Pneumococcal meningitis is an inflammation of the cerebral membranes caused by pneumococcus. It is characterized by a severe course with the development of meningoencephalitis and cerebral edema, a high percentage of disability of patients who have undergone it and mortality, without timely treatment, reaching 50%. Diagnosis is carried out by studying the anamnesis of the disease, assessing the neurological status of the patient, analyzing the results of lumbar puncture and examining the cerebrospinal fluid. Treatment is carried out inpatient, includes etiotropic antibacterial therapy, detoxification, dehydration, symptomatic, vascular and neurotropic treatment; according to indications – measures to strengthen immunity. Specific prevention consists in vaccination against pneumococcal infection.
ICD 10
G00.1 Pneumococcal meningitis
General information
In the structure of bacterial meningitis, pneumococcal meningitis occupies the second place, the first belongs to meningitis of meningococcal etiology. The features of pneumococcus as a causative agent lead to the fact that pneumococcal meningitis has a severe course, is characterized by the frequent development of complications, high disability and mortality of patients. Before the advent of antibiotics, the mortality rate of patients with this form of meningitis reached 100%. According to American neurology, today the mortality rate for pneumococcal meningitis is about 18%, and with belatedly initiated treatment can reach 50%. Given that the disease mainly affects children under the age of 10, the issue of its prevention and treatment is an urgent problem both in pediatrics and medicine in general.
Etiology and pathogenesis
The causative agent is pneumococcus (Streptococcus pneumoniae). Infection occurs by airborne droplets from carriers of pneumococcus or patients with various types of this infection (pneumococcal pneumonia, meningitis, otitis, mastoiditis or sinusitis of pneumococcal etiology). Pneumococcal meningitis develops when the pathogen enters the meninges. The latter can occur in 2 ways: when pneumococcus penetrates directly from the nasopharyngeal mucosa immediately after infection or when it is hematogenous from the primary focus of pneumococcal infection with moderate purulent otitis, sinusitis, pneumonia, etc.
Factors of particular pathogenicity of pneumococcus are its capsule and teichoic acid contained in its cell wall. The presence of the capsule prevents the implementation of such a protective mechanism of the macroorganism as phagocytosis. The interaction of teichoic acid with C-reactive protein causes the activation of the compliment system and the production of anti-inflammatory mediators. At the same time, vascular permeability increases sharply, exudate is formed, in which fibrin clots form. The pneumococci located in these clots are inaccessible to the antibodies developed against them. In this regard, already at an early stage of meningitis from the membranes of the brain, they penetrate into its substance, leading to the development of meningoencephalitis. A pronounced exudative component causes the appearance of cerebral edema. This is accompanied by a decrease in cerebral blood flow and damage to the medulla.
Symptoms
The meningitis clinic consists of general infectious, shell (meningeal) and general cerebral symptoms. The general infectious syndrome is characterized by lethargy, febrile temperature with chills, anorexia and refusal to drink, pale skin. A hectic temperature with fluctuations of 2-3 °C is possible. There is a change in the pulse with a tendency to bradycardia, muffling of heart tones, fluctuations in blood pressure. With the development of sepsis, pneumococcal meningitis is accompanied by a rash on the skin. The rashes are hemorrhagic in nature, they can debut with roseolous papular elements. Unlike a rash with meningococcal meningitis, pneumococcal rash is more persistent, with recovery, its reverse development does not occur so quickly.
The general cerebral syndrome is dominated by headache (cephalgia). It has a bursting diffuse character, sometimes localized mainly in the frontal-temporal zones of the head. It is accompanied by repeated or repeated vomiting that does not bring relief to the patient, expansion of the venous network on the eyelids and head. Possible disorders of consciousness, ranging from psychomotor agitation to sopor and coma. Convulsions of varying severity can be observed from muscle twitching to generalized epiprime. Infants have divergence of cranial sutures, bulging fontanelles, a typical “brain” cry, characterized by its shrillness and monotony. The development of meningoencephalitis leads to the appearance of focal symptoms against the background of general cerebral symptoms — oculomotor disorders, ataxia, hemiparesis, hyperkinesis.
The meningeal symptom complex is characterized by the forced position of the patient — with the head thrown back, the limbs bent and brought to the body. Hyperacusis, hyperesthesia and photophobia are observed. The rigidity of the muscles of the occiput is typical, which is determined by passively tilting the patient’s head so that his chin approaches the chest. There are so-called meningeal symptoms. Kernig’s symptom is the impossibility of passively fully extending the leg at the knee, if it is bent at the hip, it is checked lying on the back. The symptom of Brudzinsky I is flexion of the hip and lower leg when trying to passively bend the patient’s head. The symptom of Brudzinsky II is a similar flexion of the legs at the time of pressure by the doctor on the patient’s pubic joint. Symptom of Brudzinsky III — an attempt to bend the leg at the knee leads to bending at the knee and bringing the second leg to the stomach. The symptom of Mondonesi is soreness when pressing on the closed upper eyelids. The symptom of Bekhterev is the painfulness of pounding the zygomatic arch.
In infants, the symptom of Lessage is determined — pulling the legs to the abdomen while holding the child by the armpits in a suspended vertical position. In early childhood, complete shell syndrome is quite rare. Most often, with meningitis in infants, along with the symptom of Lessage, occipital rigidity is detected, less often – Kernig’s symptom.
Acute pneumococcal meningitis manifests a sharp rise in temperature to 39-40 °With and a rapid increase in general infectious symptoms. There is a general cerebral symptom complex — intense headache, anxiety, vomiting, in infants – a “brain” cry. Meningeal syndrome, as a rule, occurs on the 2-3 day of the disease. Depression of consciousness progresses, focal symptoms occur. On day 3-4, a convulsive-comatose status is noted. Possible dislocation of cerebral structures with the insertion of the brainstem into the large occipital foramen, which may be the cause of death.
Pneumococcal meningitis, which appears against the background of the primary focus of pneumococcal infection, is characterized by a subacute and low-symptomatic onset. But it proceeds more severely than the primary acute form and more often leads to death. This is usually due to the late recognition of meningitis and, accordingly, the delayed start of its therapy.
Adequate and timely treatment leads to some improvement in the patient’s condition by the end of 1 week of the disease. Within 2 weeks, there is a regression of cerebral and shell symptoms. However, pneumococcal meningitis often has a prolonged course or its relapses are noted. The liquor is sanitized for 3-4 weeks of the disease.
Diagnostics
Anamnesis and clinical picture of the disease, neurological examination data often allow to establish the presence of meningitis. If there is a history of data on the pneumococcal nature of the infection present in the body (pneumonia, otitis media, etc.), then pneumococcal meningitis can be assumed. However, a neurologist can accurately verify the diagnosis only after the results of a bacteriological analysis of the cerebrospinal fluid.
In order to obtain cerebrospinal fluid, a lumbar puncture is performed, during which the nature of the expiration of the cerebrospinal fluid is assessed and its pressure is measured. As a rule, pneumococcal meningitis is accompanied by an increase in liquor pressure above 150 mm of water. The cerebrospinal fluid loses its transparency, may be whitish, cloudy or have a greenish tinge. It shows an increased protein content, pleocytosis due to neutrophils and lymphocytes, changes in the content of chlorides and glucose. When examining cerebrospinal fluid smears under a microscope, lanceolate or oval pneumococci located in pairs and surrounded by a shell are detected. Bacteriological examination is carried out by sowing liquor and sputum (if any) on special media. It allows you to differentiate pneumococcal meningitis from other types of streptococcal infection. With the development of sepsis, pneumococci are also detected in the blood tank.
Treatment
Pneumococcal meningitis requires urgent comprehensive inpatient treatment. The patient needs strict bed rest, high-calorie chemically and mechanically gentle nutrition. Benzylpenicillin, ceftriaxone and cefotaxime are widely used as etiotropic treatment. The second-line drugs include tetracyclines, vancomycin, sulfonamides. Detoxification therapy includes oral rehydration (copious drinking of teas, mors) and infusion of glucose and NaCl solutions, dextran, salt solutions. If pneumococcal meningitis has occurred in a weakened child, the introduction of freshly frozen plasma, leukocyte suspension, and UVIB is indicated.
Of great importance in the prevention and treatment of cerebral edema is the appointment of diuretics (furosemide, 15% r-ra manitola). Vinpocetine and pentoxifylline are used to improve cerebral circulation. In order to maintain the metabolism of nervous tissue and restore connections between neurons during recovery, neurometabolites and nootropics (glycine, pyriditol, piracetam, hopanthenic acid) are used. The duration of the course of vascular and neurotropic therapy can be up to 6 months.
Prognosis and prevention
The outcome of meningitis largely determines the timeliness of its detection and initiation of etiotropic treatment. Unfortunately, despite the ongoing treatment, pneumococcal meningitis in children often leads to a lag in psychophysical development and the formation of persistent neurological deficits in the form of paresis, hearing loss, amaurosis, etc. Fatal outcome is observed with the development of cerebral edema, pulmonary heart failure of central genesis, sepsis with DIC syndrome.
The most effective way to prevent the disease is vaccination. Specific prophylaxis by administration of pneumococcal vaccine is recommended for children during the first 2 years of life, children at risk aged 2-5 years, middle-aged people with reduced immunity and people over 65 years of age.