Flavobacterium meningosepticum Meningitis: Report of Selected Aspects

Abstract

Two patients developed meningitis due to Flavobacterium meningosepticum. Because of resistance to most available antimicrobial agents, intravenous and intraventricular erythromycin was administered to one patient. Subsequent development of resistance to erythromycin prompted the use of intravenous and intraventricular rifamycin, which eventually resulted in cure. Diagnosis of F. meningosepticum meningitis in the second patient was delayed, and appropriate therapy was not administered until 4 days prior to the patient's death. Of 82 previously published cases, only 4 occurred in adults. Therapy of meningitis due to this organism has been a difficult problem, and we suggest possible modes of therapy, based on our experience and a review of the literature.Although Flavobacterium meningosepticum is not commonly considered a pathogen in humans, this organism has been reported to produce meningitis (1-5, 7-14, 16-20, 22), postoperative bacteremia (15), and endocarditis (21). Of these infections, meningitis has gained greatest attention because of its tendency to occur in local outbreaks, to involve neonates, and to result in high mortality. Difficulty in the eradication of infection in neonates may be explained by the impaired host defenses of newborns, the use of inappropriate antibiotic therapy, or the peculiar antibiotic susceptibility pattern of this organism.In this communication, we describe two additional cases of meningitis due to this organism and review the literature of previous case reports with special emphasis on the antimicrobial susceptibility patterns and therapy.CASE REPORTS Case no. 1. A 16-day-old boy was admitted to Hartford Hospital with a history of fever and increasing irritability of 4-day duration. He was delivered by Caesarian section because of uterine bleeding after 40 weeks of gestation and weighed 2.8 kg.On admission he was irritable and refused feedings. The temperature was 101°F (ca. 38.3°C) by rectum. The anterior fontanelle was not tense, arid there were no localizing neurological signs. A chest roentgenogram showed a right middle lobe infiltrate. Lumbar puncture was perforned and yielded cerebrospinal fluid (CSF) with 784 erythrocytes per mm3 and 11 white blood cells per mm3 with 8 polymorphonuclear cells and 3 lymphocytes; the sugar was 53 mg/100 ml with a simultaneous blood sugar of 130 mg/100 ml, and the protein was 90%. Gram stain did not reveal any microorganism. A presumptive diagnosis of meningitis was made, and the patient was begun on ampicillin (200 mg/kg per day) and gentamicin (7.5 mg/kg per day), both intravenously.On hospital day 2, he developed apneic episodes. Lumbar puncture was repeated, and CSF examination now revealed 7,500 erythrocytes per mm3 and 290 white blood cells per mm3 with 78% polymorphonuclear cells and 22% lymphocytes. The sugar was 3 mg/100 ml, and protein was 310 mg/100 ml.On hospital day 3, chloramphenicol (50 mg/kg per day intravenously) was started and ampicillin and gentamicin were discontinued due to no apparent clinical improvement while on th...

Flavobacterium group IIb bacteremia: report of a case and review of Flavobacterium infections

“…Meningitis seems to be the most severe type of Flavobacterium infection [2,5,12,[14][15][16]25,30] with four of eight patients dying from this opportunistic disease (Table 5). All patients had significant underlying disease (including tuberculosis in two), and most had circumstantial evidence as to how the organism could have gained access to the meninges (including a recent sterile lumbar puncture in two and rinorrhea in two).…”

Comprehensive Therapeutic Approaches to Tuberculous Meningitis: Pharmacokinetics, Combined Dosing, and Advanced Intrathecal Therapies

“…Treatment was complemented with intramuscular RIF at 20 mg/kg every 12 h. Transient jaundice was a noted side effect, with ventricular antibiotic concentrations evaluated 20 to 24 h post-administration [ 119 ]. Further reports highlighted a treatment regimen consisting of concurrent intravenous RIF at 40 mg/kg per day and IVT-RIF at 5 mg daily for 22 days, resulting in CSF sterilization without reported adverse effects or toxicity [ 120 ]. An evaluation of nine meningitis cases treated with either IT or IVT-RIF at 3 mg/kg/day for a minimum of 10 days showed that five patients achieved CSF sterilization and survival.…”

“…RIF: In seven published literature, IT/IVT-RIF was given at doses of 2–5 mg for 7–50 days in seven studies. This regimen proved highly effective, especially in complex cases and when oral drugs failed, with no significant side effects [ 22 , 23 , 106 , 120 , 121 , 122 , 123 ]. The targeted concentration of RIF in the CSF was 15 mg/L.…”

“…Nevertheless, the choice of administration route should also take into consideration patient-specific factors, such as condition, drug tolerance, and potential side effects. [22][23][24][105][106][107][108][109][110][111][112][120][121][122][123]. Some adverse events, such as infections, nerve damage, transient jaundice, seizures, etc., have been observed following the IT or IVT administration of RIF and INH [22][23][24][105][106][107][108][109][110][111][112][120][121][122][123].…”

“…[22][23][24][105][106][107][108][109][110][111][112][120][121][122][123]. Some adverse events, such as infections, nerve damage, transient jaundice, seizures, etc., have been observed following the IT or IVT administration of RIF and INH [22][23][24][105][106][107][108][109][110][111][112][120][121][122][123]. However, from our perspective, it is challenging to ascertain whether these side effects are directly attributable to RIF and INH or if they stem from disease progression or the specific procedure and route of administration.…”