation. Diagnosis is based on the analysis of cerebrospinal fluid and neuroimaging.


Presentation

Pneumococcal meningitis (PM) is caused by the Gram-positive bacteria, Streptococcus pneumoniae, which is also called the pneumococcus bacteria. A majority of adult cases of community-acquired bacterial meningitis are caused by this bacteria [1] [2]. PM became the leading cause of meningitis after the Haemophilus influenzae type b vaccine was introduced [3]. Young children, the elderly, patients with chronic diseases, and immunocompromised individuals are at the greatest risk of developing PM [3] [4] [5]. Despite medical advances, the fatality rates for PM range from approximately 2% in children to 25% in adults [3] [6]. Survivors frequently have neurological sequelae like deafness or cognitive deficits [2] [7] [8] [9].

The clinical signs and symptoms of PM depend on the age of the patient. Young babies may present with poor feeding, irritability, lethargy, vomiting, fever, and a bulging anterior fontanel [10]. Children and adults classically have a fever, severe headache, photophobia, neck stiffness, vomiting, confusion, delirium, and seizures, while elderly patients may have atypical features like altered mental status and confusion [1] [2].

Fever
  • It is imperative to recognize that young infants with bacterial meningitis can present without fever or irritability and manifest signs and symptoms consistent with many other diagnoses.[ncbi.nlm.nih.gov]
  • Young babies may present with poor feeding, irritability, lethargy, vomiting, fever, and a bulging anterior fontanel.[symptoma.com]
  • Her fever resolved, and she was playful, had good oral intake, and was discharged 24 hours after admission. Her initial blood-culture result remained negative.[ncbi.nlm.nih.gov]
  • A 26-year-old para-2 woman who had had a normal vaginal delivery at 38 weeks at a maternity home was transported to our hospital with a 39.5 C fever 11 days postpartum. Eight hours after her arrival, her state of consciousness deteriorated rapidly.[ncbi.nlm.nih.gov]
  • A 21-year-old man who presented with 3 days of headache, combativeness, and fever. Antibiotics and steroids were initiated after lumbar puncture yielded purulent cerebrospinal fluid and streptococcus pneumoniae.[ncbi.nlm.nih.gov]
Chills
  • At this point, you would start to experience symptoms like headaches, stiff neck, fever, vomiting, rash, confusion, drowsiness chills, cough, chest pains, and an immediate dislike for bright light.[myjoyonline.com]
  • […] there is leakage of spinal fluid Recent ear infection with S pneumoniae Recent pneumonia with S pneumoniae Recent upper respiratory infection Spleen removal or a spleen that does not function Symptoms usually come on quickly, and may include: Fever and chills[medlineplus.gov]
  • An infected person may develop the following: chest pain chills confusion a cough a headache a high fever vomiting weakness Other possible symptoms of this form of meningitis include: agitation irritability rapid breathing stiff neck In infants, the soft[healthline.com]
High Fever
  • None of the patients presented with a chief complaint of irritability, poor feeding, or altered mental status, and no patient had high fever, difficulty consoling, or cirulatory compromise.[ncbi.nlm.nih.gov]
  • Symptoms of the disease include stiff neck, high fever, rash, headache, vomiting, and confusion.[graphic.com.gh]
  • An infected person may develop the following: chest pain chills confusion a cough a headache a high fever vomiting weakness Other possible symptoms of this form of meningitis include: agitation irritability rapid breathing stiff neck In infants, the soft[healthline.com]
  • An infected person may develop the following: * chest pain * chills * confusion * a cough * a headache * a high fever * vomiting * weakness Other possible symptoms of this form of meningitis include: · agitation · irritability · rapid breathing · stiff[modernghana.com]
Fatigue
  • Over 12 h, she was fatigued without other symptoms. Low fever accompanied another emesis. A few hours later she was confused, and purpuric rash appeared. Emergency physicians diagnosed sepsis/meningitis and started vancomycin-ceftriaxone.[ncbi.nlm.nih.gov]
  • Other symptoms can include headaches, fatigue, feeling sick or vomiting, wheezing, joint and muscle pain, and feeling confused and disorientated (particularly in elderly people). Symptoms can appear very suddenly, or take several days to develop.[vk.ovg.ox.ac.uk]
  • […] feel breathless, even when resting rapid heartbeat fever feeling generally unwell sweating and shivering loss of appetite chest pain – which gets worse when breathing or coughing Less common symptoms include: coughing up blood (haemoptysis) headaches fatigue[nhs.uk]
  • Multifactorial conditions, such as diabetes mellitus, renal insufficiency, liver cirrhosis, malnutrition, glucocorticosteroid therapy, alcoholism, cold exposure, stress, fatigue and excess likelihood of exposure to S. pneumoniae (such as occurs in daycare[path.upmc.edu]
Recent Upper Respiratory Infection
  • upper respiratory infection Spleen removal or a spleen that does not function Symptoms usually come on quickly, and may include: Fever and chills Mental status changes Nausea and vomiting Sensitivity to light ( photophobia ) Severe headache Stiff neck[medlineplus.gov]
  • Your risk also increases if you've had a recent upper respiratory infection. Babies, children, and teens are at greatest risk. What Are the Symptoms of Meningococcal Meningitis? Symptoms of meningococcal meningitis may vary from case to case.[webmd.com]
Vomiting
  • Young babies may present with poor feeding, irritability, lethargy, vomiting, fever, and a bulging anterior fontanel.[symptoma.com]
  • At age 7, patient developed a morning headache and vomited once. Cefprozil was administered and re-dosed. Over 12 h, she was fatigued without other symptoms. Low fever accompanied another emesis.[ncbi.nlm.nih.gov]
  • At this point, you would start to experience symptoms like headaches, stiff neck, fever, vomiting, rash, confusion, drowsiness chills, cough, chest pains, and an immediate dislike for bright light.[myjoyonline.com]
  • Signs and symptoms that point toward this condition include: a fast heart rate a fever a stiff neck vomiting If you have pneumococcal meningitis, you’ll immediately be admitted to the hospital. You’ll then be treated with antibiotics.[healthline.com]
Nausea
  • […] of the common risk factors associated with the condition include recent infections, like upper respiratory tract infection, pneumonia, or ear infection with pneumococcus The classic signs and symptoms of Pneumococcal Meningitis are high-grade fever, nausea[dovemed.com]
  • Recent ear infection with S pneumoniae Recent pneumonia with S pneumoniae Recent upper respiratory infection Spleen removal or a spleen that does not function Symptoms usually come on quickly, and may include: Fever and chills Mental status changes Nausea[medlineplus.gov]
  • Case presentation Case 1 was a 34-year-old Japanese woman with a history of splenectomy who presented with pyrexia, nausea, headache, and loss of hearing in her right ear.[jmedicalcasereports.com]
Tachycardia
  • A 22-year-old man with incessant ventricular tachycardia (VT) associated with pneumococcal meningitis without obvious heart disease manifesting as febrile sensation and severe headache visited our emergency department.[ncbi.nlm.nih.gov]
  • By Antonio Pires, MD, Arber Kodra, MD, Jay Wong, MD, and Steven Mandel, MD A 61-year-old male with a past medical history of hypertension initially presented in the emergency department with fever, chest pain, and tachycardia.[practicalneurology.com]
  • On initial physical examination, she was afebrile (36.6 C), but in a hypotensive state (88/55mmHg) with tachycardia (120 beats/minute).[jmedicalcasereports.com]
Hearing Impairment
  • On long-term follow-up, we observed improvements of motor impairment, but not of hearing impairment.[ncbi.nlm.nih.gov]
  • About one in 10 children with pneumococcal meningitis die and one in six survivors will have permanent brain damage About one in three children will be left with a hearing impairment after pneumococcal meningitis.[meningitis.org.nz]
  • The possible complications of Pneumococcal Meningitis are: Hearing impairment or deafness Vision abnormalities, such as decreased vision or loss of vision Memory-related problems Learning disabilities Intellectual impairment Brain damage and edema Seizures[dovemed.com]
Neck Pain
  • Symptoms of pneumococcal meningitis: Fever, usually high Drowsiness, impaired consciousness Irritability, fussiness, agitation Severe headache Vomiting Stiff neck Pain on moving neck If you suspect meningitis, read m edical emergency.[meningitis.ca]
  • This disease takes between two to ten days to show its symptoms, some of which include neck pains, neck stiffness, convulsion and vomiting.[ghana.gov.gh]
  • His headache, neck pain, and back pain resolved. Repeat blood cultures were obtained and remained negative for five days. Infectious Disease Service was consulted and recommended eight weeks of intravenous ceftriaxone.[practicalneurology.com]
Photophobia
  • Children and adults classically have a fever, severe headache, photophobia, neck stiffness, vomiting, confusion, delirium, and seizures, while elderly patients may have atypical features like altered mental status and confusion.[symptoma.com]
  • The signs and symptoms to watch out for include sudden onset of severe headache, fever, vomiting, neck stiffness and photophobia (dislike for light). Other symptoms include lethargy, coma and convulsions.[pulse.com.gh]
  • Recent pneumonia with S pneumoniae Recent upper respiratory infection Spleen removal or a spleen that does not function Symptoms usually come on quickly, and may include: Fever and chills Mental status changes Nausea and vomiting Sensitivity to light ( photophobia[medlineplus.gov]
  • The signs and symptoms may include: Sudden onset of fever and chills Stiff neck Altered mental status Nausea and vomiting Severe headache Increase sensitivity to light (photophobia) Newborns and infants with Pneumococcal Meningitis are not usually present[dovemed.com]
Headache
  • A 61-year-old Japanese woman presented with a headache and appetite loss lasting for nine days and was admitted to our hospital, where she was diagnosed with pneumococcal meningitis associated with acute sphenoid sinusitis.[ncbi.nlm.nih.gov]
  • A 22-year-old man with incessant ventricular tachycardia (VT) associated with pneumococcal meningitis without obvious heart disease manifesting as febrile sensation and severe headache visited our emergency department.[ncbi.nlm.nih.gov]
  • A 21-year-old man who presented with 3 days of headache, combativeness, and fever. Antibiotics and steroids were initiated after lumbar puncture yielded purulent cerebrospinal fluid and streptococcus pneumoniae.[ncbi.nlm.nih.gov]
  • A 33-year-old man with Crohn's disease and azathioprine use presented to our Emergency Department with progressive headache while taking antibiotics for otitis media.[ncbi.nlm.nih.gov]
  • Bacterial meningitis commonly presents with symptoms such as headache, impaired consciousness, neck stiffness, and fever. In most cases, cerebrospinal fluid analysis will yield white cell counts 100/mm3.[ncbi.nlm.nih.gov]
Seizure
  • Abstract A 12-month-old girl with occult bacterial meningitis presented with a simple febrile seizure.[ncbi.nlm.nih.gov]
  • Patients with the risk genotype (rs10157763, AA) presented with low scores on the Glasgow Coma Scale and high rate of epileptic seizures. Thus, our results show that AKT3 influences outcome of pneumococcal meningitis.[ncbi.nlm.nih.gov]
  • When comparing PAM with pneumococcal meningitis, patients with PAM were more likely to be male (89.5 vs. 36.8 %), younger (mean age: 30 vs. 59 years), present with seizures (42.1 vs. 5.3 %).[ncbi.nlm.nih.gov]
  • Clinical manifestations include fever; headache; neck stiffness; and somnolence followed by seizures; focal neurologic deficits (notably deafness); and coma.[icd9data.com]
  • In spite of effective antibacterial treatments, approximately one third of survivors suffer from long-term sequelae, such as hearing loss, cerebral palsy, seizures, hydrocephaly or cognitive impairment.[ncbi.nlm.nih.gov]
Confusion
  • Children and adults classically have a fever, severe headache, photophobia, neck stiffness, vomiting, confusion, delirium, and seizures, while elderly patients may have atypical features like altered mental status and confusion.[symptoma.com]
  • Upon admittance, she was considered confused, with a temperature of 39.4 C and slight neutrophilic leukocytosis, but no neck stiffness.[ncbi.nlm.nih.gov]
  • A few hours later she was confused, and purpuric rash appeared. Emergency physicians diagnosed sepsis/meningitis and started vancomycin-ceftriaxone.[ncbi.nlm.nih.gov]
  • At this point, you would start to experience symptoms like headaches, stiff neck, fever, vomiting, rash, confusion, drowsiness chills, cough, chest pains, and an immediate dislike for bright light.[myjoyonline.com]
Irritability
  • It is imperative to recognize that young infants with bacterial meningitis can present without fever or irritability and manifest signs and symptoms consistent with many other diagnoses.[ncbi.nlm.nih.gov]
  • The pneumococcal vaccine-unimmunized patient was hospitalized with fever, irritability, and purpura, and was diagnosed as having meningitis, septic shock, and disseminated intravascular coagulation.[ncbi.nlm.nih.gov]
  • Young babies may present with poor feeding, irritability, lethargy, vomiting, fever, and a bulging anterior fontanel.[symptoma.com]
  • Fever and chills Mental status changes Nausea and vomiting Sensitivity to light ( photophobia ) Severe headache Stiff neck Other symptoms that can occur with this disease: Agitation Bulging fontanelles in infants Decreased consciousness Poor feeding or irritability[medlineplus.gov]
Neck Stiffness
  • Upon admittance, she was considered confused, with a temperature of 39.4 C and slight neutrophilic leukocytosis, but no neck stiffness.[ncbi.nlm.nih.gov]
  • Neck stiffness is usually seen in a majority of the adults but may be present in only 30% of the children.[symptoma.com]
  • Clinical manifestations include fever; headache; neck stiffness; and somnolence followed by seizures; focal neurologic deficits (notably deafness); and coma.[icd9data.com]
  • Dr Afreh cited high temperature, fever, headache of sudden onset, neck stiffness, unconsciousness and photo phobia as some of the major symptoms of the disease.[citifmonline.com]
  • Neurologic examination showed neck stiffness and right-sided facial nerve palsy. Empirical therapy was started with dexamethasone (10 mg) and penicillin (2 million IU). CT scan of the head showed no abnormalities.[n.neurology.org]

Workup

The diagnosis of PM depends on obtaining a detailed medical history, including a history of the patient's immunization status, physical examination, and cerebrospinal fluid (CSF) analysis. Clinically it is difficult to differentiate between bacterial and viral causes of meningitis. During the physical examination, vital signs and a complete neurological assessment should be performed. Neck stiffness is usually seen in a majority of the adults but may be present in only 30% of the children [8] [11]. Although a petechial rash is a common feature of meningococcal meningitis, a majority of patients with other forms of bacterial meningitis also develop a rash within 24 hours of onset of the initial symptoms [1] [2]. There may be evidence of a primary source of infection e.g. otitis media, sinusitis, or pneumonia. Meningeal signs and papilledema can be noted in most of the patients while babies may have a bulging anterior fontanel indicative of raised intracranial pressure.

A computed tomogram of the head should be performed prior to lumbar puncture in cases with neurological deficits, papilledema, and altered sensorium to exclude intracranial abscesses, tumors, or edema [9]. Magnetic resonance imaging (MRI) is performed to diagnose complications associated with the condition and findings include brain infarction, cerebral edema, and hydrocephalus in cases of PM [9].

CSF analysis helps to differentiate between bacterial and viral etiology while CSF culture detects the causative bacteria. Typically in bacterial meningitis, the CSF pressure is elevated with polymorphonuclear leukocytosis, and reduced glucose levels relative to the serum glucose. Inflammatory markers such as serum C-reactive protein (CRP) levels are elevated in bacterial meningitis [8]. Polymerase chain reaction (PCR) test can be performed, if available, as it is more sensitive than microbiological tests in detecting bacterial versus viral DNA. It is also useful in diagnosing a bacterial cause of meningitis in patients who have been treated with antibiotics [12].

Cerebrospinal Fluid Abnormality
  • Cerebrospinal fluid abnormalities in bacterial meningitis include a markedly increased opening pressure ( 180 mm H 2 O), increased presence of white blood cells (normal: 0-5 lymphocytes/ mm 3, bacterial meningitis: 10 - 10,000 WBCs/mm 3 with polymorphonuclear[path.upmc.edu]
Hyponatremia
  • Its delayed diagnosis may be associated with hyponatremia and hypernatremia with fatal outcome. A previously healthy nine-month-old Bangladeshi female infant was diagnosed with diarrhea, pneumonia, and convulsion due to hypernatremia.[ncbi.nlm.nih.gov]
  • […] isolate displays a minimum inhibitory concentration to cefotaxime/ceftriaxone of 4 mcg/mL or greater Meropenem, chloramphenicol, or a fluoroquinolone is a possible alternative In the acute phase, patients may experience hypotension or shock, hypoxemia, hyponatremia[pharmacytimes.com]
Brain Edema
  • FINAL PATHOLOGIC DIAGNOSES: SEVERE, ACUTE PNEUMOCOCCAL MENINGO-ENCEPHALO-RADICULITIS WITH ACUTE HYPOXIC ENCEPHALOPATHY, MODERATE BRAIN EDEMA AND EARLY THROMBOSIS OF THE SUPERIOR SAGITTAL SINUS.[path.upmc.edu]
  • This in turn leads to the influx of inflammatory cells and the breakdown of the blood-brain barrier, with local vasculitis, loss of cerebral autoregulation, and brain edema. 4 The first steroid dose should be with or just before the first dose of antibiotics[clevelandclinicmeded.com]

Treatment

  • New guidelines for the treatment of meningitis in Israel are suggested.[ncbi.nlm.nih.gov]
  • The treatment was carried out without complications and the clinical outcome was favourable.[ncbi.nlm.nih.gov]
  • Parainfectious vasculitis leading to ischemic brain damage is a known complication of bacterial meningitis but its treatment is uncertain.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: Findings support the use of third generation cephalosporin antibiotics for treatment of suspected pneumococcal meningitis even at low prevalence of pneumococcal resistance to penicillins.[ncbi.nlm.nih.gov]
  • Optimal treatment has recently become controversial, however, owing to an alarming increase in the number of penicillin-resistant isolates.[ncbi.nlm.nih.gov]

Prognosis

  • Paraplegia is rare in sickle cell disease and the prognosis is not always poor.[ncbi.nlm.nih.gov]
  • The aim of the study was to evaluate what factors are related to a poor PM prognosis.[ncbi.nlm.nih.gov]
  • Abstract Poor prognosis in Pneumococcal meningitis may be associated with high pneumolysin levels in cerebrospinal fluid (CSF).[ncbi.nlm.nih.gov]
  • Female Flow Cytometry Humans Immunoenzyme Techniques Male Meningitis, Pneumococcal/cerebrospinal fluid Meningitis, Pneumococcal/immunology* Meningitis, Pneumococcal/metabolism Meningitis, Pneumococcal/microbiology Mice Mice, Inbred C57BL Mice, Knockout Prognosis[ncbi.nlm.nih.gov]
  • (Outcomes/Resolutions) The prognosis of Pneumococcal Meningitis depends on how quickly the treatment is administered Even with prompt diagnosis and treatment, around 50% of the affected individuals develop long-term health issues Pneumococcal Meningitis[dovemed.com]

Etiology

  • Studies including serum levels of immunoglobulin and complements, brain magnetic resonance imaging, and coronal cranial computed tomography (CT) were negative for a specific etiology.[ncbi.nlm.nih.gov]
  • CSF analysis helps to differentiate between bacterial and viral etiology while CSF culture detects the causative bacteria.[symptoma.com]
  • (Etiology) Pneumococcal Meningitis is caused by the bacteria Streptococcus pneumoniae S. Pnemoniae is found in the nose and throat of about 5-10% of healthy adults and in about 20-40% of healthy children.[dovemed.com]
  • The department is conducting laboratory surveillance for bacterial etiology of meningitis since 1993 [10], [11], [26] – [28].[journals.plos.org]

Epidemiology

  • It is important to maintain epidemiological surveillance to assess the impact of immunization in Argentina.[ncbi.nlm.nih.gov]
  • This suggests that vaccine pressure alone does not explain pneumococcal epidemiological changes and that other factors could play a role.[ncbi.nlm.nih.gov]
  • The molecular epidemiology of Streptococcus pneumoniae isolates from carriage and cerebrospinal fluid (CSF) concurrently recovered from the same individual has not yet been reported.[ncbi.nlm.nih.gov]
  • The epidemiology of pneumococcal meningitis is changing because of the use of vaccines in childhood, and antibiotic resistance has increased.[ncbi.nlm.nih.gov]
  • Although respiratory viruses (including influenza) have been suggested to influence pneumococcal infections, the underlying mechanisms are still unknown, and viruses are rarely considered when studying pneumococcus epidemiology.[ncbi.nlm.nih.gov]
Sex distribution
Age distribution

Pathophysiology

  • In a murine model of pneumococcal meningitis we examined the pathophysiological roles of two inflammasome proteins, NLRP3 (Nod-like receptor protein-3) and adaptor protein ASC (apoptosis-associated speck-like protein).[ncbi.nlm.nih.gov]
  • This review discusses the most recent views on the pathophysiology of pneumococcal meningitis, as well as potential targets for (adjunctive) therapy.[ncbi.nlm.nih.gov]
  • Medical Center, Seattle, Washington, 98195 Specialized Center of Research-Pulmonary Diseases, University of Washington, Seattle, Washington 98195 Find articles by Beaty, H. in: JCI PubMed Google Scholar First published July 1, 1974 - More info Abstract Pathophysiological[jci.org]
  • . : Differences in pathophysiology in experimental meningitis caused by three strains of Streptococcus pneumoniae . J Infect Dis 1991, 163 :806–811. PubMed Google Scholar 17.[link.springer.com]
  • Pathophysiology of bacterial meningitis: mechanism(s) of neuronal injury. J Infect Dis 2002 ; 186 Suppl 2: S225 –33. Schuchat A, Robinson K, Wenger JK, Harrison LH, Farley M, Reingold Al, et al. Bacterial meningitis in the United States in 1995.[brain.oxfordjournals.org]

Prevention

  • Meanwhile, here are five steps which can help prevent Pneumococcal Meningitis: 1. You must avoid overcrowded areas, drink enough water to prevent dryness of the throat, prevent cough and sneezing etiquettes.[pulse.com.gh]
  • Based on data from the literature, we attempt to understand the possible mechanisms resulting in bacterial complications, particularly meningitis, during chickenpox and to determine the means to prevent it.[ncbi.nlm.nih.gov]
  • Guidelines for prevention are also reviewed, including a renewed call for utilization of the 23-valent pneumococcal vaccine.[ncbi.nlm.nih.gov]
  • It, therefore, behooves on the individual to be eager to know more about the disease in order to prevent it-for, after all, prevention is better than cure.[ghana.gov.gh]
  • CONCLUSIONS: Our results provide evidence that attenuation of apoptosis by vitamin B6 is multi-factorial including down-modulation of inflammation, up-regulation of the neuroprotective brain-derived neurotrophic factor and prevention of the exhaustion[ncbi.nlm.nih.gov]

References

Article

  1. Mace SE. Acute bacterial meningitis. Emerg Med Clin North Am. 2008;26:281-317.
  2. Saez-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2003;361:2139-2148.
  3. Schuchat A, Robinson K, Wenger JD, et al. Bacterial meningitis in the United States in 1995. Active Surveillance Team. New England Journal of Medicine. 1997;337(14):970–976.
  4. Robinson KA, Baughman W, Rothrock G, et al. Epidemiology of invasive Streptococcus pneumoniae infections in the United States, 1995-1998: Opportunities for prevention in the conjugate vaccine era. JAMA. 2001;285(13):1729–1735.
  5. Preventing pneumococcal disease among infants and young children. Recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR RecommRep. 2000;49(RR-9):1–35.
  6. Haddy RI, Perry K, Chacko CE, et al. Comparison of incidence of invasive Streptococcus pneumoniae disease among children before and after introduction of conjugated pneumococcal vaccine. Pediatr Infect Dis J. 2005;24(4):320–323.
  7. de Gans J, van de Beek D. Dexamethasone in adults with bacterial meningitis. N Engl J Med. 2002;347:1549–1556.
  8. van de Beek D, de Gans J, Tunkel AR, Wijdicks EF. Community-acquired bacterial meningitis in adults. N Engl J Med. 2006;354:44–53.
  9. Weisfelt M, Hoogman M, van de Beek D, de Gans J, Dreschler WA, Schmand BA. Dexamethasone and long-term outcome in adults with bacterial meningitis. Ann Neurol. 2006;60:456–468.
  10. Chavez-Bueno S, McCracken GH Jr. Bacterial meningitis in children. Pediatr Clin North Am. 2005;52:795-810;
  11. Oostenbrink R, Moons KG, Theunissen CC, et al. Signs of meningeal irritation at the emergency department: how often bacterial meningitis? Pediatr Emerg Care. 2001;17:161-164.
  12. Schuurman T, de Boer RF, Kooistra-Smid AM, et al. Prospective study of use of PCR amplification and sequencing of 16S ribosomal DNA from cerebrospinal fluid for diagnosis of bacterial meningitis in a clinical setting. J Clin Microbiol. 2004;42:734-740

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Last updated: 2019-07-11 20:42