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Clinico-bacteriological study of pyogenic meningitis with special refferance to c-reactive protein in Cerebro spinal fluid.

INTRODUCTION:

Study Method: The study includes children less than 12 years of age with suspected pyogenic meningitis, admitted to ICU and wards of department of Pediatrics, Government General Hospital, Kakinada, during the period from Sep. 2014 to Feb. 2015. This is a Prevalence study. The study includes 50 children.

RESULTS:

* Pyogenic meningitis occurred most frequently in the 1st year of life, (4) constituting 68% of cases in the present study. 12 cases were below 2 months of age (24%), 22 cases belonged to 2 months to 1 year.

* In the present study, slightly male predominance was seen.

* According to I.A.P classification of nutritional status, 44% patients were normal and remaining shows malnutrition.

* Fever was the most common accounting for 90% of the patients. (5) Convulsions were present in 70%, refusal of feeds in 54% and altered sensorium in 54% of the cases.

* 70% of the patients presented during the first 6 days of the disease. 38%within 72 hrs.

* 76% of patients had altered sensorium and 24% of patients were conscious and coherent. Altered sensorium was observed in 88% of the patients less than one year of age where as older age group (1-12yrs) showed an incidence of 50%.

* Majority of patients with pyogenic meningitis had polymorph cell count. (6) of 100-5000 [mm.sup.3] in CSF. Only 2 patients had less than 100 cells/[mm.sup.3].

* Out of 50 cases, organisms were isolated from CSF in 22 cases (44%). Among them, with proven positive bacterial culture, 11 cases (50%) were due to pneumococcus, especially in older age group.

* Protein level in CSF was raised in all cases. Majority of the patients had protein content between 100-250 mg/dl in CSF. Pandy's test was positive in all cases. (7)

* Blood culture isolated the organisms in 14% (7 cases) of patients in which most common organism was Streptococcus. (8)

* Among the 50 cases of pyogenic meningitis studied in the present series, CRP was done in 44 cases, out of which 30 cases showed positive reaction to CRP.

CONCLUSION: Pyogenic meningitis is still one of the commonest central nervous system infection. Incidence of pyogenic meningitis is more common in early age group and children belonging to low socioeconomic groups. (9) Fever, convulsions, altered sensorium, refusal of feeds and vomiting's were common modes of presentation. Mortality from pyogenic meningitis in the present study was 28.88% excluding the cases which had been discharged against medical advice. It is unfortunate that Gram's staining and CSF culture which are the definitive evidence of pyogenic meningitis are frequently negative in significant no of cases. Estimation of CRP in CSF was positive in 86% of clinical pyogenic meningitis and negative in all cases of various neurological disorders other than pyogenic meningitis indicating its sensitivity of 68% and specificity of 100%. It does not stand superior to the routine laboratory parameters in diagnosing a frank case of pyogenic meningitis but having an immense value if positive in differentiating between partially treated pyogenic meningitis and tuberculous meningitis because of its high specificity.

MATERIALS AND METHODS:

Source of Data: All children less than 12 years of age with suspected pyogenic meningitis, admitted to ICU and wards of department of Pediatrics, Government General Hospital, Kakinada during the period from Sep. 2014 to Feb. 2015. The study includes 50 children.

Sampling Method: Random Sampling.

Inclusion Criteria: Presentation with complaints and features of persisting vomiting and fever, irritability and insomnia, fever or hypothermia, neurological deficits, umbilical infection, pyoderma or septicemia, bulging of anterior frontonelle, photophobia, petechiae over skin and mucosae, tremors and convulsions, history of prior lumbar punctures, sucking difficulties/refusal of feeds. (10)

Exclusion Criteria: Cases of Congenital CNS malformations, history of head trauma, intracranial space occupying lesions, convulsive disorders, and Drug withdrawal seizures are excluded from the study

Method of collection of data: Data was collected with detailed case taking and examination in all children (50) included in the study. Diagnosis was made based on the following criteria--Clinical examination and physical examination.

CSF analysis--included Colour, pressure, Pandy' s test, sugar (Benedict's), Protein and Sugar levels (Blood sugar was also obtained at the time of lumbar puncture for comparison), Cytology, Gram's staining, Culture and C-reactive protein, Total WBC count, Blood culture, culture of any infective foci.

All cases of pyogenic meningitis diagnosed by the above criteria were clubbed in group I. A control group II was selected for estimation of CRP in the CSF from patients of neurological disorders other than pyogenic meningitis.

Detection of CRP in CSF. Kits used--Monozyme India limited. India.

RESULTS: Clinical bacteriological study of pyogenic meningitis with special reference to CRP in CSF was done in 50 patients admitted in hospital. The results as follows.

1. Age distribution: Pyogenic meningitis occurred most frequently in the 1st year of life, constituting 68%of cases in the present study. 12 cases were below 2 months of age (24%), 22 cases belonged to 2 months to 1 year, 2 cases in the age group between 1-3yrs. of life (4%), 5 cases in the age group between 3-6yrs. of life (10%), 9 cases belonged to age group of 6-12 years (18%).

Age group

           No. of cases

0-1 yr.    34
1-3 yr.    2
3-6 yr.    5
6-12 yr.   9

Note: Table made from bar graph.

Age group   No. of cases    %

0-1 yr.          34        68
1-3 yr.          2          4
3-6 yr.          5         10
6-12 yr.         9         18
Total            50        100


2. Sex distribution: In the present study, slightly male predominance was seen. I.e. 28 cases were male and 22 were female. (4:3). (12)

sex distribution

male     56%
female   44%

Note: Table made from pie chart.


3. Nutritional Status: According to I.A.P classification of nutritional status, 44% patients were normal and remaining shows malnutrition.

Nutritional status

Normal          44%
Grade I PEM     26%
Grade II PEM    22%
Grade III PEM   4%
Grade IV PEM    4%

Note: Table made from pie chart.

Nutritional status   No. of cases    %

Normal                    22        44
Grade I PEM               13        26
Grade II PEM              11        22
Grade III PEM             2          4
Grade IV PEM              2          4
Total                     50        100


4. Presenting symptom: The major presenting symptoms were fever, convulsions, refusal of feeds and altered sensorium. Fever was the most common accounting for 90% of the patients. Convulsions were present in 70%, refusal of feeds in 54% and altered sensorium in 54% of the cases.

Fever and convulsions were observed in 90% and 70% respectively. But fever was observed in only 60% cases in age group less than 1 year. Refusal of feeds and altered sensorium were more common in the age group of less than 1 year. On the other hand, ear discharge, headache, vomiting and fever were significantly more in the age group of more than 1 year.

Symptom         No. of cases   %

Fever           45             90
Convulsions     35             70
Headache        9              18
Vomiting        11             22
Irritability    6              12
Cough           8              16
Ear discharge   9              18
Pyoderma        1              2
others          1              2


5. Duration of Symptoms: 70%of the patients presented during the first 6 days of the disease. 38%within 72 hrs.

Duration(Days)   No. of cases    %

<3                    19        38
4-6                   16        32
>7                    15        30
Total                 50        100


6. Physical signs: The following physical signs were observed.

Physical signs                     No. of cases   %

Altered sensorium                       38        76
Bulging anterior frontonelle            19        38
Cranial Nerve Palsy Occulomotor         1         2
Abducent                                1         2
Facial                                  6         12
Motor system Hemiplegia                 4         8
Neck rigidity                           26        52
Kernig's sign                           18        36
Brudzinski's sign                       11        22
Fundal changes papilledema              7         14
Subdural effusion                       2         4


76% of patients had altered sensorium and 24% of patients were conscious and coherent. Altered sensorium was observed in 88% of the patients less than one year of age where as older age group (1-12yrs) showed an incidence of 50%.

Bulging anterior frontonelle was seen in 38% of patients.

Cranial nerve palsy. (13) was seen in 14% of cases, one with Abducent palsy, one with Occulomotor and facial palsies and five with isolated facial palsy. Hemiplegia was noted in 8% of the cases.

Spinal/Nuchal signs: Neck stiffness was observed in 52% of all cases. 94% of more than one year age group showed this sign, in contrast to only 29.5% in less than one year age group Kernig's sign was observed in 36% of all patients. 87.5% of more than one year age group showed this sign, in contrast to only 12% in less than one year age group.

Brudzinski's sign was noted in 22% of total cases. 3% of less than one year age group showed this sign, in contrast to 62.5% of more than one year age group.

Papilledema was seen in 7 patients only Subdural effusion was noted in a seven month old child and a 12 years old child.

7. CSF analysis:

Pressure: It was observed that CSF pressure was raised in 62%of patients.

Colour: CSF was clear in 12% cases and remaining 88%showed an opalescent or turbid CSF.

Cytology: Cell count per [mm.sup.3] in the present series of patients were as follows.

Polymorph cell count   No. of cases    %

5-100                       2          4
100-500                     21        42
500-1000                    22        44
1000-5000                   5         10
Total                       50        100


Majority of patients with pyogenic meningitis had polymorph cell count of 100-5000 [mm.sup.3] in CSF. Only 2 patients had less than 100 cells/[mm.sup.3].

Bacteriology: Organisms isolated from CSF of cases of pyogenic meningitis as follows.

Age           Pneumococci   Menigococci   Streptococci

< 2 months        --            --             2
2-12 months        3            --             --
1-3yrs             1            --             --
3-6yrs             2            --             --
6-12yrs            5            --             --
Total No          11            --             2
Total%            50            --            9.09

Age           H.influenzae   E.coli   K. pneumoniae

< 2 months         --          2           --
2-12 months        4           --           1
1-3yrs             1           --          --
3-6yrs             1           --          --
6-12yrs            --          --          --
Total No           6           2            1
Total%           27.27        9.09        4.54


Out of 50 cases, organisms were isolated from CSF in 22 cases (44%). Among them, with proven positive bacterial culture, 11 cases (50%) were due to pneumococcus, especially in older age group. Next common organism isolated was H. influenzae 6 cases (27.27%). H. influenzae meningitis occurred in the age between 2 months and 6 years. In less than 2 months age group, only in 4 cases organisms were isolated--Streptococcus and E. coli. Neisseria meningitis was isolated in a 7 years old child.

Gram's staining of CSF smear was positive in 36% (18 cases). 11 were Gram positive diplococci, 2 were Gram positive streptococci and 5 were Gram negative bacilli.

8. Biochemical analysis of CSF:

Proteins:

Protein level in CSF was raised in all cases. Majority of the patients had protein content between 100 250 mg/dl in CSF. There was less rise of protein in cases of early and partially treated pyogenic meningitis. Pandy's test was positive in all cases.

Protein content of CSF(mg/dl)    No. of cases    %

50-100                                8         16
100-250                               32        64
250-500                               10        20
Total                                 50        100


Sugar: CSF sugar levels (Blood sugar levels was also obtained at the time of lumbar puncture for the comparison) was less than 20 mg/dl in 74% (37 cases) of patients. Partially treated cases had less fall in CSF sugar.

Sugar content (mg/dl)   No. of cases    %

0-10                         23        46
11-20                        14        28
21-40                        11        22
41-60                        2          4
Total                        50        100


Chlorides: There was no significant change in chloride levels of CSF.

9. Blood culture: Blood culture isolated the organisms in 14% (7cases) of patients. Among the patients of age 0-2 months, who also had septicemia, streptococcus was isolated in three patients and E.coli was isolated in two. Pneumococcus was isolated in two patients in the older age group. The pus from the infective foci which could have been the likely source of pyogenic meningitis like ear discharge (9 cases), and pyoderma (1 case) were sent for culture. Organisms were isolated in three patients with otitis media and the same organism (pneumococcus) was isolated in CSF in two of them. In the third patient organism isolated was H.influenzae, however CSF was sterile.

10. Outcome of Patients:

Outcome of cases

Recovered   64%
Expired     26%
LAMA        10%

Note: Table made from pie chart.

Outcome                                 No. of cases    %

Recovered                                    32        64
Expired                                      13        26
Leaving against medical advice(LAMA)         5         10
Total                                        50        100


11. C-Reactive protein in Cerebrospinal fluid: Among the 50 cases of pyogenic meningitis studied in the present series, CRP was done in 44 cases, out of which 30 cases showed positive reaction to CRP. (14)

Among these 44 patients, a comparison was done between gram staining, positive CSF culture and positive CRP in CSF. Gram staining was positive in 36% and CSF culture isolated organism in 44% cases. In contrast to these, 68% of cases showed positive CRP in CSF. (15)

Parameter         No. of cases   %

Gram's staining        18        36
Culture                22        44
CRP                    30        68


Twenty patients with various neurological disorders other than pyogenic meningitis, as confirmed by clinical and laboratory parameters, were taken as control and their CSF was tested for CRP. All were negative. (16)

DISCUSSION: Pyogenic meningitis is one of the commonest type of neurological infections in the children in our country. Most of pyogenic meningitis cases were observed in less than one year age group. Male to female ratio in the present study was 4:3. Majority of them showed no evidence of malnutrition. Major symptoms are fever, convulsions, refusal of feeds, altered sensorium. Most of the patients presented within 6 days and 38% of them within 72 hours of onset of symptoms. Altered sensorium was seen more frequently, probably because this hospital is mainly a referral center and patients were being examined in the periphery hospitals and referred late in the course of the disease. Polymorph nuclear cells found in CSF analysis of all patients. Gram staining of CSF, CSF culture and blood culture are useful investigations in pyogenic meningitis. Mortality rate was 28.88% in this study. When CRP positivity in CSF was compared with positive Gram staining and positive culture in CSF, it was found that CRP has higher sensitivity than both of them. (17) CRP was estimated in various neurological disorders other than pyogenic meningitis, where it was negative in all (specificity 100%).

CONCLUSION:

* 50 cases of pyogenic meningitis in children were studied with special reference to estimation of CRP in CSF.

* Pyogenic meningitis is still one of the commonest central nervous system infection. Because of the absence of spinal/nuchal signs and high incidence of sequelae and mortality especially in infants, high index of suspicion is a must to make the diagnosis.

* Incidence of pyogenic meningitis is more common in early age group and children belonging to low socioeconomic groups.

* Fever, convulsions, altered sensorium, refusal of feeds and vomiting's were common modes of presentation.

* Mortality from pyogenic meningitis in the present study was 28.88% excluding the cases which had been discharged against medical advice.

* Detailed history, clinical examination when supported with the CSF analysis will establish the diagnosis in most of the cases. It is unfortunate that Gram's staining and CSF culture which are the definitive evidence of pyogenic meningitis are frequently negative in significant no of cases.

* Estimation of CRP in CSF was positive in 86% of clinical pyogenic meningitis and negative in all cases of various neurological disorders other than pyogenic meningitis indicating its sensitivity of 68% and specificity of 100%.

* It does not stand superior to the routine laboratory parameters in diagnosing a frank case of pyogenic meningitis but having an immense value if positive in differentiating between partially treated pyogenic meningitis and tuberculous meningitis because of its high specificity.

DOI: 10.14260/jemds/2015/1928

REFERENCES:

(1.) Behrman, Kliegman, Jenson--Nelson Text book of pediatrics 19th edition, W. B. Saunder's Philadelphia, 2000, Vol.2.P.P.1927-29.

(2.) Prasad K, Karlupia N, Kumar A. Treatment of bacterial meningitis: an overview of Cochrane systematic reviews. Respir Med 2009; 103:945-50.

(3.) Abramson JS, Hampton KD, Sylvia Babu, Wasilankar BL, Marcon MJ; The use of C-Reactive protein from other Central Nervous system diseases. Journal of infectious diseases, 151, 854-858, 1985.

(4.) I.A.P. Text book of pediatrics 5th edition. 43. p1654-65.

(5.) Chinchankar N, Mane M, Bhave S, Bapat S, Bavdekar A, Pandit A, et al. Diagnosis and outcome of acute bacterial meningitis in early childhood. Indian Pediatr 2002; 39: 914-21.

(6.) Negrini B, Kelleher KJ, Wald ER. Cerebrospinal fluid findings in aseptic versus bacterial meningitis. Pediatrics 2000; 105:316-9.

(7.) Seehusen DA, Reeves MM, Fomin DA. Cerebrospinal fluid analysis. Am Fam Phys 2003; 68: 1103-8.

(8.) O'Brien KL, Wolfson LJ, Watt JP, Henkle E, Deloria-Knoll M, McCall N, et al. Burden of disease caused by Streptococcus pneumoniae in children younger than 5 years: global estimates. Lancet 2009; 374: 893-902.

(9.) P. Suvarna Devi et al. Etiological study of pyogenic meningitis in children by CIEP.I.P.Vol.19 April.1992.

(10.) Brain's Clinical Text Book of Neurology. 12th edition 15: 799-805.

(11.) C-RP in Childhood Meningitis: Pmde HK: Harish K Et.al.--Indian Journal of pediatrics, 1996, January. p142-143.

(12.) Philip AGS, Baker CJ; Cerebrospinal fluid C-RP reactive protein in Neonatal meningitis, Journal of pediatrics, 102, 715-717, 1983.

(13.) Weber MW, Herman J, Jaffar S, Usen S, Oparaugo A, Omosigho C, et al. Clinical predictors of bacterial eningitis in infants and young children in The Gambia. Trop Med Int Health 2002; 7:722-31.

(14.) Benjamin DR, Pheem KE, Brewer L;Is C-Reactive protein useful in the management of children with suspected bacterial meningitis American Journal of clinical pathology, 81,779-782,1984.

(15.) Sabal KG Hanson LA--The Clinical usefulness of C-reactive protein Determination in Bacterial Meningitis and septicemia in infancy. Acta Paediataraica scandinevia 63, 831-838, 1974.

(16.) Clarke D, Cost K: Use of serum C-Reactive protein in differentiating septic from aseptic meningitis in children. Journal of Paediatrics, 102, 718-720, 1983.

(17.) B. N. Gokul, A. chandramukhi, R. Rajendran and P.S.R. Sreenivasabalu; Detection of C-RP in CSF for Rapid diagnosis and differentiation of pyogenic meningitis from other diseases of central nervous system. Neurology India, 37, 23-23, 1987.

K. Koteswara Rao [1], A. Krishna Prasad [2], K. Adi Reddy [3], Solomon Saawan P [4], Krishna Kumari Agarwal [5] S. Anusha [6]

AUTHORS:

1. K. Koteswara Rao

2. A. Krishna Prasad

3. K. Adi Reddy

4. Solomon Saawan P.

5. Krishna Kumari Agarwal

6. S. Anusha

PARTICULARS OF CONTRIBUTORS:

[1.] In charge Professor, Department of Pediatrics, Rangaraya Medical College, Kakinada.

[2.] Associate Professor, Department of Pediatrics, Rangaraya Medical College, Kakinada.

[3.] Junior Resident, Department of Pediatrics, Rangaraya Medical College, Kakinada.

[4.] Junior Resident, Department of ENT, Rangaraya Medical College, Kakinada.

[5.] Junior Resident, Department of Pediatrics, Rangaraya Medical College, Kakinada.

[6.] Junior Resident, Department of Pediatrics, Rangaraya Medical College, Kakinada.

FINANCIAL OR OTHER COMPETING INTERESTS: None

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. K. Adi Reddy, Junior Resident, Department of Pediatrics, Rangaraya Medical College, Kakinada.

E-mail: adi9949844121@gmail.com

Date of Submission: 15/09/2015. Date of Peer Review: 18/09/2015. Date of Acceptance: 19/09/2015. Date of Publishing: 22/09/2015.
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Title Annotation:ORIGINAL ARTICLE
Author:Rao, K. Koteswara; Prasad, A. Krishna; Reddy, K. Adi; Solomon, Saawan P.; Agarwal, Krishna Kumari; A
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Date:Sep 24, 2015
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