Dragan Lepur

Community-Acquired Bacterial Meningitis in Adults: Antibiotic Timing in Disease Course and Outcome

Objectives:Despite improvements in diagnostic and therapeutic approach to adult patients with bacterial meningitis, the overall mortality rate is still high. The aim of this study was to evaluate antibiotic timing in the course and outcome of bacterial meningitis.Methods:Two hundred and eighty six patients with community-acquired bacterial meningitis aged 14 years and more were included in this retrospective cohort study. Observational period was between 1 January 1990 and 31 December 2004. To assess the association of antibiotic timing and disease outcome we analyzed three timing periods (according to the onset of disease, onset of consciousness disturbance and the time of admission to hospital). Analysis was also performed in a subgroup of culture positive meningitis in 176 patients with altered mental status.Results:Unfavorable outcome was found in 125 (43,7%) patients. In this group, the start of appropriate antibiotic treatment in relation to the onset of first symptoms and particularly to the onset of consciousness disturbance was significantly delayed (p = 0.018 and p < 0.001, respectively) compared to the favorable group. Logistic regression analysis in a subgroup of culture positive meningitis in patients with altered mental status revealed that early adequate antibiotic treatment related to the onset of overt signs of meningitis was independently associated with favorable outcome (OR = 11.19; 95% CI 4.37–32.57; p < 0.001). Advanced age, lower GCS and seizures (OR = 1.05, OR = 1.45 and OR = 3.65, respectively) were other risk factors of poor outcome. The presence of chronic diseases, pneumococcal etiology and clinical and laboratory variables which are indicators of disease severity (renal and/or liver dysfunction, hypotension and low cerebrospinal fluid glucose) were not confirmed as independent risk factors of poor outcome. Conclusions:Our study emphasizes the importance of early and adequate antibiotic treatment in the management of bacterial meningitis which significantly enhances the chances for favorable outcome.

Induced hypothermia in adult community-acquired bacterial meningitis – more than just a possibility?

We present the case series of adult community-acquired bacterial meningitis treated with hypothermia. The major criteria for therapeutic hypothermia (TH) was impaired carbon dioxide reactivity (CO(2)R) assessed by Transcranial Doppler (TCD). In patients without temporal acoustic window, minor criteria (optic nerve sheath diameter ≥ 6.0 mm plus GCS ≤ 8) were required. According to our, although limited experience, the use of mild hypothermia in selected patients with community-acquired bacterial meningitis accompanied with appropriate monitoring could be a promising treatment tool.

Mckittrick-Wheelock syndrome : a rare cause of diarrhoea

McKittrick-Wheelock syndrome is a rare disorder caused by fluid and electrolyte hypersecretion from a rectal tumour. The most frequently reported tumours are villous adenomas. Dehydration with severe hyponatremia, hypokalemia, metabolic acidosis, acute renal failure and watery diarrhoea is typical. The authors present a case of McKittrick-Wheelock syndrome caused by rectal adenocarcinoma.

Therapeutic Hypothermia for Adult Viral Meningoencephalitis

BackgroundDespite the advances in critical care, severe viral meningoencephalitis continues to impose high rates of morbidity and mortality. Consequently, new treatment strategies are needed and we present therapeutic hypothermia (TH) as one of the possible efficacious treatment tools.MethodsWe present the case series in an adult intensive care unit of a tertiary care hospital. Eleven patients suffering from severe viral meningoencephalitis were treated with hypothermia. The major indication for TH was severely impaired consciousness associated with carbon dioxide reactivity loss assessed by Transcranial Doppler. Besides from the established treatment, all the patients underwent TH. Mild hypothermia (rectal temperature of 32–34°C) was maintained with continuous veno-venous hemofiltration.ResultsMedian Glasgow coma scale score in our patients at admission was 8 (3–10) and median Acute Physiology and Chronic Health Evaluation score was 24 (12–32). The overall mortality rate was 9% (1/11). Among survivors, the outcome was favorable in five patients [Glasgow Outcome Scale score (GOS) 4–5]. Remaining five patients had severe residual neurological deficit (GOS 3). Median GCS at discharge was 15 (8–15). With respect to disease severity, the outcome in presented patients was generally satisfactory.ConclusionsOur results suggest that use of mild hypothermia in selected adult patients with viral meningoencephalitis could be a promising treatment tool.

Incidence of neurological complications in patients with native-valve infective endocarditis and cerebral microembolism: An open cohort study

The objective of this open cohort study was to assess the association between neurological complications in patients with definite native-valve infective endocarditis (IE) and cerebral microembolism (MES). MES detection was performed with 1-h, bilateral middle cerebral arteries (MCA) insonation using a transcranial Doppler ultrasound (TCD) machine. Thirty patients with definite native-valve IE were stratified into 2 groups based upon the presence of MES. The most striking difference between the 2 groups of patients was the incidence of clinically evident neurological complications. Neurological complications of IE occurred in 10 (83.3%) patients with positive MES and in 6 (33.3%) MES-negative patients (p=0.021). Ischaemic stroke was the most common complication, occurring in 11 of 16 patients, followed by meningitis in 4 patients and cerebritis in 1 patient. There was a trend towards greater in-hospital mortality in patients with recorded MES than in the MES-negative, although this was not statistically significant (33.3% vs 16.6%; p=0.392). Our results reveal a significant association between MES and neurological complications in patients with native-valve IE. TCD is a promising tool in predicting individual patient risk for neurological complications of IE.

Prospective observational cohort study of cerebrovascular CO2 reactivity in patients with inflammatory CNS diseases

The purpose of this study was to evaluate the significance of cerebrovascular CO2 reactivity (CO2 R) in the course and outcome of inflammatory central nervous system (CNS) diseases. Sixty-eight patients with inflammatory CNS diseases and 30 healthy volunteers were included in this prospective observational cohort study. The observational period was between January 2005 and May 2009. The CO2 R was measured by transcranial Doppler (TCD) ultrasound using the breath-holding method. We compared patients with normal CO2 R (breath-holding index [BHIm] ≥ 1.18 = BHIN group) with patients who showed impaired CO2 R (BHIm < 1.18 = BHIR group). We also analyzed the association of impaired CO2 R with the etiology, severity, and outcome of disease. When compared to the BHIN group, the patients from the BHIR group were older, had a heavier consciousness disturbance, experienced more frequent respiratory failure, and, subsequently, had worse outcomes. There were no fatalities among the 28 patients in the BHIN group. The comparison of subjects with bacterial and non-bacterial meningitis revealed no significant differences. The unfavorable outcome of disease (Glasgow Outcome Scale [GOS] score 1–3) was significantly more common in subjects with impaired CO2 R (62.5% vs. 10.7%). Logistic regression analysis was performed in order to establish the prognostic value of BHIm. The outcome variable was unfavorable outcome (GOS 1–3), while the independent variables were age, Glasgow Coma Scale (GCS) score, and BHIm. The age and BHIm showed the strongest influence on disease outcome. A decrease of BHIm for each 0.1 unit increased the risk of unfavorable outcome by 17%. Our study emphasizes the importance of CO2 R assessment in patients with inflammatory CNS diseases.

Chronic fungal meningitis caused by Aureobasidium proteae

We present a case of chronic meningitis due to the mold Aureobasidium proteae. Clinical features, the disease course, as well as the diagnostic methods and optimal treatment options are discussed. This case confirms the neuroinvasiveness of A. proteae and introduces it as a new human pathogen.

Moraxella lacunata: A rare cause of infective endocarditis

We describe the first case of Moraxella lacunata definite native valve endocarditis in a patient with previously normal mitral valves. The disease was complicated with embolizations of the brain and spleen. After 6 weeks of antimicrobial treatment, valvular replacement was performed. The clinical course and diagnostic findings suggest that Moraxella lacunata possesses high aggressiveness leading to progressive valvular destruction and embolizations.

Anti-ganglioside antibodies-mediated leptospiral meningomyeloencephalopolyneuritis

A case of leptospirosis complicated with meningomyeloencephalopolyneuritis and nephrotic syndrome is presented. Anti-ganglioside antibodies were detected for the first time in a patient with neurological complications of leptospirosis. Possible pathogenic mechanisms and treatment options of these rare manifestations are discussed.

Acute pneumococcal myelitis in an adult patient.

Pneumococcal meningitis represents the most severe community-acquired bacterial meningitis. The disease is frequently associated with various complications. We present a case of pneumococcal meningitis in an immunocompetent adult patient treated with hypothermia. The disease course was complicated with severe myelitis and consequent paraplegia which is an extremely rare complication of pneumococcal disease.