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Vol. 37, No. 6 March 15, 2015 www.cmnewsletter.com

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43 Infectious Meningitis

Corresponding author:

AbdelRahman M. Zueter, M.L.S., M.Sc., Ph.D., Depart- ment of Medical Microbiology and Parasitology, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia. Tel.: 0060136709343. Fax:

0060197676289. E-mail:

Infectious Meningitis

AbdelRahman M. Zueter, M.L.S., M.Sc., Ph.D., 1 and Amani Zaiter, M.Sc., 2 1 Department of Medical Microbiology and Parasitology, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia, 2 Biological Sciences Department, Faculty of Science, Hashemite University, Zarqa, Jordan

Abstract

Infectious meningitis is a large public health concern, especially in children and immunocompromised patients. Although the epidemiology of meningitis has shown significant decline in past decades, partly due to the introduction of vaccines, outbreaks are still reported worldwide. Diagnosis of meningitis is of critical importance, and it is considered to be one of the most urgent of the microbiological medi- cal emergencies. In order to improve the treatment strategy, various diagnostic methods have been developed to detect the presence of infectious agents that cause meningitis, as well as their antibiotic resistance patterns. This article aims to enhance the understanding of meningitis and to highlight the most current updates that describe outbreaks of meningitis and the subsequent investigations. We also describe the current diagnosis and treatment options.

Introduction

Meningitis is an inflammation of the meningeal layers of the brain and spinal cord. The infec- tion involves the arachnoid, the pia mater, and the intervening cerebrospinal fluid (CSF). The inflammatory process extends throughout the subarachnoid space of the brain and spinal cord and involves the ventricles. Meningitis can cause necrosis, decreased blood and CSF flow, and impaired central nervous system (CNS) func- tions. The early symptoms are headache, fever, and chills; however, a combination of 2 to 4 symptoms (headache, fever, stiff neck, and altered mental status) is found in 95% of patients. Death occurs from shock and other serious complica- tions within hours of the appearance of symp- toms (1,2).

Meningitis is usually caused by an infection but may also occur in response to noninfectious irri- tants introduced into the subarachnoid space (1). Noninfectious cases are uncommon or rare compared with the infectious type, particularly with their inability to spread from one person to another (3). Therefore, meningitis could be divided into two categories according to the nature of the causative agents: infectious and

noninfectious meningitis (2). Noninfectious meningitis can be induced by certain drugs, auto- immune hypersensitivity disorders, neoplasms, and chemical agents (Table 1). When present in the CSF, noninfectious agents or their products, such as tumor cell products, act as inflammatory irritants that induce inflammatory processes that can progress to meningitis.

Infectious Meningitis

Infectious meningitis is a serious disease of the CNS that involves inflammation of the meninges as a result of microbial infection, and it occurs in all age groups. It is caused most commonly by viruses and bacteria, rarely by fungi and para- sites (9). The clinical presentation of meningitis depends on the virulence of the causative agent, the pathogenesis of spread to the CNS, and the area of CNS involvement (3). Headache, fever, stiff neck, confusion, vomiting, and pleocytosis are features of meningeal inflammation and are common to many types of meningitis (e.g., bacte- rial, fungal, viral, and chemical) and also to some parameningeal processes. The CSF laboratory findings are most helpful in distinguishing among these processes (2).

The age of the host and other underlying host factors (head trauma, neurosurgery, or presence of a CSF shunt) contribute to the etiology and the routes of entry. Initially, infectious agents colonize or establish localized infection in the skin, nasopharynx, respiratory tract, gastrointestinal tract, or genitourinary tract of the host. From these sites, the organisms invades by circumvent- ing host defenses (e.g., physical barriers, local immunity, and phagocytes/macrophages) and gains access to the CNS through (i) hematogenous spread, the most common route of infection, in which the organisms spread via the blood vessels of the brain to enter the subarachanoid space; (ii) direct spread from an infected neighboring site contiguous to the CNS; (iii) an anatomical defect in the CNS structure that resulted from surgery, trauma, or con- genital abnormalities, which can allow microorganisms to easily access the CNS; or (iv) travel along nerves leading to the brain, as occurs with some viruses. Of note, neonates have the highest risk of infection because of their immature immune system and the increased permeability of the blood brain barrier (10). Infectious meningitis is grouped on the basis of pathogen type (bacterial, viral, fungal, or parasitic), host age (neonate, pediatric, and adult), health status (healthy or immunocompromised), and symptom duration (acute, subacute, or chronic [recurrent]).

Meningitis is transmitted from person to person through respira- tory secretions (saliva, sputum, or nasal mucus), through the fecal- oral route, or vertically through the colonized vaginal canal. The infection is considered to be acute during the period when signs and symptoms of less than 24 hours duration are observed and subacute when signs and symptoms have been present for 1 to 7 days. Most cases of meningitis are acute, but some are chronic due to the invasion of pathogens from a neighboring infected site (10).

The common infectious agents of acute meningitis are viruses (mainly enteroviruses and, to a lesser degree, HIV, herpes sim- plex viruses (HSV), and mumps virus), bacteria (Streptococcus pneumoniae, Neisseria meningitidis, Streptococcus agalactiae (group B streptococci), Haemophilus influenzae, and Listeria monocytogenes). Less common causes of acute meningitis include parasites (Naegle- ria fowleri, Strongyloides stercoralis, and Acanthamoeba cantonensis).

Subacute or chronic meningitis is characterized by delayed symp- toms over weeks to months or even years. These patients may also have some acute meningitis symptoms, but the onset is more gradual, with lower fever and possibly associated lethargy and disability. This type of meningitis may be caused by Mycobacteria spp., spirochetes, Cryptococcus neoformans, Candida spp., and Coc- cidioides spp. (1,3).

Bacterial meningitis

Bacterial meningitis is a major cause of morbidity and mortal- ity, especially among children less than 5 years of age. The rapid progression of symptoms and potentially devastating effect of the disease necessitate early recognition and immediate treatment. Shock, coagulation disorders, endocarditis, pyogenic arthritis, and prolonged fever are the most common bacterial meningitis complications (2). Despite many new antibacterial agents, bacterial meningitis fatality rates remain high, with reported rates between

Table 1. Noninfectious causes of meningitis

noninfectious cause/agent

example a

Reference

Drug hypersensitivity

NSAID

4,5

antimicrobials

Systemic diseases

SLE

6

Neoplastic diseases

Metastatic carcinoma

7

Chemical agents

Anaesthetics

8

a NSAID, nonsteroidal anti-inflammatory drug; SLE, Systemic lupus erythomatosis.

2% and 30%. Permanent sequelae, such as epilepsy, mental retar- dation, or sensorineural deafness, are observed in 10% to 20% of those who survive (11,12).

In general, all human microbes can cause meningitis, but only a few species account for most cases of bacterial meningitis. S. agalactiae and Escherichia coli commonly infect neonates up to 3 months of age and are acquired during the passage of the baby through a colonized vaginal canal. H. influenzae infects unvac- cinated children between the age of 3 to 6 months and 6 years. N. meningitidis infects children and young adults and is the only organism that causes meningitis epidemics. S. pneumoniae occa- sionally infects children and increases in incidence with age. L. monocytogenes appears to be foodborne (dairy products, processed meat, and uncooked vegetables) and infects people with defective immunity or those receiving certain therapies (1-3). Some studies report a dramatic drop in developed countries as a result of the introduction of vaccines against common bacterial agents, such as S. pneumoniae, H. influenzae type b, and N. meningitidis (2,11).

Data for community-acquired acute bacterial meningitis suggest that almost 50% of cases are due to S. pneumoniae, 25% to N. men- ingitidis, 13% to group B streptococci, 8% to L. monocytogenes, and 7% to H. influenzae. In contrast, nosocomial meningitis is associ- ated with enteric gram-negative bacilli in up to 33% of cases. The most common gram-negative bacterial agents in adults are E. coli and Klebsiella/Enterobacter spp. Mortality rates of bacterial menin- gitis in adults remain at approximately 20% but rise to at least 40% for those older than age 60 (13). In neonates, S. agalactiae and E. coli are the most common agents of meningitis in North America (11), Australasia (14), and Europe (15). The morbidity rate of neonatal meningitis is up to 56%; if not treated, the mortality can approach 100% (16). In rare situations, other bacterial pathogens can cause acute meningitis, including coagulase-negative staphy- lococci, Burkholderia pseudomallei, Pseudomonas aeruginosa, mis- cellaneous gram-negative bacilli, Staphylococcus aureus, viridans streptococci, and anaerobic bacteria. Mixed bacterial infections might occur as complications of neurosurgical procedures (e.g., spinal puncture) and low immunity status. Meningitis caused by group A streptococci is uncommon but occasionally occurs after acute otitis media. In approximately 10% of patients with acute bacterial meningitis, the bacterial cause cannot be defined but is diagnosed on the basis of other differential laboratory findings (3). Mycobacterium tuberculosis, Treponema pallidum and Borrelia burg- dorferi are considered to be the most common causes of chronic

bacterial meningitis (13); 1% of patients suffering from tuber- culosis progress to complicated CNS tuberculosis (17).

Viral meningitis

Viral meningitis is more common than bacterial meningitis but is much less severe. The clinical course of viral meningitis is usually self-limited, with complete recovery in 7 to 10 days. Most cases of community-acquired aseptic meningitis are the result of viruses. Aseptic meningitis is suspected when CSF cultures for routine bacteria are negative and there were no antibiotics given before the lumbar puncture (16).

Enteroviruses account for 85 to 95% of aseptic meningitis (3,18). Enteroviruses are single-stranded RNA viruses and, along with rhinoviruses, represent a major group in the genus Enterovirus in the family Picornaviridae. Recent classification systems rely on RNA homology, which classifies the enteroviruses into four spe- cies designated human enteroviruses A through D, encompassing many serotypes of group A and B coxsackieviruses and enterovi- ruses, echoviruses, and polioviruses (3).

Mumps virus, HIV-1, and HSV-2 may cause chronic recurrent meningitis (2), a recurrent infection that occurs after full recovery.

The exact incidence of viral meningitis is known to be underes- timated, due to poor reporting practices. In temperate regions, seasonal aseptic meningitis usually peaks in summer and early autumn, reflected by the seasonal pattern of outbreaks. Some enteroviral serotypes (e.g., echoviruses 6, 9, 13, 18, and 30 and coxsackievirus B5) cause widespread outbreaks, while coxsacki- eviruses A9, B3, and B4 are associated with endemic infection. Echovirus 30 has been implicated in European outbreaks every 3 to 5 years. Its distribution covers large geographical areas, and infections are more common in children. On the other hand, no seasonal preference has been reported for HSV and HIV (18). Table 2 describes the recently published surveys and outbreaks of acute meningitis worldwide.

Fungal and parasitic meningitis

Fungal meningitis is rare but poses a significant challenge, span- ning a wide array of hosts, including immunocompetent and immunosuppressed individuals, patients undergoing neurosurgical procedures, and those with implantable CNS devices. C. neofor- mans and Aspergillus spp. are the most common fungal pathogens (51). C. neoformans infection is acquired by the inhalation route and can be asymptomatic and limited to the lungs in immuno- competent hosts. Upon immunosuppression, hematogenous dissemination to the meninges may occur, which can end with a fatal outcome in the absence of prompt management. Lympho- proliferative malignancies, steroid therapy, diabetes mellitus, and AIDS are the most common predisposing factors for cryptococ- cal meningitis (51). C. neoformans is the most common cause of meningitis in immunosuppressed and AIDS patients; the mortal- ity rate in that population ranges from 10 to 30% and from 13 to 44% in developed and developing countries, respectively (52,53). In one retrospective study performed in India, the prevalence of C. neoformans among HIV patients was 14.3% (53). Candida spp. cause acute meningitis indistinguishable from bacterial meningitis

in patients with low immunity or after neurosurgery procedures.

Chronic cryptococcal and candidal meningitis may mimic chronic meningitis that is caused by M. tuberculosis (52).

Parasites can infect the meninges and cause aseptic meningitis; they can also infect brain tissue, causing acute meningoencepha- litis. From warm freshwater, the free-living amoeba N. fowleri (the most virulent) invades the brain via direct extension from the nasal mucosa and causes meningoencephalitis that is lethal within 1 week in most cases, predominantly in children and young adults. Acanthamoeba species are commonly found in soil and primarily infect immunocompromised patients, usually through inhalation

or skin wounds, causing encephalitis, which can be acute or chronic (3,10). A listing of uncommon pathogens is provided in Table 3.

Approaches for Laboratory Diagnosis

Diagnosis of an infection involving the CNS is considered to be a medical emergency. Combining the physical examination with confirmatory laboratory tests and a clinical history of the patient provides the strongest evidence of meningitis. Over the last few years, many approaches have been developed and used for the diagnosis of meningitis. Currently, several diagnostic methods were evaluated in order to achieve sensitive, rapid, and specific

detection of meningitis etiology (10), especially in the case of bac- terial meningitis, which requires immediate diagnosis and rapid institution of antimicrobial therapy (2). When meningitis occurs, inflammatory immune cells flow into the CSF and are usually detectable on examination of the fluid. Therefore, the collection

of CSF specimen via lumbar puncture is one of the first steps in

the workup of a patient with suspected meningitis (2,13).

CSF collection

Routinely, CSF is collected into three sterile tubes from the same puncture after considering the proper intracranial pressure. The first tube is used for chemical and immunological testing due to the potential for cell contamination during collection. To avoid surface flora contamination, the second tube is selected for micro- biological and molecular testing. The last volume collected best represents the actual cellular composition of the CSF and is ideal for cytological testing. In cases where a low volume of CSF is collected, the sample is triaged for microbiology, cytology, and chemistry, respectively, to optimize findings. After collection, the sample is assessed for normal color, clarity, and viscosity and then sent for further laboratory examination (65).

Cytology

Direct microscopy provides a screening method of CSF samples. Various cell types in CSF should be evaluated and studied, yet few have established usefulness in diagnosing infectious menin- gitis. A microscopic examination includes total and differential white blood cell (WBC) counts, as well as counts of red blood cells (RBCs) and other cell types that could be uncommon or abnormal (13).

A total CSF cell count is usually performed manually using a

hemacytometer chamber. Automated electronic-impedance-based CSF cell counters increase precision and reduce turnaround time.

Table 2. Recent surveys and outbreaks of acute meningitis in selected countries worldwide

Country

Age group

Predominant pathogens a

study interval

Diagnostic method c

Reference

Asia

India

All b

S. aureus, Klebsiella spp., E. coli, Acinetobacter spp.,

2009-2010

Culture

19

 

N.

meningitidis, S. pneumoniae

Japan

Neonates

H. influenzae, S. pneumoniae, S. agalactiae, E. coli

2008-2010

Culture

20

Japan

Adult

Enteroviruses, mumps virus, VZV, HSV

2004-2014

PCR, culture

21

China

All

S. pneumoniae, N. meningitidis, H. influenzae

2006-2009

Agglutination, culture

22

China

Pediatric

Enteroviruses, adenoviruses

2006-2012

PCR, culture

23

China

Pediatric

Enteroviruses (echovirus 30, coxsackievirus B5)

Outbreak

PCR, culture,

24

 

2008, 2012

genotyping

Australia

All

Enteroviruses (echoviruses 6, 4, 30, 25, and coxsackievirus A9)

2007-2013

PCR, culture,

25

 

genotyping

Middle east

Jordan

Pediatric

Enteroviruses

1999

Culture, IFA

26

Palestine

Adults

Enteroviruses (echovirus 27)

1978-2012

Culture, serology

27

Kuwait

Pediatric

Enteroviruses (echoviruses 9, 11, 30)

2006-2009

PCR, hybridization

28

europe

France, Italy, Greece, Finland, Bulgaria, Serbia, Latvia, Spain,

All

Enteroviruses (echovirus 30)

Outbreak,

PCR, culture,

29,30-32

 

2009-2013

genotyping

Turkey

Children

S. pneumoniae, N. meningitidis, H. influenzae

2005-2006

PCR, culture

38

Denmark

All

S. pneumoniae, N. meningitidis, streptococcus groups A, B, G

1998-2010

Agglutination,

39

 

culture

UK

Neonates

S. agalactiae, E. coli, S. pneumoniae, N. meningitidis

2010-2011

Gram stain, culture

40

Iceland

Children

N. meningitidis, H. influenzae

1975-2010

Gram stain, culture

41

 

S.

pneumoniae, S. agalactiae

Spain

Adults,

N.

meningitidis, S. pneumoniae, L. monocytogenes

1982-2010

Gram stain, culture, agglutination

42

Elderly

S.

pneumoniae, L. monocytogenes,

 

Gram-negative bacilli

 

Americas

Brazil, Panama

All

Enteroviruses (echovirus 30)

2005, 2008

PCR, culture,

43,44

 

genotyping

Brazil

All

N. meningitidis, S. pneumoniae H. influenzae

2004-2006

Gram stain

45,46

 

2000-2010

PCR, agglutination

USA

All

S. pneumoniae, N. meningitidis

1998-2007

Culture

11

USA

All

Enteroviruses (echoviruses 30, 6)

5 yr

PCR, culture,

47

 

genotyping

Africa

Malawi

Neonates

S. agalactiae, S. pneumoniae, S. enterica

2002-2008

Gram stain, culture

12

Burkina Faso

Children

H. influenzae, S. pneumoniae, N. meningitidis

2004-2012

Gram stain,

48

 

PCR, culture

Niger

All

N. meningitidis, S. pneumoniae, H. influenzae

2002-2010

PCR, culture,

49

 

agglutination

South Africa

Pediatric

Enteroviruses (echoviruses 4, 9, and coxsackievirus B5

2010-2011

PCR, culture,

18

 

genotyping

Kenya

Pediatric

S. pneumoniae, N. meningitidis, H. influenzae

2014

Culture, Gram stain

50

a Pathogens are listed in the order of highest frequency to lowest frequency. VZV, varicella-zoster virus. b All includes pediatric patients, adults, and the elderly. c IFA, immunofluorescence assay.

Moreover, the nature of normal CSF cell constituents represent cells in low density, which interferes with the working principle of the automated counter, thus resulting in values higher than “normal” cell counts. Therefore, the impedance-based technology may not be routinely applicable, since most CSF samples tested in the laboratory are in the normal/low cell count range (65). Some studies have reported agreement of cell counts performed on automated analyzers that use flow cytometry and flow cell digital- imaging principles with those from the manual hemacytometer method (66). Unfortunately, automated systems cannot identify pathologic cell types, such as neoplastic cells, lipophages, and sid- erophages. A differential cell count is best performed by Wright’s stain of CSF sediment smear prepared by cytocentrifugation. The normal CSF does not contain RBCs; however, normal adult CSF contains a total of 0 to 5 WBCs/µl, specifically, lymphocytes and monocytes. In children, the total WBC count is 0 to 10 WBCs/ µl; in healthy neonates, counts as high as 30 WBCs/µl, with a pre- dominance of monocytes, can be normal (2,65).

Chemical examination

Numerous chemical constituents in the CSF sample are evalu- ated, but few give useful diagnostic data for meningitis etiol- ogy. Since result values differ in response to the different types of microorganisms involved, assays such as glucose, lactate, and various proteins assays can provide diagnostic information (Table 4) and help classify the type of meningitis, but results from cytol- ogy and chemistry laboratories cannot conclusively determine whether the infection is bacterial, viral, fungal, or parasitic due to similarity of results that may be obtained in response to infections

Table 3. Recent cases of meningitis of chronic and uncommon etiologies

Age/gender

Meningitis etiology

Risk factor a

by different microorganism types. Confirmatory tests should be performed (2,18).

Normal CSF glucose levels range from 50 to 80 mg/dl, which is approximately 60% to 70% of the plasma concentration. In con- trast, CSF lactate is unrelated to plasma and is present in normal concentrations of 10 to 22 mg/dl. More than 50% of infectious meningitis cases cause decreases in the CSF glucose level due to defects in glucose transport across the blood brain barrier or increased glucose consumption within the CNS. Increased lactate is an indicator of anaerobic metabolism within the CNS due to decreased oxygenation and blood supply.

The CSF total protein assay assesses the integrity of the blood brain barrier. The total CSF protein level varies with the age and the site from which the CSF is obtained and is higher when col- lected from the lumbar region. A CSF total protein level of 15 to 45 mg/dl is considered normal. Protein screens include assessment of CSF proteins and immunoglobulins by electrophoresis, and the definitive concentrations are measured by nephelometry (2,65).

Microbiological examination

Microbiological staining is used for visual detection of causative agents in the CSF sediments. The sediment could be concen- trated or smeared, dried, and stained with Gram stain, India ink, and Ziehl-Neelsen stain for bacteria and yeast, Cryptococcus spp., and Mycobacteria spp., respectively. Wet-mount preparation can be used for parasite detection (10). Direct microscopy and stain- ing of concentrated CSF sediment provide rapid presumptive diagnosis of meningitis in 60% to 80% of untreated patients and

Complication

Diagnostic method b

Outcome

Reference

50

yr/male

Rhodotorula glutinis

AIDS

Gram stain, culture

Cured

54

34

yr/male

C. neoformans

AIDS

Reversible blindness

Culture

Cured

55

42

yr/male

C. neoformans

HIV-induced IRIS

Agglutination

Relapsed

56

19

mo/male

A. cantonensis

Poor hygiene

Permanent

Microscopy

Cured

68

 

neurological sequelae

64

yr/male

Abiotrophia defectiva

Neurosurgical

Culture, genotyping

Cured

57

 

procedures

17

mo/male

M.

tuberculosis

Disseminated

PCR

Cured

59

 

tuberculosis

18

mo/male

M.

tuberculosis

Disseminated

Communicating

CT scan

Cured

 

tuberculosis

hydrocephalus

52

yr/female

Pantoea calida

Post surgery

Culture, genotyping

Cured

60

36

yr/male

Salmonella enterica

Salmonella Virchow

Culture

Cured

61

 

serovar Virchow

carrier

21

yr/female

Mycobacterium chelonae

 

Culture, RFLP

Cured

62

6

yr/male

N. fowleri

Contaminated water

Microscopy

Cured

63

 

reservoir

8

mo/male

Methicillin-resistant S. aureus (MRSA)

MRSA sepsis

Culture

Cured

64

a IRIS, immune reconstitution inflammatory syndrome. b CT, computed tomography; RFLP, restriction fragment length polymorphism.

in 40% to 60% of treated patients (65). Culture is considered the gold standard for several protocols. The organism could be grown on special nutritive medium that supports its growth after proper incubation under suitable atmosphere and temperature. Culture is routinely used for bacterial and fungal diagnosis. Traditional labo- ratory diagnostic culture methods for the identification of bacte- rial meningitis pathogens take up to 36 hours or more and enable the isolation of common types of bacteria in 80% to 90% of cases (65,67). Unfortunately, in many clinical settings, the administra- tion of short-course antibiotic therapy prior to lumbar puncture reduces the chance of isolation of bacteria in CSF culture, decreas- ing the diagnostic accuracy for bacterial meningitis to only 30%. Therefore, a growing discrepancy exists between the numbers of clinically suspected and culture-confirmed cases of bacterial men- ingitis. Thus, negative CSF cultures in patients suspected to have meningitis can be confirmed by other methods that are not affected by antibiotic administration (67), such as PCR (3).

Cell lines for viral culture are part of routine laboratory diagnosis for viral meningitis in countries where viral meningitis outbreaks are endemic. In some cases, the purpose of viral culture is more often focused on molecular genotyping applications that require isolation of the viral genome than on primary diagnosis (3,25). Enteroviruses are isolated in cell line culture with sensitivities of 65 to 75% and takes 4 to 8 days. HSV-2 can be cultured from CSF in approximately 75% of patients with aseptic meningitis (2). Devel- opment of CSF PCR panels for diagnostic purposes is ongoing.

Immunodiagnostics

Immunoassays are based on the principle of antigen-antibody reac- tion for identification of microbial agents. Microbial structures, such as capsules, can be targeted as an antigen and then detected by a reagent antibody. Rapid antigen detection from CSF has been largely accomplished by the principles of latex agglutination, coag- glutination, immunoassay, and counter-immunoelectrophoresis. Immunoassays represent a screening tool for primary diagnosis, along with other screens for microbial detection and cell counting. Currently, immunologic tests are applicable for the detection of several types of bacteria and fungi that cause meningitis, includ- ing S. pneumoniae, S. agalactiae, H. influenzae, N. meningitidis, Coc- cidioides immitis, M. tuberculosis, and C. neoformans. Additionally, certain kits are used to detect either antibodies or antigens that

Table 4. Common laboratory results in meningitis in children and adults a

Clinical status

WBCs (cells/µl)

Predominant cell type

are specific for some viruses (10,65). The latex slide agglutination test for C. neoformans antigen shows moderate to high sensitiv- ity (60% to 99%) and specificity (80% to 99%). In addition, the antigen titer serves as a good prognostic indicator (65). However, CSF serology for detection of bacterial antigens is not widely used because it has lower sensitivity and specificity than Gram stain and culture (3,10,65).

Molecular methods and applications

Molecular assays have become widely applied in the microbiol- ogy field as diagnostic and research tools. Molecular techniques

are used for confirmatory diagnosis and have been gradually introduced for routine primary diagnosis of viral meningitis (10). Nucleic acid assays, mainly PCR and its variants, have been used

in diagnosis involving direct detection of microorganisms in CSF

specimens, confirmation of bacteria and viruses grown in culture media and cell lines, genotyping of viruses beyond identification for molecular epidemiology and phylogenetic purposes, and iden- tification of antimicrobial resistance for certain bacteria.

Molecular methods shorten diagnosis time (up to 4 hours) and have increased specificity and sensitivity of diagnosis. Addition- ally, they solve the discrepancy problems in suspected patients who show culture-negative results. These combined characteristics pro- vide advantages for PCR over any other laboratory test (10,23). Reverse transcription (RT)-PCR targeting the 5' non-translated region (NTR) of the enteroviral genome, which is the most con- served genomic region, is essential for enteroviral-meningitis diag- nosis and delivers results in as little as 5 hours, thereby shortening inpatient hospital stays and minimizing the unnecessary use of empirical antimicrobial agents. In comparison with cell line cul- ture, RT-PCR sensitivity and specificity in CSF are 85 to 100% and 90 to 100%, respectively. PCR for HSV-2 DNA is usually positive in the CSF of patients with initial episodes of meningi- tis. PCR is also is positive in approximately 80% of patients with benign recurrent meningitis caused by lymphocytic choriomen- ingitis virus (2,18).

A systematic review and meta-analysis study was performed to

evaluate the accuracy of broad-range 16S rRNA PCR in the diag- nosis of bacterial meningitis. The study judged the benefit of PCR for diagnosis in emergency departments (68). Fourteen articles were analyzed, in which 488/2,780 CSF samples were proven to

Glucose (mg/dl)

Protein (mg/dl)

Normal

0-5

None

45-100

15-50

Bacterial meningitis

>1,000

Neutrophils; lymphocytes in early infection

<40

>100

Tuberculosis-meningitis

100-500

Lymphocytes, monocytes

≤40

>50

Viral meningitis

5-500

Lymphocytes

Normal

50-150

Fungal meningitis

5-500

All differential cells

≤40

>100

Parasitic meningitis

2-200

Eosinophils, neutrophils

≤40

>50

a Modified from references 2, 10, and 65.

be culture positive. Pooled analysis showed a sensitivity of 92% (95% confidence interval [CI], 75 to 98%), a specificity of 94%

(95% CI, 90 to 97%), a positive likelihood ratio of 16.26 (95% CI,

9.07

to 29.14), and a negative likelihood ratio of 0.09 (95% CI,

0.03

to 0.28). PCR also amplified 30% of culture-negative cases

(68). Many recent studies applied and evaluated various PCR- based methods, showed their utility, and compared them with other detection methods to investigate for common meningitis infectious agents, but they are beyond the scope of this review.

Recently, molecular typing approaches to enteroviruses targeting the VP1 region of the enteroviral genome that encodes serotype- specific neutralization epitopes have been successfully applied during enteroviral-meningitis outbreak investigations in many countries worldwide (18,23,24,25,27,33,34,44,47). They have provided details of enteroviral molecular phylogeny that help us to understand its association with specific disease manifestations and possible clonal geographical clustering (34) (Table 2).

Therapeutic Management

The ideal antibiotic for CNS infection would be inexpensive and would cover a broad range of gram-positive and -negative bacteria (13). If the infecting organism is observed on examination of the Gram-stained smear of the CSF sediment collected from a patient with suspected bacterial meningitis, specific therapy is initiated; otherwise, empirical antimicrobial therapy should be initiated. Prompt treatment of bacterial meningitis usually results in rapid recovery of neurologic function.

Bacterial meningitis is treated using various antibacterial families such as beta-lactams, cephalosporins, aminoglycosides, fluoro- quinolones, and other drugs, like trimethoprim-sulfamethoxazole and vancomycin; the type of antibiotic, its dose and duration, and whether to combine it with other antibiotics are all decided by the physician according to the causative agent, patient’s age, and other clinical considerations.

Effective vaccines are now available for many subtypes of H. influ- enzae type b, meningococcal serogroups (A, C, Y, and W-135),

S. pneumoniae, M. tuberculosis, and S. agalactiae (2). Adherence to

recommended vaccination schedules substantially reduces menin- gitis from each of those organisms. Previous studies indicated that

five bacteria, namely, H. influenzae, N. meningitidis, S. pneumoniae,

L. monocytogenes, and S. agalactiae, accounted for almost 80% of

cases of meningitis. However, upon the introduction of conjugate vaccines, substantial reduction in the prevalence of cases due to these five pathogens was achieved (59,69). Another study reported a 31% decline in the incidence of bacterial meningitis during the surveillance periods 1998-1999 and 2006-2007 (11).

Most viral-meningitis cases are self-limited, but some cause chronic or recurrent illness. Treatment of acute viral meningitis is directed at relief of symptoms, supportive care, and preven- tion and management of complications. Full recovery from viral meningitis usually occurs within 1 to 2 weeks of onset, although some patients describe persistence of fatigue, lightheadedness,

and asthenia for months. Introduction of mumps vaccine reduces aseptic meningitis due to mumps virus.

No approved antiviral chemotherapy is available for enterovi- ral meningitis. Intravenous acyclovir is used to treat hospital- ized, symptomatic patients with HSV-2 meningitis. In patients with frequent recurrences of HSV meningitis, it is reasonable to attempt prophylaxis with oral antivirals: valacyclovir, famciclovir, or acyclovir (2). For patients with cryptococcal CNS infection, amphotericin B plus flucytosine, followed by fluconazole, is the ideal treatment. Most experiences with therapy of Candida men- ingitis have been with amphotericin B, often in combination with flucytosine because of the latter agent’s ability to penetrate the blood brain barrier (70).

For patients with cryptococcal CNS infection, amphotericin B plus flucytosine, followed by fluconazole, is the ideal treatment. Most experiences with therapy of Candida meningitis have been with amphotericin B, often in combination with flucytosine because of the latter agent’s ability to penetrate the blood brain barrier (70). Many cases of fungal meningitis and meningioencephalitis are fatal because of the course of the disease, the considerable toxic effects of amphotericin B, and other anti-fungals, such as miconazole, ketoconazole, and flucytosine (2,18).

Conclusion

Infectious meningitis is a large public health concern. Continu- ous diagnosis improvement is necessary to minimize disease mor- tality and life-threatening complications. Continued updates to describe prevalence and expanded reporting of outbreaks will help to evaluate vaccination outcomes and impact. Viral genotyping in outbreaks provides a clearer picture for virus epidemiology and geographical distribution and helps predict the emergence of new strains by phylogenetic studies.

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