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ScienceDirect www.sciencedirect.com Médecine et maladies infectieuses (2014) 42–44
Case report
Diagnosis and treatment strategies for community-acquired Streptococcus salivarius meningitis Stratégies de diagnostic et traitement des méningites communautaires à Streptococcus salivarius N. Vignier a,b , C. Couzigou a,∗,b , J.C. Nguyen Van b , S. Gerber c , S. Gaillard d , C. Bruel e , B. Misset e , M.D. Kitzis b , A. Le Monnier b a
Équipe mobile de microbiologie clinique/équipe opérationnelle d’hygiène, groupe hospitalier Paris Saint-Joseph, 75014 Paris, France b Unité de microbiologie clinique, groupe hospitalier Paris Saint-Joseph, 75014 Paris, France c Service de radiologie, groupe hospitalier Paris Saint-Joseph, 75014 Paris, France d Service de neurochirurgie, hôpital Foch, 40, rue Worth, 92151 Suresnes, France e Service de réanimation polyvalente, groupe hospitalier Paris Saint-Joseph, 75014 Paris, France Received 3 September 2013; received in revised form 9 September 2013; accepted 21 October 2013 Available online 22 November 2013
1. Introduction Streptococcus salivarius belongs to the oral and digestive microbiota. This bacterium is a frequent cause of bacteremia, endocarditis, and sinusitis. However, it is rarely associated with meningitis. Viridans streptococci account for 0.3 to 3% of all cases of purulent meningitis [1]. 2. Clinical case A 57-year old patient was admitted to the intensive care unit because she felt faint at work, and presented with frontal headache and fever. The patient had presented with a cold for a few weeks with clear rhinorrhea, and headaches for the previous 4 days. She had a history of asthma but no history of trauma, sinusal or ear surgery, or immune deficiency. The patient had not received any antibiotic treatment before hospitalization. The initial examination revealed a fever of 39.8 ◦ C, and confusion, a stiff neck, and rhinorrhea. She did not present with any dental anomaly. She had a leucocyte count of 18,840/mm3 with 93% of neutrophils, a procalcitonin level of 59 ng/mL, 8,800 white blood cells/mm3 of CSF with 89% of polymorphonuclears, a protein level of 5.8 g/L, and a glucose level significantly lower than ∗ Corresponding author. Équipe mobile de microbiologie clinique/équipe opérationnelle d’hygiène, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France. E-mail address: [email protected] (C. Couzigou).
0399-077X/$ – see front matter © 2013 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.medmal.2013.10.005
glycemia (0.35 g/L versus 0.90 g/L respectively). No bacteria were observed in a first CSF sample either on direct examination after Gram staining or in standard culture on agar plates. The latex CSF test for Streptococcus pneumoniae (Binax Now® ) and specific polymerase chain reaction (PCR) for S. pneumoniae and Neisseria meningitis were negative. The second CSF sample was positive for bacterial DNA identified as belonging to S. salivarius, by sequencing of the 16S rRNA gene. A 475-bp segment of the 16S rRNA gene was amplified with the universal prokaryotic primers p91E and p13B [2]. The search for similarity was performed with NCBI Blast and BiBi phylogenetic tools (http://pbil.univ-lyon1.fr/). The first CSF sample cultured in an enriched broth medium became positive 7 days later and an S. salivarius strain was identified. Blood cultures were negative. The minimal inhibitory concentrations (MIC) of penicillin, amoxicillin, and cefotaxim were determined by the Etest as 0.190, 0.250, and 0.500 mg/L respectively. Brain MRI and CT scan revealed fluid in the left sphenoid sinus and a bone defect on the sinus roof (vertical segment of the clivus (Fig. 1B)). Empirical treatment was initiated with ceftriaxone (2 g IV bid) and dexamethasone (10 mg every 6 hours during 4 days). The clinical response was satisfactory. The curative treatment was given for 2 weeks. Finally, the patient was referred to a specialized neurosurgeon. The fistula between the sinus and subarachnoid space was closed by nasal endoscopy. The bone defect was confirmed during surgery and a piece of bone was sent to be analyzed. The pathology report did not document any infectious agent, abnormal cell, or sign of inflammatory disease. Two weeks
N. Vignier et al. / Médecine et maladies infectieuses (2014) 42–44
43
Fig. 1. Patient’s brain MRI (T2) and CT scan. A and B. The arrow shows the fistula between the sphenoidal sinus and the posterior cranial fossa. IRM cérébrale (T2) et scanner cérébral du patient.
after surgery, the rhinorrhea recurred but the CSF was sterile. Mild intracranial hypertension was suspected. A lumboperitoneal CSF shunt was performed and cured the rhinorrhea. The patient remained symptom-free, 24 months later. 3. Discussion We report the case of a patient presenting with communityacquired meningitis due to S. salivarus. 67 cases of meningitis due to S. salivarius have been reported so far. However, most of these reports mentioned a iatrogenic origin [3,4]. Communityacquired bacterial meningitis due to S. salivarius remains rare and usually occurs after bacteremia in patients with intestinal neoplasia or variceal bleed [4], in patients with cranial trauma, sinusitis, or sinus mucocele [3,4]. Only 3 cases were related to a spontaneous CSF fistula [4–6]. The imaging and pathological data suggested that the fluid in the sinus was due to a fistula with secondary filling of sphenoidal sinus by CSF, rather than sphenoidal sinusitis complicated by a bone defect. The patient had no history of trauma or medical issue suggesting that this fistula was spontaneous. S. salivarius may have infected the CSF by upper respiratory tract endogenous flora. The long delay before CSF culture became positive (7 days) was not due to any previous antibiotic treatment. S. salivarius grew on liquid agar but in a time that could lead to delay adequate treatment initition. Broad-range universal PCR allowed obtaining an earlier diagnosis. It has been proved superior to conventional methods for the detection of bacterial meningitis, particularly when antimicrobial therapy has already been initiated or when cultures remain negative [7]. Administrating antibiotic prophylaxis up to the neurosurgery may be discussed. The authors of a systematic review by the Cochrane Collaboration reported no benefit of antibiotic prophylaxis among patients with basilar skull fracture with or without CSF leakage [8]. Antibiotic prophylaxis may induce changes in the posterior nasopharyngeal flora promoting potentially more pathogenic
organisms resistant to the antibiotic regimen used for prophylaxis [9]. Furthermore, antibiotic prophylaxis may contribute to the emergence of multidrug resistant bacterial meningitis. Many strategies are available to treat CSF fistula including non-invasive procedures, CSF shunt, and neurosurgery. According to the authors of a meta-analysis, the endoscopic approach is highly effective and associated with a low morbidity [9]. Conservative measures such as use of laxatives, and/or decreasing the CSF pressure by drainage and puncture, do not appear to significantly influence the rate of closure success. The muscle pedicle flap technique can be used to repair a CSF fistula. As in our case, it is sometimes necessary to complete surgery by procedures to decrease CSF pressure [10]. 4. Conclusion Our case highlights the need to screen for a CSF leak (which can be easily treated by endoscopically) when a patient presents with S. salivarius meningitis without predisposing or traumatic events. It stresses the need to use broad range universal PCR for severe infections routinely. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. Acknowledgements We thank Isabelle Podglajen for her help in sequencing the 16S rRNA gene. References [1] Huyne AL, Herson H. Streptococcic viridans meningitis: a review of the literature and report of nine recoveries. Ann Intern Med 1950;33:879–902.
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N. Vignier et al. / Médecine et maladies infectieuses (2014) 42–44
[2] Podglajen I, Bellery F, Poyart C, Coudol P, Buu-Hoi A, Bruneval P, et al. Comparative molecular and microbiologic diagnosis of bacterial endocarditis. Emerg Infect Dis 2003;9(12):1543–7. [3] Cabellos C, Viladrich PF, Corredoira J, Verdaguer R, Ariza J, Gudiol F. Streptococcal meningitis in adult patients: current epidemiology and clinical spectrum. Clin Infect Dis 1999;28(5):1104-8. [4] Wilson M, Martin R, Walk ST, Young C, Grossman S, McKean EL, et al. Clinical and laboratory features of Streptococcus salivarius meningitis: a case report and literature review. Clin Med Res 2012;10(1):15–25. [5] Guerrero-Peral AL, Guerrero-Peral AB. Meningitis due to Streptococcus salivarius and spontaneous fistula: a case report. Rev Neurol 2002;35(8):799–800. [6] Enting RH, de Gans J, Blankevoort JP, Spanjaard L. Meningitis due to viridans streptococci in adults. J Neurol 1997;244(7):435–8.
[7] Welinder-Olsson C, Dotevall L, Hogevik H, Jungnelius R, Trollfors B, Wahl M, et al. Comparison of broad-range bacterial PCR and culture of cerebrospinal fluid for diagnosis of community-acquired bacterial meningitis. Clin Microbiol Infect 2007;13(9):879–86. [8] Ratilal BO, Costa J, Sampaio C, Pappamikail L. Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database Syst Rev 2011;(8):CD008448. [9] Hegazy HM, Carrau RL, Snyderman CH, Kassam A, Zweig J. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis. Laryngoscope 2000;110(7):1166–72. [10] Shiley SG, Limonadi F, Delashaw JB, Barnwell SL, Andersen PE, Hwang PH, et al. Incidence, etiology, and management of cerebrospinal fluid leaks following trans-sphenoidal surgery. Laryngoscope 2003;113(8): 1283–8.
ScienceDirect www.sciencedirect.com Médecine et maladies infectieuses (2014) 42–44
Case report
Diagnosis and treatment strategies for community-acquired Streptococcus salivarius meningitis Stratégies de diagnostic et traitement des méningites communautaires à Streptococcus salivarius N. Vignier a,b , C. Couzigou a,∗,b , J.C. Nguyen Van b , S. Gerber c , S. Gaillard d , C. Bruel e , B. Misset e , M.D. Kitzis b , A. Le Monnier b a
Équipe mobile de microbiologie clinique/équipe opérationnelle d’hygiène, groupe hospitalier Paris Saint-Joseph, 75014 Paris, France b Unité de microbiologie clinique, groupe hospitalier Paris Saint-Joseph, 75014 Paris, France c Service de radiologie, groupe hospitalier Paris Saint-Joseph, 75014 Paris, France d Service de neurochirurgie, hôpital Foch, 40, rue Worth, 92151 Suresnes, France e Service de réanimation polyvalente, groupe hospitalier Paris Saint-Joseph, 75014 Paris, France Received 3 September 2013; received in revised form 9 September 2013; accepted 21 October 2013 Available online 22 November 2013
1. Introduction Streptococcus salivarius belongs to the oral and digestive microbiota. This bacterium is a frequent cause of bacteremia, endocarditis, and sinusitis. However, it is rarely associated with meningitis. Viridans streptococci account for 0.3 to 3% of all cases of purulent meningitis [1]. 2. Clinical case A 57-year old patient was admitted to the intensive care unit because she felt faint at work, and presented with frontal headache and fever. The patient had presented with a cold for a few weeks with clear rhinorrhea, and headaches for the previous 4 days. She had a history of asthma but no history of trauma, sinusal or ear surgery, or immune deficiency. The patient had not received any antibiotic treatment before hospitalization. The initial examination revealed a fever of 39.8 ◦ C, and confusion, a stiff neck, and rhinorrhea. She did not present with any dental anomaly. She had a leucocyte count of 18,840/mm3 with 93% of neutrophils, a procalcitonin level of 59 ng/mL, 8,800 white blood cells/mm3 of CSF with 89% of polymorphonuclears, a protein level of 5.8 g/L, and a glucose level significantly lower than ∗ Corresponding author. Équipe mobile de microbiologie clinique/équipe opérationnelle d’hygiène, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France. E-mail address: [email protected] (C. Couzigou).
0399-077X/$ – see front matter © 2013 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.medmal.2013.10.005
glycemia (0.35 g/L versus 0.90 g/L respectively). No bacteria were observed in a first CSF sample either on direct examination after Gram staining or in standard culture on agar plates. The latex CSF test for Streptococcus pneumoniae (Binax Now® ) and specific polymerase chain reaction (PCR) for S. pneumoniae and Neisseria meningitis were negative. The second CSF sample was positive for bacterial DNA identified as belonging to S. salivarius, by sequencing of the 16S rRNA gene. A 475-bp segment of the 16S rRNA gene was amplified with the universal prokaryotic primers p91E and p13B [2]. The search for similarity was performed with NCBI Blast and BiBi phylogenetic tools (http://pbil.univ-lyon1.fr/). The first CSF sample cultured in an enriched broth medium became positive 7 days later and an S. salivarius strain was identified. Blood cultures were negative. The minimal inhibitory concentrations (MIC) of penicillin, amoxicillin, and cefotaxim were determined by the Etest as 0.190, 0.250, and 0.500 mg/L respectively. Brain MRI and CT scan revealed fluid in the left sphenoid sinus and a bone defect on the sinus roof (vertical segment of the clivus (Fig. 1B)). Empirical treatment was initiated with ceftriaxone (2 g IV bid) and dexamethasone (10 mg every 6 hours during 4 days). The clinical response was satisfactory. The curative treatment was given for 2 weeks. Finally, the patient was referred to a specialized neurosurgeon. The fistula between the sinus and subarachnoid space was closed by nasal endoscopy. The bone defect was confirmed during surgery and a piece of bone was sent to be analyzed. The pathology report did not document any infectious agent, abnormal cell, or sign of inflammatory disease. Two weeks
N. Vignier et al. / Médecine et maladies infectieuses (2014) 42–44
43
Fig. 1. Patient’s brain MRI (T2) and CT scan. A and B. The arrow shows the fistula between the sphenoidal sinus and the posterior cranial fossa. IRM cérébrale (T2) et scanner cérébral du patient.
after surgery, the rhinorrhea recurred but the CSF was sterile. Mild intracranial hypertension was suspected. A lumboperitoneal CSF shunt was performed and cured the rhinorrhea. The patient remained symptom-free, 24 months later. 3. Discussion We report the case of a patient presenting with communityacquired meningitis due to S. salivarus. 67 cases of meningitis due to S. salivarius have been reported so far. However, most of these reports mentioned a iatrogenic origin [3,4]. Communityacquired bacterial meningitis due to S. salivarius remains rare and usually occurs after bacteremia in patients with intestinal neoplasia or variceal bleed [4], in patients with cranial trauma, sinusitis, or sinus mucocele [3,4]. Only 3 cases were related to a spontaneous CSF fistula [4–6]. The imaging and pathological data suggested that the fluid in the sinus was due to a fistula with secondary filling of sphenoidal sinus by CSF, rather than sphenoidal sinusitis complicated by a bone defect. The patient had no history of trauma or medical issue suggesting that this fistula was spontaneous. S. salivarius may have infected the CSF by upper respiratory tract endogenous flora. The long delay before CSF culture became positive (7 days) was not due to any previous antibiotic treatment. S. salivarius grew on liquid agar but in a time that could lead to delay adequate treatment initition. Broad-range universal PCR allowed obtaining an earlier diagnosis. It has been proved superior to conventional methods for the detection of bacterial meningitis, particularly when antimicrobial therapy has already been initiated or when cultures remain negative [7]. Administrating antibiotic prophylaxis up to the neurosurgery may be discussed. The authors of a systematic review by the Cochrane Collaboration reported no benefit of antibiotic prophylaxis among patients with basilar skull fracture with or without CSF leakage [8]. Antibiotic prophylaxis may induce changes in the posterior nasopharyngeal flora promoting potentially more pathogenic
organisms resistant to the antibiotic regimen used for prophylaxis [9]. Furthermore, antibiotic prophylaxis may contribute to the emergence of multidrug resistant bacterial meningitis. Many strategies are available to treat CSF fistula including non-invasive procedures, CSF shunt, and neurosurgery. According to the authors of a meta-analysis, the endoscopic approach is highly effective and associated with a low morbidity [9]. Conservative measures such as use of laxatives, and/or decreasing the CSF pressure by drainage and puncture, do not appear to significantly influence the rate of closure success. The muscle pedicle flap technique can be used to repair a CSF fistula. As in our case, it is sometimes necessary to complete surgery by procedures to decrease CSF pressure [10]. 4. Conclusion Our case highlights the need to screen for a CSF leak (which can be easily treated by endoscopically) when a patient presents with S. salivarius meningitis without predisposing or traumatic events. It stresses the need to use broad range universal PCR for severe infections routinely. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. Acknowledgements We thank Isabelle Podglajen for her help in sequencing the 16S rRNA gene. References [1] Huyne AL, Herson H. Streptococcic viridans meningitis: a review of the literature and report of nine recoveries. Ann Intern Med 1950;33:879–902.
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N. Vignier et al. / Médecine et maladies infectieuses (2014) 42–44
[2] Podglajen I, Bellery F, Poyart C, Coudol P, Buu-Hoi A, Bruneval P, et al. Comparative molecular and microbiologic diagnosis of bacterial endocarditis. Emerg Infect Dis 2003;9(12):1543–7. [3] Cabellos C, Viladrich PF, Corredoira J, Verdaguer R, Ariza J, Gudiol F. Streptococcal meningitis in adult patients: current epidemiology and clinical spectrum. Clin Infect Dis 1999;28(5):1104-8. [4] Wilson M, Martin R, Walk ST, Young C, Grossman S, McKean EL, et al. Clinical and laboratory features of Streptococcus salivarius meningitis: a case report and literature review. Clin Med Res 2012;10(1):15–25. [5] Guerrero-Peral AL, Guerrero-Peral AB. Meningitis due to Streptococcus salivarius and spontaneous fistula: a case report. Rev Neurol 2002;35(8):799–800. [6] Enting RH, de Gans J, Blankevoort JP, Spanjaard L. Meningitis due to viridans streptococci in adults. J Neurol 1997;244(7):435–8.
[7] Welinder-Olsson C, Dotevall L, Hogevik H, Jungnelius R, Trollfors B, Wahl M, et al. Comparison of broad-range bacterial PCR and culture of cerebrospinal fluid for diagnosis of community-acquired bacterial meningitis. Clin Microbiol Infect 2007;13(9):879–86. [8] Ratilal BO, Costa J, Sampaio C, Pappamikail L. Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database Syst Rev 2011;(8):CD008448. [9] Hegazy HM, Carrau RL, Snyderman CH, Kassam A, Zweig J. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis. Laryngoscope 2000;110(7):1166–72. [10] Shiley SG, Limonadi F, Delashaw JB, Barnwell SL, Andersen PE, Hwang PH, et al. Incidence, etiology, and management of cerebrospinal fluid leaks following trans-sphenoidal surgery. Laryngoscope 2003;113(8): 1283–8.
