Recurrent meningitis in a child due to an occult spinal lesion

Abstract

The case: A 1-year-old girl presented to hospital with fever, lethargy and vomiting. She had had an episode of Escherichia coli meningitis at 2 months of age, which had been treated with antibiotics. No further investigation was conducted at that time. The remainder of her medical history was unremarkable.On examination, the child was febrile, lethargic and cried with neck flexion. She had a port-wine stain over her lumbar spine at the midline (Fig. 1). Lumbar puncture revealed a leukocyte count of 3340 × 10 6 /L (normal value < 5 × 10 6 /L) with 78% polymorphs, an erythrocyte count of 110 × 10 6 /L, a glucose level of 1.9 mmol/L (the serum glucose level was 13.3 mmol/L) and a protein level of 0.74 g/L (normal 0.15-0.40 g/L). Results of blood and urine cultures were negative. Her cerebrospinal fluid tested positive for E. coli. In addition,

Epidemiology, Etiology, Pathogenesis, and Diagnosis of Recurrent Bacterial Meningitis

“…The tract may appear as only a tiny dimple in the midline of the spine or the posterior skull, and identification upon physical examination may be challenging, particularly when located in the occipital region, where the opening may be covered by hair (10,103,198). In a spinal location, dermal sinus tracts are frequently associated with visible cutaneous stigmata in the surrounding area, such as naevi, port wine stains, or a tuft of hair (10).…”

“…In contrast, in infants and young children with dermal sinuses in the lumbosacral location, gram-negative organisms, particularly E. coli, and enterococci are the most common causative organisms of meningitis, most likely secondary to fecal contamination (10,115).…”

“…The literature search identified 24 cases of recurrent bacterial meningitis associated with dermoid and epidermoid cysts (6,10,26,80,103,115,172,198). Histologically, only one tumor was determined to be an epidermoid cyst (26); 17 cases were reported as being dermoid cysts.…”

“…A thorough physical examination is vitally important, as illustrated by several cases of patients with dermal sinus tracts, which had been missed on previous admissions, that were detected by examination alone (10,103). Particular attention should be given to the examination of the head and spine, as this may reveal fistulous tracts or cutaneous stigmata suggestive of occult spinal defects.…”