A RENT THAT LET MENINGITIS FOR LEASE

DR.V.AKILA SIVAKUMAR

(DNB PG)

BRS HOSPITAL,CHENNAI.

ž 6 ½ yrs old developmentally normal, school going boy

ž high grade fever with irritability and vomiting x 1 day.

On examination :

ž irritable, febrile.

ž Anthropometry-normal

ž vitals - normal

ž neck stiffness, positive Kernig’s and Brudzinki’ssigns.

ž Other system examination - normal.

ž Fundus examination - normal.

ž Investigations:

ž CBC- polymorphic leucocytosis (TC-14,600); Hb & platelets-normal,peripheral smear study-normal.

ž LFT & RFT-Normal.

ž CT Brain – Normal study.

ž CSF analysis- sugar-low; protein-normal,

cells- polymorphs predominant.

Gram stain-Gram positive cocci in clusters .

Treatment:

Meningitic dose of Ceftriaxone (Responded very well).

Past history :

ž Treated for bacterial meningitis at 4 years 8 months of age (Jan 2011).

ž CSF analysis-sugar-50mg/dl

protein-83mg/dl

cells-235/cu mm, polymorphs

predominant.

Gram stain-showed Gram negative

bacilli .

ž CT brain at that time was normal.

ž Responded to antibiotics.

ž Presented with left lower lobe pulmonary

consolidation 1 year later (Jan 2012).

ž Pulmonary tuberculosis was suspected.(doubtful

history of contact).

ž BAL done & it was positive for PCR for TB.

ž ATT given for 6 months.

ž Diagnosed as ?TBM 3 months after completing ATT.

ž CT brain was normal.

ž CSF analysis- gram stain –no organism,

PCR for TB was positive.

ž ATT started again.

ž Current episode was within 1 month of starting ATT

(Oct -2012 )

ž No H/O head trauma or surgery.

ž Immunoglobulin levels - normal

ž HIV Elisa - negative.

ž CBC - normal during all episodes

MOTHER’s Major concern…….

ž Persistent rhinorrhoea since 4 years of age.

ž “typical allergic salute’’ present

ž treated as allergic rhinitis frequently .

ž on probing - -> he had nasal discharge without allergic symptoms also .

ž Nasal examn – clear non - sticky discharge from the right nostril

?CSF rhinorrhoea

ž Nasal secretion analysis:

ž Clear, sugar – 70 mg/dl.

ž CSF cisternogram:

Ø A tiny rent measuring 1.8mm in right fovea ethmoidalis & cribriform plate junction.

Ø Another tiny rent of 0.8 mm size seen in right fovea ethmoidalis.

Ø Cotton ball kept in the right nasal cavity became soaked with contrast –suggestive of CSF leak on right side.

Ø Bilateral sino nasal polyposis.

Further course of this episode

ž Diagnostic nasal endoscopy done and CSF leak from right middle meatus was confirmed (left nostril normal)

ž Endoscopic CSF leak repair (using temporalis fascia as graft) done by ENT surgeon

ž Discharged on the 5th post operative day.

ž Condition at discharge – afebrile, no vomiting / headache

FOLLOW UP

ž No recurrence of symptoms or signs of

meningitis.

ž Needs further follow up for :

ØRecurrence of meningitis

ØAudiological evaluation

ØDetailed immunological workup

RECURRENT MENINGITIS

ž Indicates pyogenic meningitis occurring on two or more occasions after an intervening period of full convalescence.

ž Etiology

v anatomical abnormalities- congenital / acquired

v immunodeficiencies - congenital / acquired

vchronic parameningeal infections.

PRESENCE OF A MINOR ANTIBODY DEFICIENCY SHOULDNOT PRECLUDE THE SEARCH FOR A CRANIAL DEFECT!

2008;21:519-537

APPROACH TO

A CASE OF RECURRENT MENINGITIS

CSF RHINORRHOEACAUSES:

ž Traumatic

Ø Non surgical –blunt and penetrating (80% of all CSF leaks). -2-3% of all major head trauma

-15-30% of skull base fractures

Ø Iatrogenic –neurosurgical

endoscopic sinus surgery

ž Non traumatic

Ø High pressure leaks

Ø Normal pressure leaks

Ø spontaneous leaks- only 5% of all CSF leaks.

Ø Congenital causes

HISTORY:

ž Typical history - clear, watery discharge from a

single nare

ž An increase in postnasal drip while in the supine

position.

ž Older child may complain of a salty taste in his or

her mouth.

ž In the case of headaches, the child may state that the

headache resolves when the leak occurs.

PHYSICAL EXAMINATION:

ž Mostly unremarkable.

ž Maneuvers :

Ø Ask the child lean forward and strain. This raises ICP

and may elicit a leak.

Ø Another way to raise ICP is to compress both jugular

veins.

Rhinorrhoea is typically clear but may be mixed with

blood (look for ‘Ring sign’ or ‘Halo sign’).

BIO - CHEMISTRY:

ž Glucose estimation:

ž If mixed with blood – false positive.

ž In meningitis /CNS infections – false negative.

Ø If not blood stained , glucose >30 mg/dl –suspect

CSF.

Ø If no glucose –that specimen doesn’t contain CSF.

ž Beta-2-transferrin estimation:

Ø almost exclusively found in the CSF

Ø blood or nasal secretion does not disturb the test .

Ø not present in blood, nasal mucus, tears or mucosal

discharge.

Ø Sensitivity of near 100% and specificity of about

95 %.

ž (Ref: CSF Rhinorrhea ,Grand Rounds Presentation, UTMB, Dept. of Otolaryngology)

ž CT scan :

Ø in all cases of suspected skull base defects

Ø images should be 1mm in thickness with axial, sagittaland coronal views.

ž MRI :

Ødetecting soft tissue abnormalities

Ødistinguishing CSF from other fluid located in a sinus cavity ( CSF has high signal intensity on T2 images)

Ø MRI can also be combined with intrathecal dye injection to improve accuracy.

Ø not as good as CT to detect bony defects

CT CISTERNOGRAPHY

ž Done by injecting contrast in the intrathecal space by

doing a lumbar puncture.

ž Put the patient on prone position with head end of the

bed down for 10-15 mins.

ž Take high resolution CT .

ž Only active leaks can be detected.

TREATMENT

ž The majority of traumatic CSF leaks respond well

to conservative management.

ž Spontaneous leaks tend to require surgical

correction.

ž The presence of a CSF leak increases the risk of

meningitis 10-fold.

MEDICAL:

ž Bed rest for 7-10 days with the head of bed at 15-30

degrees .

ž Advised not to strain,cough

ž 75-80% of all traumatic CSF leaks will resolve.

ž The use of antibiotics in the treatment of CSF rhinorrhea

remains controversial.

ž When there is increased ICP, diuretic use should be

considered –acetazolamide.

If the leak fails to responds after 5-7 days of conservative management

ž Consider is the use of a lumbar drain

ž Continuous drainage is recommended .

ž The rate of drainage should be about 10-15cc/hr.

ž Side effects such as headaches, nausea, and emesis.

SURGERYž The surgical management of CSF rhinorrhea :Ø intracranial approachØ extracranial approach

ž The defects can be repaired by primary closure with or without the use of grafts.

ž Grafting material - cartilage, bone (septum, mastoid tip,

middle turbinate), mucoperichondrium, septal mucosa,

turbinate mucosa and/or bone, fascia (temporalis, fascia lata),

abdominal fat, and pedicled septal or turbinate flaps.

Post operative care:

ž should be placed on bed rest with the head of the bed set at 15-30 degrees for 3-5 days.

ž The patient’s blood pressure should be maintained at a normal level.

ž The patient should also be placed on stool softeners to prevent straining,

ž Instructed not to cough, blow his or her nose, and avoid any heavy lifting.

ž Some surgeons will utilize a lumbar drain post-operatively.

SIMILAR CASE REPORTS

ž CSF rhinorrhoea and recurrent meningitis –Dennis G Pappas et al. (Clinical infectious diseases,Vol 17, no 3,sep 1993)

ž CSF Rhinorrhea and Recurrent Meningitis Caused by Transethmoidal Meningoencephaloceles - Parul Garg,VinitaRathi,Satish K. Bhargava,Anju Aggarwal

ž Remediable Recurrent Meningitis--K. Rajeshwari,AjaySharma (Indian pediatrics- Vol 32-April 1995)

ACKNOWLEDGEMENTS

ž Dr. D. Vijayasekaran

ž Dr. N. Mahesh

ž Dr. Balakumar

ž Dr. S.Ramesh