and streptomycin in such cases have been published. In India except in large cityhospitals, bacteriological investigation even of hospital cases is not often possible and much less so in private practice. In view of the rarity of such an investigation, with positive findings of H. influenza, it was thought proper to report the following case :?
sera
Case report child, aged six months, admitted in a private nursing home with a history of low fever for 15 days, irritability and occasional convulsions, was seen by a physician at this stage. Kernig's sign positive. There was some rigidity of the neck. Lumbar puncture on 9th December, 1948; C.S.F. pumlent under pressure. (The other laboratory investigations are given A female
below.)
started with Treatment.?Treatment was intramuscular and intrathecal injections of penicillin. Fever came down but rigidity and convulsions increased. Second lumbar puncture was done on 17th December, 1948; C.S.F. findings as before. Sulphadiazine two tablets fourhourly given. Fever kept at 99?F., there was marked opisthotonos. Third lumbar puncture was done on 29th December, 1948; C.S.F. much less turbid. Case continued with remissions and relapses with meningeal symptoms. Patient was further given intramuscular and intrathecal injections of streptomycin. Patient had three changcs of physicians since admission to the nursing home and was removed against advice before recovery. Attempts to trace him have failed.
A CASE OF MENINGITIS DUE TO
HAEMOPHILUS INFLUENZAE By SULOCHANA D. SOMAN, m.b., h.s. (Bom.), d.b. (Manchester), d.t.m.&h. (Lond.) Lecturer in Bacteriology, Grant Medical College, Bombay and V. H. SALASKAR, m.d. (Bom.) Demonstrator in Bacteriology, Grant Medical College,
Laboratory investimation
Bombay
C.S.F. was examined by one of on three occasions and the results below :
Meningitis due to H. influenza is not an unusual finding especially in a child. It lias
9th December, 1948
QuantityAppearance Proteins Chlorides Cells
Organisms (Gram's
j
Diminished 610
per
c.mm.
predominate.
Not
seen
410
per
j
Gram
?
ve
610 mg. per cent.
polymorphs 110
bacilli
grown
Colonies of Gram bacilli in fair numbers. acid-fast bacilli.
been reported by many workers in Europe and America and the strains isolated have been studied. The reports about the effects beneficial or otherwise of various sulpha group of drugs with and without anti-haemophilus specific
per c.mm.
Stray Gram
smears. vc bacilli Gram ? H. influenzai.
No deposit.
j Diminished.
c.mm.
predominate,
tabulated
Increased.
Diminished
polymorphs
(V. H. S.)
5 cc.
I Faintly turbid.
610 mg. per cent
acid-fast
methods). Culture
5 cc.
cc.
are
28th December, 1948
Turbid, deposit and coagulum Same as before present. Increased Increased 600 mg. per cent
Sugar Microscopic?
and
7
17th December, 1948
us
ve
polymorphs few. ve
bacilli
seen.
No growth.
No
The direct smears and the culture of the second lumbar puncture C.S.F. were brought to the senior author for opinion. The smears showed fair numbers of, intra- and extra-cellular Gram-negative, pleomorphic bacilli with halo
July, 1949] round them
MENINGITIS DUE TO H. INFLUENZAE of
suggestive
a
capsule
and
they
resembled atypical H. influenza; which appear
predominantly
in
bacillary
or
filamentous forms
with swollen and bulbed portions. Culture on blood agar being rather old showed similar but faintly stained organisms. These were sub-
cultured
in
to a blood agar in glucose broth. Out of the three colonies subcultured on different part of the same agar slope, only one grew. The colonies in further subculture were tiny, ' transparent, smooth and shiny like S' forms of H. were and non-hsemolytic. The influenza, organisms were further tested in different media with the following results ;
glucose
slope. There
was
broth and no
on
growth
!?
SOMAN
Glucose broth Blood agar with Staph,
3. 4. 5.
Same as 2, but with penicillin Glucose broth with Staph, aureus Same as 4, but with penicillin
No growth Discrete but crowded colonies as described before, round the Staph. colonies. No growth of either Scanty growth of bacilli with cocci No growth of either
Chocolate agar slope (prepared by dipping for a minute a blood agar slope in boiling water and
Profuse but discrete colonies as described above showing niorphologically H. influenza} in 24 hours.
Same
Very scanty growth after
6-
7.
resloping). on
as 6, but with its surface.
i
penicillin
i
From the growth
on chocolate agar slope, made as follows to further ascertain its cultural requirements :
subcultures
were
Medium 8. 9.
10.
Peptone water Peptone water with Staph, aureus Peptone water with heated blood
48 hours
was carried out with last culture the Roseindole reagent after extracting the culture with ether. A faint pink colour was seen. Thus it was feebly positive. Test was negative on peptone water with heated blood used as control. Pathogenicity test was carried out with two white mice. A thick was made in normal saline
' '
V ' factors absent. ' ' and V factors present.
'X' alone (from blood). 'V' alone (from cocci). 'X' and 'V' absent (no
cocci).
blood;
no
Both 'X' and 'V' available (from heated RBC).
t
The strain appears to be sensitive.
influenza. The organism was found to be to penicillin to a certain extent. Bacteriostatic effect of penicillin on a large of H.
No growth No bacilli but cocci grown Bacilli as described before grown
Indole test
' X' and Both ' X
sensitive
Result
by adding
589
' Remarks with regards to X' and ' V' factors in the media
,
2.
aureus
& SALASKAR
and studied was atypical H. injiuenzce requiring both ' X ' and ' V ' factors, showing slow and scanty growth on blood agar, not producing haemolysis, and differing from typical strains in showing predominantly bacillary or filamentous morphology with swollen and bulbed portions and a halo suggestive of a capsule. It stained feebly with counter stain in Gram's method, a property in common with this group. Indole production was doubtful. No fermentation tests were put up. Virulence test was not decisive, possibly because it was not done with the primary culture or an adequate dose was not administered or a sufficient number of animals Colonial characters were those was not used.
Result
Medium
:
' Remarks with regards to X' and ' V' factors in the media
No 'X' and 'V'. ' V alone. X ' and ' V ' present.
' '
number of strains of H. influenza? lias now been well established. The bacilli were present in three samples of C.S.F. from the patient on different dates. It was missed in the direct smear first time, probably due to its faintly staining character and atypical morphology.
peritoneal^
Pittman's (1931) antigenic study of H. influin U.S.A. showed that most of the strains from the pathological lesions chiefly meningitis ' ' colonies. smooth produced characteristic formed and found to were be They capsulated
Discussion In accordance with the classification given by Wilson and Miles (1946), the bacillus isolated
group. Serological types been described by her and ' ' type b occurred with the greatest frequency in the cases of meningitis. She also noted that those from the respiratory tract were non' ' hemolytic, non-capsulated R forms and seroland non-pathogenic. ogically heterogeneous Mulder (1939) and Gordon, Woodcock and Zinnemann (1944) have described cases of
suspension
from chocolate agar, \
cc. was injected intrain one and \ ccthe other. Animals looked ill after 18 hours. The one with smaller dose was killed after 24 hours as it appeared more ill. Smears and cultures were made from peritoneal surface and heart blood. No organisms were seen or grown, the other animal recovered.
enza;
fairly homogeneous b, c, d, e, f have
a,
THE INDIAN MEDICAL GAZETTE
290
' ' due to R forms. In the for absence of facilities serological typing but in our case it appears the findings judged by that this organism would fall in line with one of the Pittman's serological types. With regard to other findings in C.S-.F., it may be pointed out that the cell count should be interpreted in the light of the coagulum formed. Rhoads (1947) in his review of 550 cases of bacterial meningitis noted in connection with meningococcic meningitis that the higher the cell count in C.S.F. the worse was the prognosis, the count usually being in thousands. In the fatal group of H. influenza; meningitis, he found the spinal fluid glucose too low to read. Glucose was diminished in our case. Assessment of the effect of drug in this case was not possible, as the treatment was delayed and the patient was under different physicians and was removed from the nursing home against advice. In spite of the delayed therapy, the patient had remissions and had regained consciousness; relapses were probably due to want of continuity of intensive treatment. Reference to the literature regarding therapy in II. influenza; meningitis would not be out of place here. The importance of using large doses of sulphonamides and their continued use after meningeal symptoms have disappeared in order to avoid relapses had been stressed by Davies (1943) and Moir (1943). Mutch (1941) and Davies (1943), however, are not impressed by the curative value of these drugs, particularly in infants. Bolsevert, Fousek and Grossman (1944) have with reported successful outcome in three babies ' ' meningitis due to II. influenzae type b treated with intramuscular injection of specific anti' H. influenza type b ' rabbit serum, combined with sulphadiazine. In such cases mortality was 100 per cent prior to the introduction of
purulent meningitis
Rhoads (1947), in his review and clinical of 550 cases of bacterial meningitis, encountered 15 cases of II. influenza meningitis. All 15 were in infants and children between the ages of 2 months and 5 years and he concluded that combination of sulphadiazine in full doses plus specific serum in as large doses as possible offered the best outlook for the patient. However, streptomycin 2 to 4 gm. daily 100,000 units given alone intrathecally or combined with the above treatment was recommended as the best choice. such investigation of H. in India has been found so far except one case described by Dutta and Baruah (1948). No details as to the morpholor cultural characters of the strain ogy encountered by them are given. They reported having cured it by sulphadiazine orally and injections of penicillin for 5 days till the temperature was completely normal. In view of the relapses noted by various workers and by us in our own case, further observation in their case would have been desirable. They also stated that the strain appeared to be quite unlike the strains investigated and reported by others. That some strains are sensitive to penicillin has been reported in the past. The present strain recovered by us at least was sensitive in vitro experiments. In any case, the combination of treatment as advocated appears to be the best. No
*
reference
to
influenza meningitis
Summary In view of the rarity of laboratory investigation a case of II. influenza meningitis is described. 1. Atypical H. influenza was found repeatedly in C.S.F. from this case. It was seen intra- and extra-cellularly with polymorphonuclear leuco-
cytes predominating. 2.
and
Zinnemann (1944) described a clinically severe case of meningitis due to II. influenza type 1 b ' which responded well to sulphapyridine. Patient had three relapses of meningitic symptoms whenever therapy was cut short. They advised the continuation of treatment for some days after clinical cure. Zinnemann (1946) has analysed 20 cases of H. influenza; meningitis, 19 of these were due to ' ' type b strain. He found that combined treatment with sulphonamide and penicillin gave definitely better results than sulphonamide alone. Alexander and Leidy (1947) have reported ' ' treatment of 14 cases of type b H. influenza; meningitis with streptomycin alone. Ten cases recovered, and in 3 of the 4 remaining cases, failure was proved to be due to bacilli developing resistance to streptomycin during treatment. Specific antiserum and combined sulphadiazine were substituted with success. Woodcock
1949
analysis
serum.
Gordon,
[July,
The strain was studied morphologically, and for its pathogenicity.
culturally 3.
The
organism stained feebly and was likely special search has to be made. 4. Literature on therapeutics in H. influenza meningitis is summarized with a hope that it may to be missed hence
be useful to those interested. to
Our thanks are due to Dr. F. G. Shafi for allowing report this case from his private nursing home.
us
REFERENCES
Alexander, H. E., and Leidy, G. (1947). Bolsevert, P. L., Fousek, M. D., and Grossman, M. F. (1944). Davies, J. N. P. (1943). D. and Dutta, K., Baruah, R. C. (1948). Gordon, J., Woodcock, H. E. de C., and Zinnemann, K. (1944). Mora, R. A. (1943) Mulder, J. (1939) ..
..
J. Exper. Med., 85, 329. J.
Amer. 220.
Med. ^ssoc., 124,
Lancet, i, 553. Indian Med. Gaz., 83, 417. Brit. Med. J., i, 779.
Lancet, i, 556. J. Path, and Bact., 48, 175.
July, 1949]
ENCEPHALITIS IN RURAL BENGAL: KUNDU
Mutch, N. (1941) Pittman, M. (1931) Rhoads, P. S. (1947)
Zinnemann,
..
..
..
K. (1946).
Lancct, ii, 751. J. Expcr. Med., 53, 471. Amer. Practitioner, 1, 305. Brit. Med. J., ii, 931.
BIBLIOGRAPHY W ilson,
Miles,
G. S., and A. A. (1946).
Topley
and
Wilson's
Prin-
ciples oj Bacteriology and Immunity. Edward Arnold & Co., London.
291
sera
Case report child, aged six months, admitted in a private nursing home with a history of low fever for 15 days, irritability and occasional convulsions, was seen by a physician at this stage. Kernig's sign positive. There was some rigidity of the neck. Lumbar puncture on 9th December, 1948; C.S.F. pumlent under pressure. (The other laboratory investigations are given A female
below.)
started with Treatment.?Treatment was intramuscular and intrathecal injections of penicillin. Fever came down but rigidity and convulsions increased. Second lumbar puncture was done on 17th December, 1948; C.S.F. findings as before. Sulphadiazine two tablets fourhourly given. Fever kept at 99?F., there was marked opisthotonos. Third lumbar puncture was done on 29th December, 1948; C.S.F. much less turbid. Case continued with remissions and relapses with meningeal symptoms. Patient was further given intramuscular and intrathecal injections of streptomycin. Patient had three changcs of physicians since admission to the nursing home and was removed against advice before recovery. Attempts to trace him have failed.
A CASE OF MENINGITIS DUE TO
HAEMOPHILUS INFLUENZAE By SULOCHANA D. SOMAN, m.b., h.s. (Bom.), d.b. (Manchester), d.t.m.&h. (Lond.) Lecturer in Bacteriology, Grant Medical College, Bombay and V. H. SALASKAR, m.d. (Bom.) Demonstrator in Bacteriology, Grant Medical College,
Laboratory investimation
Bombay
C.S.F. was examined by one of on three occasions and the results below :
Meningitis due to H. influenza is not an unusual finding especially in a child. It lias
9th December, 1948
QuantityAppearance Proteins Chlorides Cells
Organisms (Gram's
j
Diminished 610
per
c.mm.
predominate.
Not
seen
410
per
j
Gram
?
ve
610 mg. per cent.
polymorphs 110
bacilli
grown
Colonies of Gram bacilli in fair numbers. acid-fast bacilli.
been reported by many workers in Europe and America and the strains isolated have been studied. The reports about the effects beneficial or otherwise of various sulpha group of drugs with and without anti-haemophilus specific
per c.mm.
Stray Gram
smears. vc bacilli Gram ? H. influenzai.
No deposit.
j Diminished.
c.mm.
predominate,
tabulated
Increased.
Diminished
polymorphs
(V. H. S.)
5 cc.
I Faintly turbid.
610 mg. per cent
acid-fast
methods). Culture
5 cc.
cc.
are
28th December, 1948
Turbid, deposit and coagulum Same as before present. Increased Increased 600 mg. per cent
Sugar Microscopic?
and
7
17th December, 1948
us
ve
polymorphs few. ve
bacilli
seen.
No growth.
No
The direct smears and the culture of the second lumbar puncture C.S.F. were brought to the senior author for opinion. The smears showed fair numbers of, intra- and extra-cellular Gram-negative, pleomorphic bacilli with halo
July, 1949] round them
MENINGITIS DUE TO H. INFLUENZAE of
suggestive
a
capsule
and
they
resembled atypical H. influenza; which appear
predominantly
in
bacillary
or
filamentous forms
with swollen and bulbed portions. Culture on blood agar being rather old showed similar but faintly stained organisms. These were sub-
cultured
in
to a blood agar in glucose broth. Out of the three colonies subcultured on different part of the same agar slope, only one grew. The colonies in further subculture were tiny, ' transparent, smooth and shiny like S' forms of H. were and non-hsemolytic. The influenza, organisms were further tested in different media with the following results ;
glucose
slope. There
was
broth and no
on
growth
!?
SOMAN
Glucose broth Blood agar with Staph,
3. 4. 5.
Same as 2, but with penicillin Glucose broth with Staph, aureus Same as 4, but with penicillin
No growth Discrete but crowded colonies as described before, round the Staph. colonies. No growth of either Scanty growth of bacilli with cocci No growth of either
Chocolate agar slope (prepared by dipping for a minute a blood agar slope in boiling water and
Profuse but discrete colonies as described above showing niorphologically H. influenza} in 24 hours.
Same
Very scanty growth after
6-
7.
resloping). on
as 6, but with its surface.
i
penicillin
i
From the growth
on chocolate agar slope, made as follows to further ascertain its cultural requirements :
subcultures
were
Medium 8. 9.
10.
Peptone water Peptone water with Staph, aureus Peptone water with heated blood
48 hours
was carried out with last culture the Roseindole reagent after extracting the culture with ether. A faint pink colour was seen. Thus it was feebly positive. Test was negative on peptone water with heated blood used as control. Pathogenicity test was carried out with two white mice. A thick was made in normal saline
' '
V ' factors absent. ' ' and V factors present.
'X' alone (from blood). 'V' alone (from cocci). 'X' and 'V' absent (no
cocci).
blood;
no
Both 'X' and 'V' available (from heated RBC).
t
The strain appears to be sensitive.
influenza. The organism was found to be to penicillin to a certain extent. Bacteriostatic effect of penicillin on a large of H.
No growth No bacilli but cocci grown Bacilli as described before grown
Indole test
' X' and Both ' X
sensitive
Result
by adding
589
' Remarks with regards to X' and ' V' factors in the media
,
2.
aureus
& SALASKAR
and studied was atypical H. injiuenzce requiring both ' X ' and ' V ' factors, showing slow and scanty growth on blood agar, not producing haemolysis, and differing from typical strains in showing predominantly bacillary or filamentous morphology with swollen and bulbed portions and a halo suggestive of a capsule. It stained feebly with counter stain in Gram's method, a property in common with this group. Indole production was doubtful. No fermentation tests were put up. Virulence test was not decisive, possibly because it was not done with the primary culture or an adequate dose was not administered or a sufficient number of animals Colonial characters were those was not used.
Result
Medium
:
' Remarks with regards to X' and ' V' factors in the media
No 'X' and 'V'. ' V alone. X ' and ' V ' present.
' '
number of strains of H. influenza? lias now been well established. The bacilli were present in three samples of C.S.F. from the patient on different dates. It was missed in the direct smear first time, probably due to its faintly staining character and atypical morphology.
peritoneal^
Pittman's (1931) antigenic study of H. influin U.S.A. showed that most of the strains from the pathological lesions chiefly meningitis ' ' colonies. smooth produced characteristic formed and found to were be They capsulated
Discussion In accordance with the classification given by Wilson and Miles (1946), the bacillus isolated
group. Serological types been described by her and ' ' type b occurred with the greatest frequency in the cases of meningitis. She also noted that those from the respiratory tract were non' ' hemolytic, non-capsulated R forms and seroland non-pathogenic. ogically heterogeneous Mulder (1939) and Gordon, Woodcock and Zinnemann (1944) have described cases of
suspension
from chocolate agar, \
cc. was injected intrain one and \ ccthe other. Animals looked ill after 18 hours. The one with smaller dose was killed after 24 hours as it appeared more ill. Smears and cultures were made from peritoneal surface and heart blood. No organisms were seen or grown, the other animal recovered.
enza;
fairly homogeneous b, c, d, e, f have
a,
THE INDIAN MEDICAL GAZETTE
290
' ' due to R forms. In the for absence of facilities serological typing but in our case it appears the findings judged by that this organism would fall in line with one of the Pittman's serological types. With regard to other findings in C.S-.F., it may be pointed out that the cell count should be interpreted in the light of the coagulum formed. Rhoads (1947) in his review of 550 cases of bacterial meningitis noted in connection with meningococcic meningitis that the higher the cell count in C.S.F. the worse was the prognosis, the count usually being in thousands. In the fatal group of H. influenza; meningitis, he found the spinal fluid glucose too low to read. Glucose was diminished in our case. Assessment of the effect of drug in this case was not possible, as the treatment was delayed and the patient was under different physicians and was removed from the nursing home against advice. In spite of the delayed therapy, the patient had remissions and had regained consciousness; relapses were probably due to want of continuity of intensive treatment. Reference to the literature regarding therapy in II. influenza; meningitis would not be out of place here. The importance of using large doses of sulphonamides and their continued use after meningeal symptoms have disappeared in order to avoid relapses had been stressed by Davies (1943) and Moir (1943). Mutch (1941) and Davies (1943), however, are not impressed by the curative value of these drugs, particularly in infants. Bolsevert, Fousek and Grossman (1944) have with reported successful outcome in three babies ' ' meningitis due to II. influenzae type b treated with intramuscular injection of specific anti' H. influenza type b ' rabbit serum, combined with sulphadiazine. In such cases mortality was 100 per cent prior to the introduction of
purulent meningitis
Rhoads (1947), in his review and clinical of 550 cases of bacterial meningitis, encountered 15 cases of II. influenza meningitis. All 15 were in infants and children between the ages of 2 months and 5 years and he concluded that combination of sulphadiazine in full doses plus specific serum in as large doses as possible offered the best outlook for the patient. However, streptomycin 2 to 4 gm. daily 100,000 units given alone intrathecally or combined with the above treatment was recommended as the best choice. such investigation of H. in India has been found so far except one case described by Dutta and Baruah (1948). No details as to the morpholor cultural characters of the strain ogy encountered by them are given. They reported having cured it by sulphadiazine orally and injections of penicillin for 5 days till the temperature was completely normal. In view of the relapses noted by various workers and by us in our own case, further observation in their case would have been desirable. They also stated that the strain appeared to be quite unlike the strains investigated and reported by others. That some strains are sensitive to penicillin has been reported in the past. The present strain recovered by us at least was sensitive in vitro experiments. In any case, the combination of treatment as advocated appears to be the best. No
*
reference
to
influenza meningitis
Summary In view of the rarity of laboratory investigation a case of II. influenza meningitis is described. 1. Atypical H. influenza was found repeatedly in C.S.F. from this case. It was seen intra- and extra-cellularly with polymorphonuclear leuco-
cytes predominating. 2.
and
Zinnemann (1944) described a clinically severe case of meningitis due to II. influenza type 1 b ' which responded well to sulphapyridine. Patient had three relapses of meningitic symptoms whenever therapy was cut short. They advised the continuation of treatment for some days after clinical cure. Zinnemann (1946) has analysed 20 cases of H. influenza; meningitis, 19 of these were due to ' ' type b strain. He found that combined treatment with sulphonamide and penicillin gave definitely better results than sulphonamide alone. Alexander and Leidy (1947) have reported ' ' treatment of 14 cases of type b H. influenza; meningitis with streptomycin alone. Ten cases recovered, and in 3 of the 4 remaining cases, failure was proved to be due to bacilli developing resistance to streptomycin during treatment. Specific antiserum and combined sulphadiazine were substituted with success. Woodcock
1949
analysis
serum.
Gordon,
[July,
The strain was studied morphologically, and for its pathogenicity.
culturally 3.
The
organism stained feebly and was likely special search has to be made. 4. Literature on therapeutics in H. influenza meningitis is summarized with a hope that it may to be missed hence
be useful to those interested. to
Our thanks are due to Dr. F. G. Shafi for allowing report this case from his private nursing home.
us
REFERENCES
Alexander, H. E., and Leidy, G. (1947). Bolsevert, P. L., Fousek, M. D., and Grossman, M. F. (1944). Davies, J. N. P. (1943). D. and Dutta, K., Baruah, R. C. (1948). Gordon, J., Woodcock, H. E. de C., and Zinnemann, K. (1944). Mora, R. A. (1943) Mulder, J. (1939) ..
..
J. Exper. Med., 85, 329. J.
Amer. 220.
Med. ^ssoc., 124,
Lancet, i, 553. Indian Med. Gaz., 83, 417. Brit. Med. J., i, 779.
Lancet, i, 556. J. Path, and Bact., 48, 175.
July, 1949]
ENCEPHALITIS IN RURAL BENGAL: KUNDU
Mutch, N. (1941) Pittman, M. (1931) Rhoads, P. S. (1947)
Zinnemann,
..
..
..
K. (1946).
Lancct, ii, 751. J. Expcr. Med., 53, 471. Amer. Practitioner, 1, 305. Brit. Med. J., ii, 931.
BIBLIOGRAPHY W ilson,
Miles,
G. S., and A. A. (1946).
Topley
and
Wilson's
Prin-
ciples oj Bacteriology and Immunity. Edward Arnold & Co., London.
291
