International Journal of Research in Medical Sciences

Mohanty N et al. Int J Res Med Sci. 2017 Jun;5(6):2519-2523

www.msjonline.org

pISSN 2320-6071 | eISSN 2320-6012

Original Research Article

DOI: http://dx.doi.org/10.18203/2320-6012.ijrms20172440

Etioclinical profile and outcome of acute bacterial meningitis in post neo natal U-5 children: a study from tertiary care center of coastal Odisha, India

Niranjan Mohanty1*, Tapan Kumar Biswas1, Smita Satapathy2, Shantanu Kumar Meher1, Debasis Patro1

1Department of Pediatrics, Maharaja Krushna Chandra Gajapati Medical College, Berhampur, Ganjam, Pin 760004, Odisha, India

2Senior Registrar in Pediatrics, Ispat General Hospital, Rourkela, Odisha, India

Received: 20 March 2017

Accepted: 19 April 2017

*Correspondence:

Dr. Niranjan Mohanty,

E-mail: mohantyniranjan84@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Acute bacterial meningitis (ABM) continues to remain an important cause of morbidity, mortality and handicap in children despite availability of wide range of antimicrobials. The microorganisms vary according to age, socio economic condition and geographical area along with other factors.

Methods: A prospective study was conducted over 2.5 years from October 2012 to April 2015 in the department of pediatrics, SVP Institute of Pediatrics, SCB Medical College, Cuttak, Odisha, India. Total 104 subjects were included after taking meticulous inclusion criteria.

Results: Out of 104 cases, majority (70.2%) were infants. 60.6% were male with M:F ratio 1.5:1. Fever was the commonest symptom in 69.2% followed by convulsion 61.5%, vomiting 36.5%, altered sensorium 33.7%. On examination 69.2% children were febrile, having bulging fontanelle in 34.6%, pneumonia 31.7%, positive meningeal sign 29.8%, cranial nerve palsies 14.4%, papilledema 12.5% and hemiplegia 11.5% cases. GCS were poor (<7) in 26.9% cases. 33.6% had high CSF cell count (>100/cumm). In 82 cases (78.8%) etiological agents were identified consisting of H. influenzae in 46.4%, S. pneumoniae in 36.6%, E. coli in 8.6% and others in 8.4%. CT scan of brain revealed brain edema in 29.4% followed by subdural effusion 19.6%, hydrocephalus 17.6% and infarction in 5.9%. 63.5% children were recovered completely. Mortality was 16.3% with sequelae in 20.2% cases.

Conclusions: Hib and Pneumococci were two most common organisms causing ABM in U-5 children with high mortality and sequelae which can be prevented by early diagnosis, optimum lab diagnostic facility and mass vaccination. There is urgent need to include Pneumococcal vaccine in NIP for substantial reduction of infant mortality.

Keywords: ABM, H. influenzae, Mortality, S. pneumoniae, Sequelae, U-5 children

INTRODUCTION

Acute bacterial meningitis (ABM) is an important preventable cause of U-5 child deaths and long term neurological sequelae specifically in developing countries with limited resources like ours.1 The community incidence of ABM in India varies from 0.5% to 2.6%.2 Despite the availability of a wide range of antibiotics, mortality rate remains significantly high in India and other developing countries, ranging from 16-32%.3 In a recent study it is stated that pneumonia and meningitis are responsible for 22% of U-5 deaths and Hib as the leading cause of purulent meningitis.4-8 The organisms associated with ABM are different in neonatal and older children group. They vary according to geographical area. But the prevalence of organisms in neonatal group are mainly Gr-B Streptococcus, E coli, Listeria and in older children are H. influenza, S. pneumoniae and N. meningitides.9 Immune suppressed conditions increase the risk of meningitis from less common pathogens viz. coagulase negative Staph aureus, Pseudomonas and Salmonella etc. The identification of causative organisms of ABM chiefly depends on the method used and standard of the laboratory. Acute complications and long-term sequelae of ABM are not infrequent. The rate of residual abnormality after meningitis ranges from 10-30%.1 The most distressing handicap are hearing and visual impairment, developmental delay, mental retardation and persistent seizure. The median risk of sequelae is quite high (approx. 25%) for both Hib and Pneumococcal meningitis.10 In this context it can be reiterated that though Hib vaccine has been incorporated in NIP of India, there is urgent need for inclusion of Pneumococcal vaccine for rapid reduction of U-5 mortality and handicap in children.

METHODS

A prospective study was done over a period of 2.5 years from October 2012 to April 2015 in the department of Pediatrics, SVPPGIP, SCB Medical College, Cuttack, Odisha, India. Total of 104 cases were selected after taking in view of the inclusion criteria. Further the cases were subjected to detailed clinical probing and lab investigations like CSF study and C/S, blood C/S, latex agglutination test and other appropriate test as required and the final data was analysed. CSF was tested for bacterial antigens by LPAT using Biorad Pastorex meningitis kit.

RESULTS

Out of 104 cases, 70.2% were infants and 29.8% were of age group 1-5 years and 60.6% were male and male: female ratio was 1.5:1 (Table 1).

Table 1: Age and sex wise distribution.
Table reproduced from source PDF page 2
Table 2: Clinical profile.
Table reproduced from source PDF page 2
Table 3: Distribution of isolated organism (n=82).
Table reproduced from source PDF page 2

Fever was the commonest symptom with total incidence of 69.2% followed by convulsion 61.5%, irritability 43.2%, vomiting 36.5% altered sensorium 33.7% and lethargy 33.7%. On examination 69.2% children were febrile. Bulging fontanelle were 34.6%, hepatomegaly 34.6%, splenomegaly 18.3%, pneumonia 31.7%, positive meningeal sign 29.8%, cranial nerve palsies 14.4%, papilledema 12.5% and hemiplegia 11.5%, GCS were poor (<7) in 26.9% cases (Table 2).

Table 4: CT scan of brain findings (n=51).
Table reproduced from source PDF page 3

In 82 cases (78.8%) etiological agent were identified and among them 46.4% were due to H. influenza, 36.6% S. pneumoniae, 8.6% due to E. coli and 8.4% were due to others (Table 3). CT scan brain was done in total 51 cases, among them brain edema was found in 29.4% followed by subdural effusion 19.6%, hydrocephalus 17.6% and 5.9% infarction (Table 4). In present study 63.5% children were recovered completely and 16.3% children died. 20.2% children had sequelae in the form of seizure disorder, deafness, cranial nerve palsy and behavioral disorder on one year follow up (Table 5). Out of total death, 82.4% was due to Hib and Pneumococcus with a higher case fatality rate of Pneumococcus 26.7% (Table 6).

Table 5: Outcome of the patients according to etiology.
Table reproduced from source PDF page 3
Table 6: Mortality related to Hib and Pneumococcus.
Table reproduced from source PDF page 3

DISCUSSION

In present study, out of 104 cases, 70.2% were infants and 29.8% were of age group 1-5 years. High incidence in infancy could be due to low immunity and rapid spread of haematogenous infection which were similar to the study by Kabra SK et al.2 In this study 60.6% were male, M:F ratio being 1.5:1. Male preponderance was also observed in studies by Bhat BV et al and Sahai S et al.11,12 Fever was the commonest symptom in 69.2% followed by convulsion 61.5%, irritability 43.2%, vomiting 36.5% altered sensorium 33.7% and lethargy 33.7% which can be comparable with studies by Bhat BV et al and Chinchankar N et al.3,11 Chinchankar N et al observed fever in 96% cases, refusal to feed in 83% cases, convulsion in 81% cases and altered sensorium in 96% cases, which were slightly higher than the observation in this study. Bulging fontanelle were 34.6%, positive meningeal sign 29.8%, cranial nerve palsies 14.4%, papilledema 12.5% and hemiplegia 11.5% cases. GCS were poor (<7) in 26.9% cases. Jain M et al had reported meningeal sign in 26% of cases and GCS<7 22% of cases which is similar to our observations.13 Majority of children had high CSF cell count 33.6%, high protein 56.7% and low sugar 68.3%. which was similar with a study by Devianayagam N et al.14

In present study 82 cases etiological agent were identified and among them 46.4% were due to H. influenza, 36.6% S. pneumoniae, 8.6% due to E. coli and 8.4% were due to others. Viswanath G et al also reported similar observations of Hib (22.5%) Pneumococcus (15%) and Staph. aureus in 10% cases.15 In the current study 51 patients out of 104 had undergone radiological evaluation, of which brain edema was found in 29.4% cases followed by subdural effusion 19.6% and hydrocephalus 17.6%. Arrumugham R et al documented normal sonographic findings in 36% cases of pyogenic meningitis, whereas ecogenic sulci 26%, ventriculomegaly 26%, brain abscess 18%, subdural effusion 10% and cerebral edema 10% were noted in other cases.16 Soni JP et al in their study had found that 35.4% patients had normal radiological findings, ventriculomegaly was present in 59%, subdural effusion in 2.2% and brain abscess in 2.2% cases.17 Both of their study findings were more or less similar to our observations.

In present study 63.5% children were recovered completely, case fatality rate (CFR) was 16.3% and 20.2% had sequelae. A study by Farag HFM et al, also found 78.2% children were fully recovered from meningitis and the case fatality rate was 13.9%.18 Another study by Singhi P et al19, observed occurrence of sequelae in 40% of his study population which was little bit higher from our study. The differences in mortality and sequelae depends on the level of health care facility and referral system. All the children who had infarction or hydrocephalus in radiological finding had severe sequelae.

CONCLUSION

Acute bacterial meningitis is found to be a significant cause of mortality and morbidity in this part of India like most other places. The infants were found to be most common victim with a higher case fatality rate, specifically from Hib and Pneumococcus which warrants mass vaccination against these two killer infections. Although clinical identification of ABM can be done by pediatrician and other trained primary care level doctors, the lab detection of organisms is not uniformly available. Latex agglutination test can be a quick and handy method at secondary health care level for an early diagnosis, treatment or referral whenever required. This process can go a long way to reduce mortality and handicap. Though Hib has been included in NIP, Pneumococcal vaccine need urgent inclusion to limit this preventable cause of U-5 mortality.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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