Indian ft. P#diat. 43:
226, 197~
A CLINICO-BACTERIOLOGICAL STUDY OF MENINGITIS IN I N F A N C Y K l q l m CHILDHOOD V. TAMASKARAND N.R. B1Z^NDARI
Bhopal Meningitis is one of the few conditions which present as an acute emergency where prompt disagnosis and optimal antimicrobial therapy is of utmost importance. In spite of the introduction of newer potent antibiotics and corticosteroids the mortality rate and incidence of post-meningitic sequelae continue to remain high. The picture of meningitis, particularly tuberculous in nature, in the early phase has no special characteristics and is further bFarred by illiteracy, poverty and misdirected treatment.
the chest and sknll were done in In addition to biochemical and logical analysis of cerebrospinal flotation hydrocarbon technique for detection of acid fast bacilli.
Early confirmation of diagnosis is very important. Demonstration of organisms by direct smear is no doubt the most convincing method but it is often difficult to find the organisms. The flotation hydrocarbon test is more o f t e n positive and helpful in early diagnosis.
Table 1 shows that 64% of the were males and the majority were undem 3 years of age.
Material and Methods
Fifty cases of mening[tis admitted to the children's ward of the Hamidia Hospital, Gandhi Medical College, Bhopal, during the period from September 1971 to August 1972 were taken up for the present study. A detailed physical examination including funduscopy was carried out in each case. Besides routine tests for blood and urine, Mantoux test and skia~ams of *From the Department of Paediatrics, Gandhi Medical College, BhopaL Received on January 20, 1976.
all c ~ bactc,~tln fluid,~I~ was u u m
Observations
Out of the total 2,968 admissions duriilm the period of twelve months, 50 cases (1.7~ were diagnosed as meningitis. Of thesm 29 were of tuberculous meningitis while 9,, cases suffered from pyogenic meningitis.
Nearly 50% of cases were from the socioe economic lower group. A moderate to severe degree of malnutrition was associated with tuberculous meningitis (62.4%). A pa~. history of meas]es and contact with an adult tuberculous patient were present in 17.2% cases each. Pyogenic foci elsewhere in the body were responsible for septic meningitiq in 23% cases and 2 cases g a v e a history of head injury (Table 2). Fever, convulsions and vomiting were the common presenting features in both types of meningitis. Cranial nerve palsies and fundus changes were seen in 41.3% and 45% cases respectively of tuberculous meningitis whereas the fundal changes were seen in only 9.5% cases of the pyogenic group (Table 3).
~ $ K A R AND BIIANDARI--A CLINICO-BACTERIOLOOICALSTUDY' O F MENINOITIS
Table i.
Age and sex incidence in meningitis.
Male
Female
group
Total T . B . M . PY. M.
~
227
T.B.M.
PY. M.
Percentage
r
Under 1 yr.
4
fi
5
7
22
44
I-3
7
1
1
1
l0
20
3 - 5 yrs.
4
1
2
--
7
14
5 - - 7 yrs.
1
I
-
--
2
4
7 - - 9 yrs:
3
1
--
2
6
12
9 - - 1 2 yrs.
2
1
--
--
3
6
Total
21
11
8
10
50
100
yr:~.
T.B.M.--Tuberculou~ meningiti~ PY. M.--Pyogenic meningitis.
T a b l e 2.
Predisposingfaaors. T u b e r c u l o u s meningitis
Factors
~ [ a l n u t r i t i o n grades I I & I I I
No. o f cases
Percentage
P y o g e n i c meningitis No. o f cases
Percentage
18
62.4
3
14.2
Recurrent fever and respiratory refections
8
27.5
4
19.0
Contact with T.B.
5
17.2
-
--
[Measles
5
17.2
--
--
[?ast t u b e r c u l o u s infection
3
10.3
--
--
Septic foci
4
13.8
5
23.8
--
2
9.5
lZlead i n j u r y
-
2~0
VOL. 43, No;
INDIAN JOURNAL OF PEDIATRICS
Table 3.
Prominentsymptoms and signs. Tuberculous meningitis
CI inical features
No. o1'
Pyogenic meningkm
Percent-
No. of
Pere~
Symptoms Fever
24
82.7
20
95.2
Convulsions
19
65.5
15
7.1
Irritability
15
51.7
5
23.3
Vomiting
~,
27.6
11
52.3
Constipation
7
24.1
3
14.3
Headache
5
17.5
3
14.3
Meningeal irrit3 tiovt
24
82.7
13
61.9
Pupillary changes
14
48.2
8
38.1
Fundtts changes
13
45.0
2
9.5
12
14.3
2
9.5
9
31.0
12
57.1
Signs
a) b)
Optic atrophy Papilloedema
Cranial nerve paralysis Bulging fontanelle
Out of the total of 21 cases of pyogenic meningitis, organisms could be isolated in 16 cases either by smear examination or by culture. In 5 cases no organism eotdd be demonstrated. Pneume.cocci were responsible for the illness in 28.6% cases followed by meningococci, staphylococci and H. influenzae with an incidence of 14.3% each (Table 4). Table 5 shows that though a cobweb was formed in the C.S.F. of 65.4% cases
oftuberctdar meningitis, in only 24~ was the acid fast bacillus demonstrated .~,HI the flotation hydrocarbon method. Fig. 1 shows the percentage mort~i~ll in various age groups. 44.8#/0 cases.~R tubercular meningitis died, tile majorl~ being trader 1 ye.~ of age. The mortalim was 52.30/0 in t h e . ~ n i c group and I greater in meniugoco.,alr and H. tnfluen~ infections, being 66.6% in. each of the I groups.
,~AMASKAR AND BHANDARI--A
GINIGO'BACTRRIOLOOICAL
Table 4.
STUDY
229
OF' M I ~ . N | N O I T I S
Organisms holated in pyogenic meningitis,
Organisms
No. of cases
I
Percentage I
I
pneumococci
6
28.6
Meningococci
3
14.3
Staphylococci
3
14.3
tf. influenzae
3
]4.3
E. coli
1
4.7
No organism (letecwd
5
23.8
hospital admissions varies from 2.2% to as Low as0.26%. The most vulnerable period in general is said to be below the age of" 5 years with a male preponderance (Kapur 1969). Vagve symptomatoioow and paucity of physical signs are the hallmark of the
Discussion The incidence of different types of ~aeningitis varies with the type of studie~ and composition of samples taken. A perusal of the literature shows that the incidence of pyogenic meningitis among
A [J_ltllC0 BA[.TERIOL(~IEALSTUDYOF NEI~INGITIS ,r=,RA.pH S H O W I N G PE~CE.kITA, ro[ I m O R ' T A L I T Y 1'1,,I D I F F E R E N T AGF- G R g U P IN Nf.~I;N{.~ITI.~
I
O - ,). VE.AI~,
[] DEATH
I-
Zo
~a
r~
=~. Fig. I.
~AMAgKAP. AND IqIA~qr)ARI---A CI,INICO-ItAGTERIOLOOICAI. STUDY OF MENINOITIS
Our thanks arc due to the Dear,, Gandhi Medical ~j011cge~Bhopal ar,d Superimendent, Hamidia flo~pital, i0r perrnitqion to r o,t this work and u~ hospital ~cords.
Summary
e x a m i n a t i o n r e v e a l e d infection witl, pneumococci, m e n i n g o c o c c i , staphylococci a n d H. influenzat in that order of frequency. J~e~Ql'QIICefJ
M e n i n g i t i s c o m t i t l t t e d 1.7% of the total p a e d i a t r i c admissions. O f these cases, 0.97% were o f tuberc,dolls m e n i n g i t i s a n d 07.% cases were' sufl'cring from pyogenic meningitis. T h e maximum number of patients was e n c o u n t e r e d u n d e r 3 years of age w i t h a significant m a l e p r e p o n d e r a n c e . Cranial nerve palsies a n d o c u l a r changes were observed more frequently in tubercular meningitis. T h e flotation hydrocarbon test was helpful in d e m o n s t r a t i n g acid fast bacUli in 24.1% cases whereas direct s m e a r was n e g a t i v e in all cases.
231
Bacteriological
Gandhi, V.K. (11~69). Treatment of septic meningitis with intravenous chemotherapy, Indian Pedlar. 6, 158. Haggerty, R.F. and Ziai, Moh~en (1065). Acute bacterial meningitis. Adv. Pedlar. 13, 129. Kaput, $. (1969). Evaluation of treatment of tubercular meningitis since the use of steroid as an adjuvant. Indian Pediat. 6, 166. Thaper, R.K., Atal, P.R. and Dayal, R.S. (1969). Flotation hydrocarbon technique in isolation of tubercle bacilli from cerebrospinal fluid in tuberculosis meningitis. Indian Pedlar. 6, 172. Udani, P.M. Quoted by Thaper R.K. (196"9~
226, 197~
A CLINICO-BACTERIOLOGICAL STUDY OF MENINGITIS IN I N F A N C Y K l q l m CHILDHOOD V. TAMASKARAND N.R. B1Z^NDARI
Bhopal Meningitis is one of the few conditions which present as an acute emergency where prompt disagnosis and optimal antimicrobial therapy is of utmost importance. In spite of the introduction of newer potent antibiotics and corticosteroids the mortality rate and incidence of post-meningitic sequelae continue to remain high. The picture of meningitis, particularly tuberculous in nature, in the early phase has no special characteristics and is further bFarred by illiteracy, poverty and misdirected treatment.
the chest and sknll were done in In addition to biochemical and logical analysis of cerebrospinal flotation hydrocarbon technique for detection of acid fast bacilli.
Early confirmation of diagnosis is very important. Demonstration of organisms by direct smear is no doubt the most convincing method but it is often difficult to find the organisms. The flotation hydrocarbon test is more o f t e n positive and helpful in early diagnosis.
Table 1 shows that 64% of the were males and the majority were undem 3 years of age.
Material and Methods
Fifty cases of mening[tis admitted to the children's ward of the Hamidia Hospital, Gandhi Medical College, Bhopal, during the period from September 1971 to August 1972 were taken up for the present study. A detailed physical examination including funduscopy was carried out in each case. Besides routine tests for blood and urine, Mantoux test and skia~ams of *From the Department of Paediatrics, Gandhi Medical College, BhopaL Received on January 20, 1976.
all c ~ bactc,~tln fluid,~I~ was u u m
Observations
Out of the total 2,968 admissions duriilm the period of twelve months, 50 cases (1.7~ were diagnosed as meningitis. Of thesm 29 were of tuberculous meningitis while 9,, cases suffered from pyogenic meningitis.
Nearly 50% of cases were from the socioe economic lower group. A moderate to severe degree of malnutrition was associated with tuberculous meningitis (62.4%). A pa~. history of meas]es and contact with an adult tuberculous patient were present in 17.2% cases each. Pyogenic foci elsewhere in the body were responsible for septic meningitiq in 23% cases and 2 cases g a v e a history of head injury (Table 2). Fever, convulsions and vomiting were the common presenting features in both types of meningitis. Cranial nerve palsies and fundus changes were seen in 41.3% and 45% cases respectively of tuberculous meningitis whereas the fundal changes were seen in only 9.5% cases of the pyogenic group (Table 3).
~ $ K A R AND BIIANDARI--A CLINICO-BACTERIOLOOICALSTUDY' O F MENINOITIS
Table i.
Age and sex incidence in meningitis.
Male
Female
group
Total T . B . M . PY. M.
~
227
T.B.M.
PY. M.
Percentage
r
Under 1 yr.
4
fi
5
7
22
44
I-3
7
1
1
1
l0
20
3 - 5 yrs.
4
1
2
--
7
14
5 - - 7 yrs.
1
I
-
--
2
4
7 - - 9 yrs:
3
1
--
2
6
12
9 - - 1 2 yrs.
2
1
--
--
3
6
Total
21
11
8
10
50
100
yr:~.
T.B.M.--Tuberculou~ meningiti~ PY. M.--Pyogenic meningitis.
T a b l e 2.
Predisposingfaaors. T u b e r c u l o u s meningitis
Factors
~ [ a l n u t r i t i o n grades I I & I I I
No. o f cases
Percentage
P y o g e n i c meningitis No. o f cases
Percentage
18
62.4
3
14.2
Recurrent fever and respiratory refections
8
27.5
4
19.0
Contact with T.B.
5
17.2
-
--
[Measles
5
17.2
--
--
[?ast t u b e r c u l o u s infection
3
10.3
--
--
Septic foci
4
13.8
5
23.8
--
2
9.5
lZlead i n j u r y
-
2~0
VOL. 43, No;
INDIAN JOURNAL OF PEDIATRICS
Table 3.
Prominentsymptoms and signs. Tuberculous meningitis
CI inical features
No. o1'
Pyogenic meningkm
Percent-
No. of
Pere~
Symptoms Fever
24
82.7
20
95.2
Convulsions
19
65.5
15
7.1
Irritability
15
51.7
5
23.3
Vomiting
~,
27.6
11
52.3
Constipation
7
24.1
3
14.3
Headache
5
17.5
3
14.3
Meningeal irrit3 tiovt
24
82.7
13
61.9
Pupillary changes
14
48.2
8
38.1
Fundtts changes
13
45.0
2
9.5
12
14.3
2
9.5
9
31.0
12
57.1
Signs
a) b)
Optic atrophy Papilloedema
Cranial nerve paralysis Bulging fontanelle
Out of the total of 21 cases of pyogenic meningitis, organisms could be isolated in 16 cases either by smear examination or by culture. In 5 cases no organism eotdd be demonstrated. Pneume.cocci were responsible for the illness in 28.6% cases followed by meningococci, staphylococci and H. influenzae with an incidence of 14.3% each (Table 4). Table 5 shows that though a cobweb was formed in the C.S.F. of 65.4% cases
oftuberctdar meningitis, in only 24~ was the acid fast bacillus demonstrated .~,HI the flotation hydrocarbon method. Fig. 1 shows the percentage mort~i~ll in various age groups. 44.8#/0 cases.~R tubercular meningitis died, tile majorl~ being trader 1 ye.~ of age. The mortalim was 52.30/0 in t h e . ~ n i c group and I greater in meniugoco.,alr and H. tnfluen~ infections, being 66.6% in. each of the I groups.
,~AMASKAR AND BHANDARI--A
GINIGO'BACTRRIOLOOICAL
Table 4.
STUDY
229
OF' M I ~ . N | N O I T I S
Organisms holated in pyogenic meningitis,
Organisms
No. of cases
I
Percentage I
I
pneumococci
6
28.6
Meningococci
3
14.3
Staphylococci
3
14.3
tf. influenzae
3
]4.3
E. coli
1
4.7
No organism (letecwd
5
23.8
hospital admissions varies from 2.2% to as Low as0.26%. The most vulnerable period in general is said to be below the age of" 5 years with a male preponderance (Kapur 1969). Vagve symptomatoioow and paucity of physical signs are the hallmark of the
Discussion The incidence of different types of ~aeningitis varies with the type of studie~ and composition of samples taken. A perusal of the literature shows that the incidence of pyogenic meningitis among
A [J_ltllC0 BA[.TERIOL(~IEALSTUDYOF NEI~INGITIS ,r=,RA.pH S H O W I N G PE~CE.kITA, ro[ I m O R ' T A L I T Y 1'1,,I D I F F E R E N T AGF- G R g U P IN Nf.~I;N{.~ITI.~
I
O - ,). VE.AI~,
[] DEATH
I-
Zo
~a
r~
=~. Fig. I.
~AMAgKAP. AND IqIA~qr)ARI---A CI,INICO-ItAGTERIOLOOICAI. STUDY OF MENINOITIS
Our thanks arc due to the Dear,, Gandhi Medical ~j011cge~Bhopal ar,d Superimendent, Hamidia flo~pital, i0r perrnitqion to r o,t this work and u~ hospital ~cords.
Summary
e x a m i n a t i o n r e v e a l e d infection witl, pneumococci, m e n i n g o c o c c i , staphylococci a n d H. influenzat in that order of frequency. J~e~Ql'QIICefJ
M e n i n g i t i s c o m t i t l t t e d 1.7% of the total p a e d i a t r i c admissions. O f these cases, 0.97% were o f tuberc,dolls m e n i n g i t i s a n d 07.% cases were' sufl'cring from pyogenic meningitis. T h e maximum number of patients was e n c o u n t e r e d u n d e r 3 years of age w i t h a significant m a l e p r e p o n d e r a n c e . Cranial nerve palsies a n d o c u l a r changes were observed more frequently in tubercular meningitis. T h e flotation hydrocarbon test was helpful in d e m o n s t r a t i n g acid fast bacUli in 24.1% cases whereas direct s m e a r was n e g a t i v e in all cases.
231
Bacteriological
Gandhi, V.K. (11~69). Treatment of septic meningitis with intravenous chemotherapy, Indian Pedlar. 6, 158. Haggerty, R.F. and Ziai, Moh~en (1065). Acute bacterial meningitis. Adv. Pedlar. 13, 129. Kaput, $. (1969). Evaluation of treatment of tubercular meningitis since the use of steroid as an adjuvant. Indian Pediat. 6, 166. Thaper, R.K., Atal, P.R. and Dayal, R.S. (1969). Flotation hydrocarbon technique in isolation of tubercle bacilli from cerebrospinal fluid in tuberculosis meningitis. Indian Pedlar. 6, 172. Udani, P.M. Quoted by Thaper R.K. (196"9~
