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BackgroundGram stain of cerebrospinal fluid (CSF) is widely used in the diagnosis of acute meningitis, however, it is often conducted in the laboratory, as only some hospitals have access to point-of-care Gram stain (PCGS). The purpose of this study was to demonstrate the clinical impact and utility of PCGS in diagnosing and treating both bacterial and aseptic meningitis in adults.MethodsThis was a hospital-based, retrospective observational study at a referral center in Okinawa, Japan. We reviewed the records of all patients aged 15 years or older who were admitted to the Division of Infectious Diseases between 1995 and 2015 and finally diagnosed with bacterial (n = 34) or aseptic meningitis (n = 97). For bacterial meningitis, we compared the treatments that were actually selected based on PCGS with simulated treatments that would have been based on the Japanese guidelines. For aseptic meningitis, we compared the rates of antibiotic use between real cases where PCGS was available and real cases where it was not.ResultsPCGS was the most precise predictor for differentiating between bacterial and aseptic meningitis (sensitivity 91.2%, specificity 98.9%), being superior in this regard to medical histories, vital signs and physical examinations, and laboratory data available in the emergency room (ER). In bacterial meningitis, PCGS reduced the frequency of meropenem use (1/34 = 3.0%) compared with simulated cases in which PCGS was not available (19/34 = 55.9%) (pp = 0.006).ConclusionsPCGS of CSF distinguishes between bacterial and aseptic meningitis more accurately than other predictors available in the ER. Patients with bacterial meningitis are more likely to receive narrower-spectrum antimicrobials when PCGS is used than when it is not. PCGS of CSF thus can potentially suppress the empiric use of antimicrobials for aseptic meningitis.

Over the past 20 years there has been growing awareness of community-acquired primary liver abscess caused by strains ofKlebsiella pneumoniae(K. pneumoniae) especially in patients of Asian descent, a minority of which are characterized by metastatic spread. A common and frequent destructive complication is endophthalmitis as well as the involvement of the central nervous system (CNS), causing suppurative meningitis or brain abscess. Here we report a case of invasive liver abscess caused byK. pneumoniaein an Asian patient who presented to our hospital in Tanzania with bilateral lower limb swelling for 6 weeks with acute onset of difficulty in breathing.

This report describes a suppurative meningitis in a young cynomolgus. The animal had neutrophil aggregation in the subarachnoid space and hemorrhage in bilateral adrenal glands. Staphylococcus was identified by FISH in brain. To our knowledge, this is the first case of staphylococcal meningitis with Waterhouse-Friderichsen syndrome in a cynomolgus monkey.

Community-acquired Enterobacteriaceae infection and culture-negative meningitis are rare and atypical subtypes of meningitis in adults. Of 37 patients who had atypical suppurative meningitis during 1993–2015 in Okinawa, Japan, 54.5% had strongyloidiasis, of which 9.1% cases were hyperinfections and 3.0% dissemination. Strongyloidiasis should be considered an underlying cause of atypical suppurative meningitis.

This study describes suppurative infectious diseases of the central nervous system (CNS) in domestic ruminants of southern Brazil. Reports from 3.274 cattle, 596 sheep and 391 goats were reviewed, of which 219 cattle, 21 sheep and 7 goats were diagnosed with central nervous system inflammatory diseases. Suppurative infectious diseases of the CNS corresponded to 54 cases (28 cattle, 19 sheep and 7 goats). The conditions observed consisted of listerial meningoencephalitis (8 sheep, 5 goats and 4 cattle), suppurative leptomeningitis and meningoencephalitis (14 cattle, 2 goats and 1 sheep), cerebral (6 cattle and 2 sheep), and spinal cord (7 sheep) abscesses, and basilar empyema (4 cattle and 1 sheep). Bacterial culture identified Listeria monocytogenes (9/54 cases), Escherichia coli (7/54 cases), Trueperella pyogenes (6/54 cases) and Proteus mirabilis (1/54 cases). All cases diagnosed as listeriosis through histopathology yielded positive immunostaining on immunohistochemistry, while 12/17 of the cases of suppurative leptomeningitis and meningoencephalitis presented positive immunostaining for Escherichia coli. Meningoencephalitis by L. monocytogenes was the main neurological disease in sheep and goats, followed by spinal cord abscesses in sheep. In cattle, leptomeningitis and suppurative meningoencephalitis was the most frequent neurological disease for the species, and E. coli was the main cause of these lesions. Basilar empyema, mainly diagnosed in cattle, is related to traumatic injuries, mainly in the nasal cavity, and the main etiologic agent was T. pyogenes. RESUMO: Neste trabalho são descritas as doenças neurológicas infecciosas supurativas de ruminantes domésticos na Região Sul do Brasil. Foram avaliados laudos de 3.274 bovinos, 596 ovinos e 391 caprinos, dos quais 219 bovinos, 21 ovinos e sete caprinos foram diagnosticados como doenças inflamatórias no sistema nervoso central. As doenças neurológicas infecciosas supurativas corresponderam a 54 casos (28 bovinos, 19 ovinos e sete caprinos). As enfermidades observadas foram meningoencefalite por Listeria monocytogenes (oito ovinos, cinco caprinos e quatro bovinos), leptomeningite e meningoencefalite supurativa (14 bovinos, dois caprinos e um ovino), abscessos cerebrais (seis bovinos e dois ovinos) e medulares (sete ovinos); e empiema basilar (quatro bovinos e um ovino). Através do isolamento bacteriano foram identificados: L. monocytogenes (9/54 casos), Echerichia coli (7/54 casos), Trueperella pyogenes (6/54 casos) e Proteus mirabilis (1/54 casos). Todos os casos diagnosticados como listeriose por histologia foram positivos na imuno-histoquímica para L. monocytogenes, e 12/17 casos de leptomeningite e meningoencefalite supurativa foram positivos na imuno-histoquímica para E. coli. A meningoencefalite por L. monocytogenes representou a principal enfermidade neurológica em ovinos e caprinos, seguido dos abscessos medulares em ovinos. A leptomeningite e meningoencefalite supurativa foi a doença neurológica supurativa mais frequente em bovinos e o principal agente causador da lesão foi E. coli. O empiema basilar, frequentemente, diagnosticado em bovinos, foi relacionado com lesões traumáticas, principalmente, de cavidade nasal e o principal agente causador foi T. pyogenes.

Pneumocephalous is characterised by presence of air or gas in the cranial cavity and the majority of cases occurs secondary to a mechanical trauma to skull or neurosurgical intervention. Bacterial meningitis due to Escherichia coli is an extremely uncommon cause of extensive pneumocephalous in a

In addition to listeriosis which is relatively common in ruminants, there are three other uncommon suppurative intracranial processes (SIP) identifiable in adult ungulates as brain abscess, basilar empyema and suppurative meningitis. The present paper reports the epidemiological, clinical, laboratorial, pathological and microbiological findings of 15 domestic ruminants with SIP. A total of 15 animals were selected (eight sheep, four cattle and three goats); with the definitive diagnoses of basilar empyema (n=3), brain abscess (n=1), listeriosis (n=5) and suppurative meningitis (n=6). Hematology revealed leukocytosis with inversion of the lymphocyte/ neutrophil ratio in 4 cases. In the majority of animals, cerebrospinal fluid (CSF) presented light yellow coloration and cloudy aspect due to neutrophilic pleocytosis (15 - 997 leukocytes/µL). Microbiological culture of CSF or central nervous system (CNS) fragments resulted on isolation of Trueperella (Arcanobacterium) pyogenes,Listeria monocytogenes,Escherichia coli and Stenotrophomonas sp. In a goat with thalamic abscess, microbiological assay was not performed, but Gram positive bacilli type bacteria were observed in histology. The diagnosis of these outbreaks was based on the association of epidemiological, clinical, pathological and bacteriological findings; reiterating that the infectious component remains an important cause of CNS disease in domestic ruminants and also shows the need for dissemination of information about the most effective preventive measures for the ranchers. Além da listeriose, que é relativamente comum em ruminantes, existem outros três processos supurativos intracranianos (PSI) identificáveis em ungulados adultos, que não são comuns, como: abscesso cerebral, empiema basilar e meningite supurativa. O presente trabalho tem como objetivo relatar os achados epidemiológicos, clínicos, laboratoriais, patológicos e microbiológicos de 15 ruminantes domésticos com PSI. O total de 15 animais foi selecionado (oito ovinos, quatro bovinos e três caprinos), com o diagnóstico definitivo de empiema basilar (n=3), abscesso cerebral (n=1), listeriose (n=5) e meningite supurativa (n=6). A hematologia revelou leucocitose com inversão da relação linfócito/ neutrófilo em quatro animais. Na maioria dos animais, a análise do líquido cefalorraquidiano (LCR) revelou coloração amarelado clara e aspecto turvo devido à pleocitose neutrofílica (15 - 997 leucócitos/µL). A cultura microbiológica de LCR ou de fragmentos do sistema nervoso central (SNC), permitiu o isolamento de Trueperella (Arcanobacterium) pyogenes,Listeria monocytogenes,Escherichia coli e Stenotrophomonas sp. No caprino com abscesso de tálamo, a cultura microbiológica não foi realizada, mas bactérias Gram positivas tipo bacilos foram observadas na histologia. O diagnóstico desses surtos foi baseado na associação dos achados epidemiológicos, clínicos, patológicos e bacteriológicos; reiterando que o componente infeccioso continua sendo uma causa importante de doença do SNC em ruminantes domésticos e também mostra a necessidade de disseminação da informação sobre as medidas preventivas mais eficazes para os criadores.

Background: Suppurative meningitis (SM) or bacterial meningitis is a life-threatening condition, which is exceptionally due to pituitary tumors (PT). Our aim was to analyze its frequency among male macroprolactinomas (MPRL) deemed to be aggressive, to report the cases we observed in our practice and describe the circumstances under which SM appeared. Materials and Methods: We retrospectively analyzed 82 male MPRL in order to look for a history of well proved SM and the circumstances under which SM appeared. We also took into account the possibility of SM relapsing. Results: Four out of 82 male MPRL had SM = 4.87%. Three consulted for SM symptoms. SM was confirmed in Infectious Diseases department, but only one had rhinorrhea. Hormonal assessment and cerebral magnetic resonance imaging pleaded for aggressive prolactinomas. After antibiotics, SM was sterilized. Then, MPRL were treated with bromocriptine, which normalized prolactin and reduced PT. SM never relapsed. The 4 th case was hospitalized for a large multidirectional prolactinoma invading and/or arising from the skull base. He was operated on 3 times and then he was given Bromocriptine. After 3 months, he had rhinorrhea and then SM which was successfully treated by antibiotics. SM never relapsed after tumor reduction. Conclusion: SM was demonstrated in 4.87%. SM has revealed MPRL in 3 cases and appeared after bromocriptine intake in the 4 th one. Endocrinologists should be aware of this severe condition, which can be avoided by repairing as soon as possible the bony defect secondary to aggressive tumors, unless it is clogged by fibrosis: What probably happened in our cases.

発熱が遷延し治療に難渋した化膿性髄膜炎の1歳男児例について報告する．症例は1歳，男児．近医にて上気道炎と診断された後，発熱・嘔吐があり当院受診した．一旦帰宅するも倦怠感増強し入院となった．髄膜刺激徴候は明らかではなかったが，全身状態の悪化，炎症反応の増大があり髄液検査の結果，化膿性髄膜炎と診断した．DEX，CTRX，PAPM／BPにて治療を開始し，第6病日に痙攣出現したためPBを開始した．第10病日，発熱継続し薬剤熱を疑いCTRXのみ中止した．第13病日，痙攣発作の改善なくDZPを追加した．髄液検査で菌検出なく第15病日に抗生剤を終了した．第19病日にPBを，第23病日にすべての服薬を中止するも発熱は続いた．第35病日，血液，髄液検査では異常なかった．下痢を認め，便検査にてロタウィルス腸炎と診断した．以降，下痢，発熱も改善し第39病日に退院した．本例において発熱が遷延した原因について考察を行った．

Immune-mediated central nervous system inflammation is described in a series of 12 juvenile boxer dogs. A diagnosis of steroid-responsive meningitis-arteritis was made based on the clinical presentation and on diagnostic findings. The boxer breed was at a higher risk for this inflammatory condition than other breeds. Long-term follow-up (>2 years) confirmed a better prognosis in this breed than in the beagle and the Bernese mountain dog. Complete resolution of clinical signs without significant deficits or recurrences was obtained in all cases. Early clinical recognition and immunosuppressive treatment resulted in a better response and complete resolution of the disorder.

BACKGROUND Spontaneous disappearance of an arachnoid cyst is very rare, particularly after suppurative meningitis. CASE REPORT A 2-month-old boy with a high fever was diagnosed with suppurative meningitis by cerebrospinal fluid examination. Computed tomography disclosed a large arachnoid cyst in the left middle cranial fossa. Two months later, the meningitis was cured. The arachnoid cyst disappeared with long-term antibiotic therapy alone. CONCLUSION Although an infected arachnoid cyst may disappear with antibiotic treatment alone, careful observation and individualized patient management are essential.

Sepsis (S) and bacterial suppurative meningitis-meningoencephalitis (M-ME) are common causes of death in bovine neonates. The aim of this prospective study was to evaluate the prevalence of S and M-ME in critically ill neonatal Piedmontese calves. Critically ill animals up to 15 days old referred by practitioners were registered according to their status and subsequently assigned to clinical standardized score. Calves with a clinical score > = 5 were further assessed under a clinical and clinical-pathological protocol to strengthen the suspicion of S and M-ME. Critically ill neonatal calves sent for necropsy were included in the study as well. Fifty-nine calves were investigated, 26 of which referred alive and 33 dead. Ten out of the 26 clinically evaluated calves were classified as suspicious of S on the basis of the clinical and clinical-pathological protocols. S was confirmed by positive bacteriologic culture in 7 cases and in 3 cases on the basis of necroptic lesions. Concomitant suppurative M-ME suspected in 6 of these 10 calves was subsequently confirmed by CSF analysis or histological findings. Of the 33 calves examined only post-mortem, 20 showed pathognomonic findings of S and 14 signs of M-ME. The prevalence of S and M-ME was 46 and 36 %, respectively. Clinical signs of S were confirmed to be vague and overlapping with other diseases. The developed protocol was highly accurate in predicting S in these neonatal calves.

The article by Haring et al 1 in the January issue of theArchiveswas rather shocking in my opinion. It could have as well read "And by the way, we put all our meningitis patients on full-dose heparin, doesn't everybody?" They then conclude that the heparinization was one strategy "that seemed to account for the favorable outcomes in our patients." 1 They cannot conclude that on the basis of any data presented in their article. The use of heparin to prevent stroke in suppurative meningitis must, certainly, be characterized as experimental. The article gave the most cursory discussion to the rationale for this therapy. Practitioners would be quite wrong, in my opinion, to draw the conclusion from this article that it is a reasonable "empirical" therapy in bacterial meningitis to prevent stroke. Bacterial meningitis most often occurs in the setting of an associated systemic sepsis. The risks of heparinization

A 57-year-old patient with nasopharyngeal carcinoma was treated with interferons, anti-cancer drugs and irradiation.He developed suppurative meningitis three years after the diagnosis and died from acute respiratory insufficiency. At autopsy edema of the left cerebral hemisphere was marked and uncal and cingular herniation were noted.Undifferentiated cancer cells were found in the left posterior wall of the sphenoid and left pyramidal bones, but there was no infiltration of cancer cells to the optic nerves or pituitary. The route of both bacterial infection infiltration of cancerous cells was considered to be via the foramen lacerum.

SummaryTwo patients with a rare localization of Salmonella typhi murium infection are presented : the first one, an adult with leukaemia had a pneumonia or a bronchopneumonia; the second one, a four months old girl, had a suppurative meningitis.

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Dr. Heath has carefully analyzed a large number of cases of meningococcic meningitis and shown the frequency of the different ocular sequelae. All I can add is a comparison between the lesions of this disease and those of suppurative meningitis of aural or nasal origin. Taking his findings as a basis, I am going to suggest that physicians attempt to prevent the ocular sequelae of meningococcic meningitis by treating the various lesions causing the ocular disturbance at the site of the embolic infarction in a manner similar to that now employed in the treatment of suppurative meningitis. In dissecting injected heads, 1 I noticed several anatomic facts to which my attention had never before been directed. All have been of assistance to me in the early diagnosis and treatment, as well as in arriving at an understanding of the sequelae, of any form of meningitis. A (a) sensory cranial

Otitic meningitis, an infection of the cerebrospinal fluid system, is comparable to otitic sepsis, an infection of the blood stream. Nature attempts in both conditions to localize the infection by erecting protective barriers which tend to limit the bacteria to the area of initial involvement. Finally, when nature unaided is insufficient to prevent a general invasion, the bacteria circulate freely in the blood stream or in the cerebrospinal fluid system. This results in general sepsis, with a noticeable reduction in the number of recoveries, or in suppurative meningitis, with few recoveries. Here the end result widens the comparison tremendously and gives significance to the need of adopting toward otitic suppurative meningitis a definite surgical attitude, similar in principle to that generally taken toward otitic sepsis. Formerly, when meningitis occurred during otitic infection, there was often undue delay before the primary focus was eliminated. Now the mastoid infection is exenterated as

Intracranial involvement, complicating otitis media, is especially likely to prove fatal to patients who have a turbid spinal fluid, papilledema or definite bradycardia. Karbowski 1 refers to seventeen cases of meningitis of otitic origin; of these, four patients who had a clear spinal fluid recovered, while all but one of the thirteen who had a cloudy fluid died. Papilledema occurs in about 44 per cent of patients with an otitic meningitis; in White's 2 experience this indicated a fatal prognosis. Likewise complication with bradycardia gives a bad prognosis. 3 Otitic meningitis, a bacterial meningitis with a cloudy spinal fluid, is described by Wharry, 4 who called it meningitis maligna; he states that only 2 or 3 per cent of these patients have been known to recover, and that the disease in those who recovered was of a staphylococcic origin. The patient whose case I report recovered, although most of

Uranin solution (10%) was injected in four cases of otogenic suppurative meningitis, and two or three hours after the injection, content of uranin in the spinal liquid was measured by fluors- cope comparing the fluid with the standard solution in the light of ultra-violet (3600A) ray. The results of the examination were analysed in codsideration with other clinical findings and conclusions were as follows. 1.In case of healthy man, content of uranin in the spinal liquid was less than 10r/dl three hours after the intramuscular injection of 10% uranin solution in doses of 0.3cc per 1 kilogram body weight. 2.In case of otogenic suppurative meningitis, content of uranin was 60∼100r/dl while the disease was progressive, and the contents decreased when the patient had the tendency to recover, and at last when the content showed 10∼20r/dl, it was observed that the patient recovered with- out giving further medication. Then it could be concluded that when the content arrived at the level of 10∼20r/dl, the infl- ammation of meninges diminished and it was not necessary to give any medicament. 3.The uranin content was paralleled with the grade of globulin reaction of the fluid, but no relation between uranin content and the spinal pressure or number of cells in the fluid was observed. 4.It could be concluded that the measurement of uranin in the spinal fluid was valuable to establish diagnosis and prognosis of suppurative meningitis.

During the past few years, 367 persons with suppurative meningitis originating from the ear or nose were admitted at the Newark Eye and Ear Infirmary and the Newark City Hospital. Two hundred and thirteen patients were operated on; of these, 145 died, 68 recovered (about 32 per cent), and 105 autopsies were performed.1 This report is an attempt to summarize this experience and to add what knowledge has been acquired since my last reports.2Its chief value lies in the surgical information obtained from the autopsies, each autopsy having been conducted to ascertain (a) the particular lesion present, (b) what had been accomplished by the treatment and (c) whether further or different surgical measures might not have resulted in the patient's recovery. SUBARACHNOID SPACE MENINGITIS VERSUS MENINGITIS SECONDARY TO PHLEBITIS OF ARACHNOID VESSELS Surgically, there are two types of meningitis, depending on (a) the mode of entrance into

In theARCHIVES OFOTOLARYNGOLOGY 1 for January 1935 a paper was published entitled "Reinfection of the Wound Following Mastoidectomy." The third case which was reported in that paper has given rise to discussion. I have claimed and still believe that this was a case of meningitis sympathica. Dr. Samuel J. Kopetzky believes that the case was one of acute suppurative meningitis with recovery. Because of the divergence of opinion, Dr. Kopetzky has requested that the history of the case be given in detail, and since there is so marked a controversy I believe that this should be done. The details were omitted in the original paper, as the object was not to report either meningitis or meningitis sympathica but to discuss reinfection after mastoidectomy. In the present communication it is my intention not to argue the question but to give the various clinical details which were not mentioned

A survey of current literature reveals a significant reduction in the incidence of otogenic complications. 2 This is universally attributed to the use of antibiotic and chemotherapeutic agents. 3,5,9,11,12 The purpose of this paper is to call attention to the fact that the problem of otitic meningitis in this antibiotic era has not fully been solved. This is particularly true in infants and young children. The mortality rate still remains high in this age group. Successful conduct of suppurative meningitis requires a concerted effort of both the public and the practitioners of medicine. The public must be conditioned to seek medical aid promptly. The key to an early diagnosis is in the hands of the general practitioners and pediatricians. They are likely to see the child with meningeal symptoms first. They must be ever meningitis conscious. However, the otologist must share his responsibility in order to reduce this high incidence

The complication of the gravest importance which concerns the otologist is probably the invasion of the subarachnoid spaces by infecting organisms and the subsequent progressive suppurative meningitis. It is a disease of such serious consequences that any light, no matter how small, which might be shed on it may be welcomed, with the hope of a clearer illumination in the future. At best, the mortality in all varieties of septic meningitis is excessively high. It will run well over 90 per cent, and in many forms will probably be more than 95 per cent. In 1921, Eagleton 1 was able to collect reports of cure in only thirty cases of purulent meningitis following operation. It is true acute suppurative meningitis with the infecting organisms proliferating and elaborating their toxins in the subarachnoid space that demands one's attention. The lethal effects of this invasion are due to three distinct and yet

Retrospective studies of the case histories of 237 children suffering from bacterial meningitis at the department of pediatrics, university of Graz, show the significant difference between cured, deceased and children with permanent sequels. The risk factors for the fatal outcome of meningitis were: age (less than 1 year), bacteria (pneumococcus), concomitant disease (pneumonia), low initial white cell count in the blood (less than or equal to 5000/cmm) as well as in cerebrospinal fluid (less than or equal to 4000/cmm), high cerebrospinal fluid protein (greater than or equal to 336 mg%) and a high bacterial inoculum (greater than or equal to 10(7) CFU/cmm). With all these risk factors at the time of diagnosis of purulent meningitis the chance for recovery is poor.

Quantitative estimation of the immunoglobulins IgG, IgA and IgM in serum and CSF of 42 patients (25 had viral encephalitis and 17 had suppurative meningitis) and 20 controls were done using the single diffusion precipitation method.