Journal of Infection (I99 I) zz, 77-79
CASE R E P O R T Pneumococcal meningitis in a child with a ventriculo- peritoneal shunt P. T. O'Keeffe* a n d R. B a y s t o n T
* St George's Hospital, Blackshaw Road, London SLoI7 oQT and afInstitute of Child Health, 30 Guildford Street, London W C I N IEH, U.K. Accepted for publication I3 June I99o Summary A case of pneum0coccal meningitis in an infant with a ventriculo-peritoneal shunt is reported. There was initial failure of treatment with penicillin and cefotaxime in full dosage. Eradication of infection without shunt removal was eventually achieved by adding rifampicin to the antibiotic regime.
Case report Previous history A 6-month-old girl presented with a 24 h history of fever, lethargy and poor feeding. She was born at 3o weeks' gestation by vaginal delivery following a febrile illness in the mother. T h e baby suffered early onset neonatal sepsis with Listeria monocytogenes which was isolated from both blood and cerebrospinal fluid (CSF). After a protracted illness she was left with a non-communicating hydrocephalus for palliation of which a ventriculo-peritoneal shunt was inserted at 2 months of age. At subsequent follow-up she displayed marked development delay and hypotonia.
Current illness On examination the baby was febrile and irritable; there was tenderness in the right upper abdominal quadrant and the spleen tip was palpable. Investigations showed a haemoglobin of IO.8 g/dl, WBC count of I4"9 × IO9/1, and platelets of 699 × IO9/1. Blood and urine cultures were sterile. Results of serial CSF examinations are shown in Table I. Treatment was commenced with benzylpenicillin (I8o m g / k g / d a y ) and gentamicin (6 mg/kg/day). Gram-positive organisms seen on microscopy of the initial CSF specimen were thought to resemble Listeria; this impression was reinforced by the baby's previous history. However, culture yielded a growth of Streptococcus pneumoniae whereupon gentamicin was withdrawn. Continued treatment with benzylpenicillin alone resulted in modest clinical improvement, though fever persisted (Fig. i). On day 6 of the illness, cefotaxime (2oo m g / k g / d a y ) was added even though the organism was fully sensitive to penicillin on disc testing. Despite this addition, fever persisted. (A request for estimation of CSF bactericidal activity at this stage could not be met for technical reasons. Rifampicin (I 5 m g / k g / d a y ) by mouth was added on oi63-4453/9I/OiOO77+o3 $03.00/0
© I991 The British Society for the Study of Infection
78
P.T.O~KEEFFE
Table I
WBC x toG/1 RBC x IOS/1 Protein g/1 Gram-stain Culture result CSF glucose mmol/l Blood glucose mmol/1 *
A N D R. B A Y S T O N
Ventricular CSF results Day I
Day 5
Day 8
Day 19
44 o 0"68 Gram- + ve cocci + r e ~' r'9 6"4
I46 o N.D. Scanty cocci -ve 0'3 5"4
Io7 23 I'9 Nil
6 99 > r'o Nil
-re o'4 6"5
-ve N.D. N.D.
Streptococcus pneumoniae type 4 isolated. N.D. = Not done. b.d. Recfal lemperafure
39
38
37
Penicillin
[
Cefo?axirne
[ 35
O
L 5
Rifampicin
I I0 Days of illness
I 15
20
Fig. I. Temperature chart in relation to treatment.
t h e I o t h d a y o f t r e a t m e n t . T h i s r e s u l t e d in r e s o l u t i o n o f f e v e r a n d p r o m p t clinical r e c o v e r y . S u b s e q u e n t l y t h e c h i l d h a s r e m a i n e d well a n d 17 m o n t h s l a t e r is m a k i n g m o d e r a t e p r o g r e s s t h o u g h t h e r e is still m a r k e d d e v e l o p m e n t a l d e l a y a n d hypotonia.
Discussion B a c t e r i a l m e n i n g i t i s is p r o b a b l y n e i t h e r m o r e n o r less c o m m o n in p a t i e n t s w i t h C S F s h u n t s t h a n in t h e g e n e r a l p o p u l a t i o n ; f e w r e p o r t s h a v e b e e n f o u n d in t h e l i t e r a t u r e . Haemophilus influenzae a c c o u n t s f o r i 6 o f t h e r e p o r t e d cases in p a t i e n t s w i t h s h u n t s , Neisseria meningitidis f o r t w o ; o n l y f o u r ca~es d u e to S. pneumoniae are k n o w n to us. 1' 2
Meningitis and ventriculo-peritoneal shunt
79
M o s t reports of cases due to these three organisms, including our own, 3 advocate treatment of the meningitis w i t h o u t removal of the shunt; this is in direct contrast to the r e c o m m e n d a t i o n s for cases caused b y coagulase-negative staphylococci. A frequent finding in shunted patients with meningitis is a relatively poor inflammatory response with a rather low C S F neutrophil count and a protein concentration which is normal or only moderately raised. This, in turn, leads to poor penetration of intravenously administered antimicrobials into the C S F ; the betalactam antibiotics suffer the additional disadvantage of being subject to the organic acid excretion p u m p 4 which, in their case, reduces the C S F concentration even further. In the case u n d e r discussion it is felt that it was these factors, rather than the decision not to remove the shunt (which was not malfunctioning) which were responsible for the clear lack of response to penicillin and cefotaxime. U n f o r t u n a t e l y , because the p n e u m o c o c c a l isolate was no longer viable, we were unable to measure C S F bactericidal activity and therefore could not demonstrate poor antimicrobial penetration. E v e n so, rifampicin was added to the regimen since it is k n o w n that this drug will pass the b l o o d / b r a i n barrier even in the absence of inflammation. M o r e o v e r , addition of rifampicin to theoretically appropriate treatment which is failing has resulted in clinical cures 5, 6 and this p r o v e d to be so in our case. W e conclude b y r e c o m m e n d i n g that shunted patients with p n e u m o c o c e a l meningitis whose C S F neutrophil count a n d / o r protein content are only moderately raised or w h o show inadequate response to Iv penicillin should have rifampicin added to their antibiotic regime. References I. Schoenbaum SC, Gardener P, Shillito J. Infections of cerebrospinal fluid shunts: epidemiology, clinical manifestations and therapy. J Infect Dis 1975 ; 131 : 543-552. 2. Bayston R. In: Hydrocephalus shunt infections. London: Chapman and Hall, 1989. 3. Stern S, Bayston R, Hayward RJ. Haemophilus influenzae meningitis in the presence of cerebrospinal fluid shunts. Child's Nerv Syst 1988; 4: 164-165. 4. Heiber JP, Nelson JD. A pharmacological evaluation of penicillin in children with purulent meningitis. N EnglJ Med 1977; 297: 41o-413. 5. Archer GL, Tenenbaum MJ, Haywood HB. Rifampicin therapy of Staphylococcus epidermidis. JAMA 1978; 24o : 751-753. 6. Ring ]C, Cares KL, Belani KK, Gaston TL, Sveum RJ, Marker SC. Rifampicin for CSF shunt infections caused by coagulase negative staphylococci. J Pediatr 1979; 95:317-319.
CASE R E P O R T Pneumococcal meningitis in a child with a ventriculo- peritoneal shunt P. T. O'Keeffe* a n d R. B a y s t o n T
* St George's Hospital, Blackshaw Road, London SLoI7 oQT and afInstitute of Child Health, 30 Guildford Street, London W C I N IEH, U.K. Accepted for publication I3 June I99o Summary A case of pneum0coccal meningitis in an infant with a ventriculo-peritoneal shunt is reported. There was initial failure of treatment with penicillin and cefotaxime in full dosage. Eradication of infection without shunt removal was eventually achieved by adding rifampicin to the antibiotic regime.
Case report Previous history A 6-month-old girl presented with a 24 h history of fever, lethargy and poor feeding. She was born at 3o weeks' gestation by vaginal delivery following a febrile illness in the mother. T h e baby suffered early onset neonatal sepsis with Listeria monocytogenes which was isolated from both blood and cerebrospinal fluid (CSF). After a protracted illness she was left with a non-communicating hydrocephalus for palliation of which a ventriculo-peritoneal shunt was inserted at 2 months of age. At subsequent follow-up she displayed marked development delay and hypotonia.
Current illness On examination the baby was febrile and irritable; there was tenderness in the right upper abdominal quadrant and the spleen tip was palpable. Investigations showed a haemoglobin of IO.8 g/dl, WBC count of I4"9 × IO9/1, and platelets of 699 × IO9/1. Blood and urine cultures were sterile. Results of serial CSF examinations are shown in Table I. Treatment was commenced with benzylpenicillin (I8o m g / k g / d a y ) and gentamicin (6 mg/kg/day). Gram-positive organisms seen on microscopy of the initial CSF specimen were thought to resemble Listeria; this impression was reinforced by the baby's previous history. However, culture yielded a growth of Streptococcus pneumoniae whereupon gentamicin was withdrawn. Continued treatment with benzylpenicillin alone resulted in modest clinical improvement, though fever persisted (Fig. i). On day 6 of the illness, cefotaxime (2oo m g / k g / d a y ) was added even though the organism was fully sensitive to penicillin on disc testing. Despite this addition, fever persisted. (A request for estimation of CSF bactericidal activity at this stage could not be met for technical reasons. Rifampicin (I 5 m g / k g / d a y ) by mouth was added on oi63-4453/9I/OiOO77+o3 $03.00/0
© I991 The British Society for the Study of Infection
78
P.T.O~KEEFFE
Table I
WBC x toG/1 RBC x IOS/1 Protein g/1 Gram-stain Culture result CSF glucose mmol/l Blood glucose mmol/1 *
A N D R. B A Y S T O N
Ventricular CSF results Day I
Day 5
Day 8
Day 19
44 o 0"68 Gram- + ve cocci + r e ~' r'9 6"4
I46 o N.D. Scanty cocci -ve 0'3 5"4
Io7 23 I'9 Nil
6 99 > r'o Nil
-re o'4 6"5
-ve N.D. N.D.
Streptococcus pneumoniae type 4 isolated. N.D. = Not done. b.d. Recfal lemperafure
39
38
37
Penicillin
[
Cefo?axirne
[ 35
O
L 5
Rifampicin
I I0 Days of illness
I 15
20
Fig. I. Temperature chart in relation to treatment.
t h e I o t h d a y o f t r e a t m e n t . T h i s r e s u l t e d in r e s o l u t i o n o f f e v e r a n d p r o m p t clinical r e c o v e r y . S u b s e q u e n t l y t h e c h i l d h a s r e m a i n e d well a n d 17 m o n t h s l a t e r is m a k i n g m o d e r a t e p r o g r e s s t h o u g h t h e r e is still m a r k e d d e v e l o p m e n t a l d e l a y a n d hypotonia.
Discussion B a c t e r i a l m e n i n g i t i s is p r o b a b l y n e i t h e r m o r e n o r less c o m m o n in p a t i e n t s w i t h C S F s h u n t s t h a n in t h e g e n e r a l p o p u l a t i o n ; f e w r e p o r t s h a v e b e e n f o u n d in t h e l i t e r a t u r e . Haemophilus influenzae a c c o u n t s f o r i 6 o f t h e r e p o r t e d cases in p a t i e n t s w i t h s h u n t s , Neisseria meningitidis f o r t w o ; o n l y f o u r ca~es d u e to S. pneumoniae are k n o w n to us. 1' 2
Meningitis and ventriculo-peritoneal shunt
79
M o s t reports of cases due to these three organisms, including our own, 3 advocate treatment of the meningitis w i t h o u t removal of the shunt; this is in direct contrast to the r e c o m m e n d a t i o n s for cases caused b y coagulase-negative staphylococci. A frequent finding in shunted patients with meningitis is a relatively poor inflammatory response with a rather low C S F neutrophil count and a protein concentration which is normal or only moderately raised. This, in turn, leads to poor penetration of intravenously administered antimicrobials into the C S F ; the betalactam antibiotics suffer the additional disadvantage of being subject to the organic acid excretion p u m p 4 which, in their case, reduces the C S F concentration even further. In the case u n d e r discussion it is felt that it was these factors, rather than the decision not to remove the shunt (which was not malfunctioning) which were responsible for the clear lack of response to penicillin and cefotaxime. U n f o r t u n a t e l y , because the p n e u m o c o c c a l isolate was no longer viable, we were unable to measure C S F bactericidal activity and therefore could not demonstrate poor antimicrobial penetration. E v e n so, rifampicin was added to the regimen since it is k n o w n that this drug will pass the b l o o d / b r a i n barrier even in the absence of inflammation. M o r e o v e r , addition of rifampicin to theoretically appropriate treatment which is failing has resulted in clinical cures 5, 6 and this p r o v e d to be so in our case. W e conclude b y r e c o m m e n d i n g that shunted patients with p n e u m o c o c e a l meningitis whose C S F neutrophil count a n d / o r protein content are only moderately raised or w h o show inadequate response to Iv penicillin should have rifampicin added to their antibiotic regime. References I. Schoenbaum SC, Gardener P, Shillito J. Infections of cerebrospinal fluid shunts: epidemiology, clinical manifestations and therapy. J Infect Dis 1975 ; 131 : 543-552. 2. Bayston R. In: Hydrocephalus shunt infections. London: Chapman and Hall, 1989. 3. Stern S, Bayston R, Hayward RJ. Haemophilus influenzae meningitis in the presence of cerebrospinal fluid shunts. Child's Nerv Syst 1988; 4: 164-165. 4. Heiber JP, Nelson JD. A pharmacological evaluation of penicillin in children with purulent meningitis. N EnglJ Med 1977; 297: 41o-413. 5. Archer GL, Tenenbaum MJ, Haywood HB. Rifampicin therapy of Staphylococcus epidermidis. JAMA 1978; 24o : 751-753. 6. Ring ]C, Cares KL, Belani KK, Gaston TL, Sveum RJ, Marker SC. Rifampicin for CSF shunt infections caused by coagulase negative staphylococci. J Pediatr 1979; 95:317-319.
