Community-acquired Bacterial Meningitis in Adults With Cerebrospinal Fluid Leakage

Abstract

Background Cerebrospinal fluid (CSF) leakage is a risk factor for developing bacterial meningitis. Methods We analyzed episodes of community-acquired bacterial meningitis associated with CSF leakage from a prospective nationwide cohort study. Results CSF leakage was identified in 65 episodes of 2022 episodes (3%) in 53 patients. The cause of CSF leakage was identified in 49 of 65 episodes (75%), which most commonly consisted of ear-nose-throat surgery (19 of 49 episodes [29%]) and remote head trauma (15 of 49 episodes [23%]). The episode was a recurrent meningitis episode in 38 patients (59%). Of the recurrent episodes, 27 had known CSF leakage (71%) of whom 20 (53%) had previous surgery aiming to close the leak. Nine patients (38%) with known CSF leakage had been vaccinated (23-valent pneumococcal vaccine in 9 patients, meningococcal serogroup C vaccine in 2, meningococcal serogroup A and Haemophilus influenzae type b vaccine each in 1 patient). Streptococcus pneumoniae was cultured in 33 episodes (51%) and H. influenzae in 11 episodes (17%). The most common pneumococcal serotypes were 3 (4 episodes), 35B, 9N, 38, and 15C (each 2 episodes). Haemophilus influenzae was unencapsulated in all 10 episodes with known capsule type. The outcome was unfavorable in 8 episodes (12%) and no patient died. Conclusions Bacterial meningitis in patients with CSF leakage has a high recurrence rate, despite surgical repair or vaccination, and outcome is generally favorable. CSF leakage should be suspected in patients with bacterial meningitis presenting with liquorrhea, recurrent meningitis, or with disease caused by H. influenzae.

Recurrent Community-Acquired Bacterial Meningitis in Adults

“…Patients with recurrent bacterial meningitis have a more favorable outcome compared with nonrecurrent meningitis patients. This is in line with previous results of smaller studies [ 3 , 4 ]. Although speculative, the favorable disease outcome in recurrent meningitis patients can be explained by several factors.…”

“…No underlying risk factor was found in a substantial number of patients with recurrent meningitis (28%). Early identification of the predisposing factor may lead to prevention of new recurrences [ 4 , 13–15 ]. The active search for predisposing factors should focus on anatomical defects and immunodeficiencies.…”

“…Second, patients with recurrent meningitis had a lower rate of bacteremia and systemic complications [ 24 , 25 ]. Episodes are often predisposed by a CSF leakage, which contributes to a better prognosis due to the relatively benign pathophysiology [ 4 ]. Third, patients with recurrent meningitis might have a less severe inflammatory response, potentially caused by immunocompromise and inborn errors of innate immunity.…”

Changing Epidemiology of Bacterial Meningitis Since Introduction of Conjugate Vaccines: 3 Decades of National Meningitis Surveillance in The Netherlands

“…The majority of the H. influenzae meningitis cases are due to nontypeable strains [ 17 ], and are mainly identified in predisposed patients and patients of extreme age [ 18 ]. In adults with bacterial meningitis, H. influenzae is often seen in patients with CSF leakage [ 19 ].…”

Neuroinvasive Listeria monocytogenes infection triggers accumulation of brain CD8+ tissue-resident memory T cells in a miR-155-dependent fashion

“…In addition, recent data show that CD8 + BT RM induced by neurotropic viral infection can inflict neurological damage by secreting IFN-γ, activating microglia, and causing neuronal apoptosis [14,49,50]. With the advent of antimicrobial therapy, recurrent CNS infection by the same bacterial pathogen is uncommon outside specific situations such as cerebrospinal fluid leak [51]. Even though BT RM induced by bacterial infections may not have a role suppressing latent infection, they likely have the potential to damage the host similar to BT RM elicited by other pathogens or via bystander activation [52].…”