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ABSTRACT: We have previously developed and validated a prognostic model to predict the risk for unfavorable outcome in Dutch adults with bacterial meningitis. The aim of the current study was to validate this model in adults with bacterial meningitis from two developing countries, Vietnam and Malawi. Demographic and clinical characteristics of Vietnamese (n = 426), Malawian patients (n = 465) differed substantially from those of Dutch patients (n = 696). The Dutch model underestimated the risk of poor outcome in both Malawi and Vietnam. The discrimination of the original model (c-statistic [c] 0.84; 95% confidence interval 0.81 to 0.86) fell considerably when re-estimated in the Vietnam cohort (c = 0.70) or in the Malawian cohort (c = 0.68). Our validation study shows that new prognostic models have to be developed for these countries in a sufficiently large series of unselected patients.
PLoS ONE 01/2012; 7(3):e34311. · 4.09 Impact Factor
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ABSTRACT: To evaluate clinical features and prognostic factors of cerebral infarctions in adults with community-acquired bacterial meningitis.
An observational cross-sectional study, including 696 patients of whom 174 had cerebral infarction, from a prospective nationwide cohort of community-acquired bacterial meningitis (period, 1998-2002), confirmed by culture of cerebral spinal fluid (CSF) in patients aged over 16 years. Two investigators independently determined the presence of infarction.
Cerebral infarction occurred in 174 episodes (25%), with a high inter-rater agreement for determining the presence of cerebral infarction (kappa 0.95). Cerebral infarctions occurred in 128 of 352 patients (36%) with pneumococcal meningitis, in 22 of 257 (9%) with meningococcal meningitis and in 24 of 87 patients (28%) with meningitis caused by other bacteria. Patients with infarctions were older (P < 0.001) and often presented with predisposing conditions, such as otitis and/or sinusitis (P = 0.001) or an immunocompromised state (P = 0.003) compared to those without infarction. Patients with infarctions presented with lower scores on the Glasgow Coma Scale (P < 0.001), lower CSF white cell counts (P = 0.001), and higher serum erythrocyte sedimentation rate (ESR) (P < 0.001). Unfavorable outcome occurred in 108 (62%) patients with infarctions. In a multivariate analysis, infarction was related with unfavorable outcome (odds ratio 3.37; 95% confidence interval 2.19-5.21; P < 0.001). We identified lower CSF white cell counts and high ESR to be independent risk factors for cerebral infarction.
Cerebral infarction is a common and severe complication in adults with community-acquired bacterial meningitis. Preventing cerebral infarctions will be important in reducing the high morbidity and mortality rate in adults with community-acquired bacterial meningitis.
Neurocritical Care 10/2011; 16(3):421-7. · 2.47 Impact Factor
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ABSTRACT: There is a widely held belief that cerebral infarction after bacterial meningitis is always caused by vasculitis; however, evidence is weak. We hypothesized that diffuse cerebral intravascular coagulation is an additional explanation of cerebral infarction in patients with pneumococcal meningitis.
Sixteen brains of adults who died from pneumococcal meningitis were investigated. Clinical data were collected, and brain sections were scored for signs of inflammation and activation of coagulation. Patients with and without cerebral infarction on autopsy were compared.
In total, 38% of patients had focal neurological deficits. Patients died at a median of 7 days (range, 0-32 days) after admission. On autopsy, the nine patients (56%) with cerebral infarctions more often had arterial thrombosis (p = 0.04) than patients without infarction. Patients with infarction tended to have more inflammatory infiltrations of brain parenchyma, microvascular proliferation, small vessel vasculitis/endarteritis obliterans, blood clotting/vessel clogging, and venous thrombosis. None of the patients had large vessel vasculitis. Five patients had cerebral infarctions without vasculitis or endarteritis obliterans. Although four patients with cerebral infarctions had small vessel vasculitis or endarteritis obliterans, areas of infarction could not be localized to the blood flow distribution of these vessels. Blood clotting/vessel clogging was seen in all four patients with vasculitis or endarteritis obliterans, but this was also observed in 10 patients without vasculitis or endarteritis obliterans. None of the patients developed disseminated intravascular coagulation.
Our results suggest that diffuse cerebral intravascular coagulation is an additional explanation of cerebral infarction complicating pneumococcal meningitis.
Neurocritical Care 10/2010; 13(2):217-27. · 2.47 Impact Factor
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Neurology 07/2010; 75(2):193; author reply 193-4. · 8.31 Impact Factor
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ABSTRACT: Despite the availability of effective antibiotics, vaccination programmes and skilled acute-care facilities, there is still a significant mortality and morbidity from bacterial meningitis. Neurologists are often called on to "rule out bacterial meningitis", which can be difficult with the history and physical examination alone. In this review the authors will discuss the epidemiology, diagnosis and treatment of acute community-acquired bacterial meningitis in adults, focussing particularly on the management of patients with neurological complications, and stressing the importance of adjunctive dexamethasone.
Practical Neurology 03/2008; 8(1):8-23.
