Clinical features, complications, and outcome in adults with pneumococcal meningitis: a prospective case series

doi:10.1016/S1474-4422(05)70288-X

The Lancet Neurology

Volume 5, Issue 2, February 2006, Pages 123-129

https://doi.org/10.1016/S1474-4422(05)70288-X Get rights and content

Summary

Background

Bacterial meningitis is a grave disease of high incidence, especially in less developed countries. Here, we describe its clinical presentation, spectrum of complications, prognostic factors, and outcome in adults with pneumococcal meningitis.

Methods

From October, 1998, to April, 2002, we assessed 352 episodes of community-acquired pneumococcal meningitis, confirmed by culture of cerebrospinal fluid (CSF), which occurred in patients older than 16 years. Predictors for an unfavourable outcome (Glasgow outcome scale score 1–4) were identified by logistic regression with multiple imputation techniques.

Findings

245 (70%) episodes of pneumococcal meningitis were associated with an underlying disorder. Cranial CT was done for 85% of episodes and revealed underlying disorders in 17% (50/299) and meningitis-associated intracranial complications in 39% (117/299). Independent predictors for an unfavourable outcome were a low score on the Glasgow coma scale, cranial nerve palsies, a raised erythrocyte sedimentation rate, a CSF leucocyte count less than 1000 cells per mm³, and a high CSF protein concentration on admission. Overall in-hospital mortality was 30%. Prevalence of neurological and systemic complications did not differ between patients aged younger than 60 years and those aged 60 years and older; however, systemic complications were the cause of death in 59% (32/54) of fatal episodes in patients aged 60 years and older, whereas neurological complications were the cause of death in 65% (20/31) of fatal episodes in younger patients.

Interpretation

Pneumococcal meningitis is associated with high mortality and morbidity rates in adults. Whereas neurological complications are the leading cause of death in younger patients, elderly patients die predominantly from systemic complications.

Introduction

Bacterial meningitis is a serious and life-threatening disease. The estimated incidence is 2·6–6 per 100 000 adults per year in developed countries and is up to ten-times higher in less developed countries.¹ Streptococcus pneumoniae is the leading cause of bacterial meningitis in adults.1, 2 Case series on adults with pneumococcal meningitis have been published previously. However, these studies were mainly retrospective.1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 In this prospective cohort study we provide a detailed description of the clinical course, the spectrum of complications, prognostic factors, and outcome in 352 adults with community-acquired pneumococcal meningitis.

Section snippets

Patients

In the Dutch Meningitis Cohort Study, a nationwide observational cohort study in the Netherlands, 696 episodes of community-acquired acute bacterial meningitis were assessed prospectively.² The causative organisms were identified by culture of the cerebrospinal fluid (CSF), which yielded S pneumoniae in 352 (51%) episodes, Neisseria meningitidis in 257 (37%) episodes, and other bacteria in 87 (13%) episodes (figure 1). Inclusion and exclusion criteria have been extensively described elsewhere.²

Results

In total, 352 episodes of pneumococcal meningitis occurred in 343 patients; nine patients had a second episode during the study period. In 245 (70%) episodes, underlying disorders were present, such as otitis or sinusitis, pneumonia, or an immunocompromised state (table 1). Patients with otitis or sinusitis were significantly younger than patients with other underlying disorders (mean age 56 years [SD 15] vs 61 years [16]; p=0·008). A previous episode of pneumococcal meningitis (before or

Discussion

This study describes adults with pneumococcal meningitis from a large prospective cohort study of adults with bacterial meningitis. Our findings confirm the serious and life-threatening status of pneumococcal meningitis; systemic and neurological complications occurred in a large proportion of patients and resulted in a high mortality rate (30%) and high rate of neurological sequelae (30%) in surviving patients, such as hearing loss and hemiparesis.

By undertaking a categorisation of the cause

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Bacterial meningitis is a medical emergency that is common in many areas of the tropics. The epidemiology varies with geographical and climatic conditions, with age, with rate of HIV infection and other causes of immunosuppression, and with the availability of vaccines. The epidemiology has substantially changed in the past 25 years after the introduction of vaccines against Haemophilus influenzae type B, Streptococcus pneumoniae, and Neisseria meningitidis, although only recently these vaccinations have reached populations in research poor settings, where the incidence is highest. Currently, two pathogens cause most cases outside the neonatal period: Streptococcus pneumoniae and Neisseria meningitidis. Neonatal meningitis may also be caused by these organisms but other bacteria such as Escherichia coli, Streptococcus agalactiae (Group B streptococcus), and Klebsiella pneumoniae tend to predominate. The relative importance of H. influenzae, pneumococci, and meningococci outside the neonatal period varies according to country; for example, in humid low-lying regions S. pneumoniae and H. influenzae predominate, whereas in dryer regions, for example the meningitis belt of sub-Saharan Africa, the meningococcus causes vast spreading epidemics. Bacterial meningitis has a high mortality and carries a high risk of neurological sequelae.
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From 2006 through 2020, 39 of 2,357 (2%) episodes presented with a normal CSF leukocyte count. Immunocompromising conditions were present in 19 of 39 patients (49%), compared to 690 of 2303 (30%) in patients with elevated leukocytes (P = 0.02). The triad of fever, neck stiffness, and altered consciousness was present in 6 of 34 patients (18%). CSF protein was abnormal in 25 of 37 patients (68%). We identified 3 clinical subgroups: those with severe pneumococcal meningitis (20 patients [51%]), with mainly sepsis (8 [21%]), and a miscellaneous group (11 [28%]). All patients with severe pneumococcal meningitis presented with high CSF protein levels and 18 of 19 (95%) had bacteria in the CSF Gram stain. Outcome was unfavorable in 23 of 39 (59%) patients and 12 (31%) died.
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The central nervous system (CNS) is protected from the invading pathogen by cellular barriers, such as the blood-brain barrier (BBB) and the blood-cerebrospinal fluid barrier (BCSFB) that consist of complex and dynamic structures. In line with the cellular barriers, the immune response from the CNS specified cells respond against the microbial invasion to maintain the central homeostasis. Nevertheless, infective microbes have the potential to breach this barrier and enter the CNS to cause brain infection, which leads to a substantial amount of mortality and morbidity. In this chapter, we focus on the bacterial brain infection that leads to meningitis and encephalitis. We also explain the mechanisms of bacterial invasion, the CNS immune response to bacterial attack, and its long-term clinical consequences.

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Fast track — ArticlesClinical features, complications, and outcome in adults with pneumococcal meningitis: a prospective case series

Summary

Background

Methods

Findings

Interpretation

Introduction

Section snippets

Patients

Results

Discussion

J Infect

J Infect

Lancet

Lancet Infect Dis

Acute bacterial meningitis in adults: a review of 493 episodes

N Engl J Med

Clinical features and prognostic factors in adults with bacterial meningitis

N Engl J Med

Acute bacterial meningitis in adults: a 12-year review

Medicine (Baltimore)

Community-acquired bacterial meningitis: risk stratification for adverse clinical outcome and effect of antibiotic timing

Ann Intern Med

Bacterial meningitis

Clinical evaluation of pneumococcal meningitis in adults over a twelve-year period

Eur J Clin Microbiol Infect Dis