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Joseph Junewick, MD FACR
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Hemophilus Influenza B Meningitis

Case Detail

Anatomy: Brain-Spine
Junewick
Joseph Junewick, MD FACR
Diagnostic Category: Infectious-Inflammatory
Created: over 5 years ago
Updated: over 5 years ago
Tags: PEDS
Modality/Study Types: MR
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History

6 month male with seizure.


Case Images


Diagnosis

Hemophilus Influenza B Meningitis

Findings

MR – Intense leptomeningeal enhancement on post-gadolinium images with intraventricular debris-fluid level on DWI and post-gadolinium images.

Discussion

Bacterial meningitis is an important diagnosis in the pediatric population as death occurs in approximately 5% of cases and significant morbidity in up to 30% of patients. Among neonates, it is estimated that there are 0.2-0.5 cases per 1000 term newborns and 1.4-2.3 cases per 1000 preterm newborns. Beyond the newborn period, the incidence is approximately 0.1-6.6 cases per 100,000 population. The most common signs and symptoms of bacterial meningitis in the neonate include poor feeding, respiratory distress, bulging fontanel, apnea and seizures while older children generally experience symptoms of fever, headache, photophobia and stiff neck. Potential complications of bacterial meningitis in the pediatric population can be devastating and include SIADH, cranial neuropathies, deafness and venous and arterial strokes.

Risk factors in the neonate include premature rupture of membranes, maternal delivery, traumatic delivery, prematurity and disturbance in humoral or cell-mediated immunity. In patients greater than 1 month of age, diabetes mellitus, sickle cell disease, Cushing syndrome and complement depleting diseases comprise the most common risk factors. Typical organisms implicated in pyogenic meningitis in the neonate are Group B streptococcus, Escherichia coli, and Enterobacteriaceae, with Streptococcus pneumonia, Neisseria meningitides and Haemophilus influenza-although vaccination programs have markedly decreased the incidence of this latter organism-more common in patients older than 1 month. Typical routes of infection include hematogenous spread to the meninges and choroid plexus, from contiguous infections in the paranasal sinuses or mastoid air cells and penetrating trauma. Congenital malformations of the neural tube have also been recognized to provide a portal of infection.

While meningitis is primarily a clinical-laboratory diagnosis, recognizing the imaging characteristics of bacterial meningitis and its associated neurologic complications is crucial. In general, neuroimaging studies are indicated if the diagnosis is unclear or if there are clinical findings of increased intracranial pressure or neurologic deterioration. Noncontrast CT may be normal, but increased attenuation in the basilar cisterns or sylvian fissures due to inflammatory debris, ventricular dilatation secondary to hydrocephalus, subarachnoid space enlargement or a subdural effusion may be seen. Contrast enhanced CT findings include variable meningeal enhancement and an empty delta sign if cortical venous thrombosis extends to the dural sinuses. MR of the brain with contrast and including DWI is invaluable, and indeed, more sensitive, for detecting infarction, subdural empyema or abscess formation.

Reference

Chavez-Bueno S et al: Bacterial meningitis in children. Pediatr Clin North Am. 52(3): 795-810, vii, 2005.

Jan W et al: Diffusion-weighted imaging in acute bacterial meningitis in infancy. Neuroradiology. 45(9): 634-9, 2003.

Saez-Llorens X et al: Bacterial meningitis in children. Lancet. 361(9375): 2139-48, 2003.

Contributor

Zagum Bhatti, MD



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