Introduction

Neonatal meningitis (NM) is a devastating disease known for more than a century. The first publications highlighted its clinical rarity and cumbersome diagnostic process 1,2. However, over time it has been reported on all continents, and despite scientific and technological advances, it continues to be a public health problem 3. The incidence varies considerably. In developed countries, it is estimated around 0.3 cases per thousand live births; while, in developing countries this incidence can reach up to 6.1 cases per thousand live births3. With new methods, detection has improved and mortality has decreased; However, morbidity remains high (20-60%) 4.

NM is classified as early and late 5. Early NM begins within the first 72 hours and is related to contamination through the birth canal with bacteria such as Escherichia coli, Streptococcus group B and Listeria monocytogenes9,10. After 72 hours, late MN is related to germs from the hospital environment, such as coagulase-negative Staphylococcus and gram-negative bacilli (Escherichia coli, Klebsiella pneumoniae, Enterobacter spp.) 5.

MN constitutes a health emergency, and as soon as it is suspected, empirical antibiotic treatment should be indicated 12. However, the diagnosis is complex due to the low specificity of the signs and symptoms and the difficulty in isolating the germs by culture, leaving it as The only recourse is clinical suspicion in the presence of risk factors 5

Given the scarce information on MN in our country, such as its frequency, impact on morbidity and mortality and the prevalence of the pathogens involved, it is of utmost importance to know the epidemiological and clinical profile of the disease. For this reason, the objective of the study was to estimate the incidence, associated factors, clinical and cerebrospinal fluid (CSF) characteristics, etiology and complications of MN.

Clinical Case

A 20-day-old male newborn, the result of the first pregnancy of a 19-year-old mother, was born by cesarean section indicated for suspected macrostomia at 38 weeks without complications and spontaneous neonatal adaptation, Silverman Anderson with a score of 0 without signs of respiratory distress, with a complete negative STORCH, admitted to a second level hospital (Pitalito – Huila) in the arms of his mother who reported a clinical picture of 24 hours of evolution characterized by unquantified feverish peaks associated with easy crying and loss of appetite, he repeatedly denied diarrhea, cough, rhinorrhea, rash and drowsiness, she was referred to a first level hospital due to persistence of fever, which they quantified up to 38.2 °C. Upon admission to this institution, a fever peak of 38.5° was documented. He denied close contact with patients with suspected and/or diagnosed COVID 19. He was admitted in acceptable general conditions, hemodynamically stable, febrile, dry mucous membranes, with clinical signs of SIRS, no evidence of SIRS. respiratory difficulty, oximetry appropriate to the environment, no signs of low output, no neurological focus. Paraclinical admission with low-risk blood count, clearly positive c-reactive protein, preserved kidney and liver function, non-prolonged coagulation times, normal blood glucose and electrolytes, non-pathological urinalysis, Gram negative, lumbar puncture procedure was performed without complications, finding cerebrospinal fluid pathological, with marked pleocytosis of neutrophilic predominance, severe hypoglycorrhachia and marked hyperproteinorrachia, GRAM, KOH, BK, Indian ink negative. Therefore, they are referred to our neonatal intensive care unit Clínica Uros for multidisciplinary management.

Patient is admitted in stable conditions hemodynamically compensated in cardiorespiratory sufficiency, with adequate pattern and saturations, from the hemodynamic point of view with adequate distal perfusion, looks pink, no signs of low output, differential blood pressure in the 4 normal extremities without requiring inotropic support at the time, At the gastro-intestinal level, she continues with breastfeeding, without distension or emesis, and adequate metabolic controls. At an infectious level, it looks bad, infected, for which studies are expanded in the context of a newborn presenting with acute febrile syndrome, with suspicion of late neonatal sepsis, due to clinical and laboratory findings, suspicion of bacterial meningitis, under antibiotic management If the diagnosis is suspected, an evaluation by pediatric infectious disease is requested. This is a patient in the course of late neonatal sepsis of meningeal focus, with documentation of meningitis due to meningococcus documented by nested PCR of meningitis performed in the clinical laboratory of the UROS clinic, presents a septic appearance in course, a meningitis form is filled out. HERPES TYPE 6 was also documented, for which treatment was started with acyclovir, it is very probable chromosomal passage without indication to start acyclovir, it was decided to suspend, given that his pleocytosis at the remission site was very important, a head CT scan was added while an MRI could be performed given that the possibility of empyema exists.

On neurological examination, active, with adequate response to stimuli, focal seizure was reported lasting more than 20 minutes with respiratory difficulty, cyanosis, oxygen was required under a nasal cannula, which was managed to be removed, impregnation with phenytoin was initiated, pediatric neurology evaluation was requested, patient was referred with high neurological risk due to meningitis and neonatal crisis, with neurological examination with deficit for gestational age, positive suction for gestational age, with simple head CT without pathological alterations, who due to paroxysmal crisis is started on management with AED, currently without new visible seizures , with 12-hour telemetry that shows pathological activity, due to this finding, anti-seizure management is appropriate, with simple brain MRI that shows occupation of the occipital horns of the lateral ventricles that presents restriction in diffusion and there are also centers of restriction in the subarachnoid space in the frontal, temporal and left parietal convexities as well as the interhemispheric sulcus. Focal hyperintensity that presents diffusion restriction in the knee of the left internal capsule of 4 mm. Rest of the brain parenchyma with signal intensity appropriate for age. Central midline. Turkish chair with usual appearance. Normal sized ventricular system. Vascular structures with signal void. Opinion: The findings described are attributed to meningitis with ventriculitis and a small ischemic lesion in the internal capsule due to a probable vasculitic focus secondary to an infectious process. An evaluation by physiatry is requested, the rehabilitation process begins, at the time of antibiotic management, with an adequate response to treatment, it is expected to evaluate short, medium and long-term sequelae.

Table 1

Figure 1: Simple Brain Resonance Images

Simple brain MRI that evidences occupation of the occipital horns of the lateral ventricles that presents restriction in diffusion and there are also foci of restriction in the subarachnoid space in the frontal, temporal and left parietal convexities, as well as the interhemispheric sulcus. Focal hyperintensity that presents diffusion restriction in the knee of the left internal capsule of 4 mm. Rest of the brain parenchyma with signal intensity appropriate for age. Central midline. Turkish chair with usual appearance. Normal sized ventricular system. Vascular structures with signal void. Opinion: The findings described are attributed to meningitis with ventriculitis and small ischemic lesion in the internal capsule due to a probable vasculitic focus secondary to an infectious process.

Conclusions

The incidence of meningitis is higher in the neonatal period than in any other stage of life. An estimated incidence of 0.2-1 per 1000 live newborns is estimated. The mortality of neonatal meningitis continues to be high: between 10 and 30% Of those who survive, between 20-60% present sequelae

The late form of meningitis is more common than the vertical or early form

The most frequent microorganisms in the vertical meningitis group were gram positive, while in the late meningitis group they were gram negative.

The number of meningitis due to gram-positive and negative microorganisms was similar, although in the group of patients weighing less than 1500 g the percentage of meningitis due to gram-negative microorganisms was much higher.

HHV-6 causes various clinical symptoms, including severe symptoms with important neurological sequelae. This virus is inhibited by acyclovir only at probably toxic concentrations, so it is not considered as a treatment. Although HHV-6 becomes undetectable with ganciclovir at therapeutic doses, this unfortunately does not correlate with the resolution of neurological symptoms as in the case presented.

References

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3. Coto-Cotallo GD, López-Sastre JB, Fernández-Colomer B. Castrillo Hospital Group. Neonatal meningitis. Epidemiological study of the Castrillo Hospital Group. An Pediatr. 2002; 56(6): 556-563

4. Lewis G, Schweig M, Guillén-Pinto D, Rospigliosi ML. Neonatal meningitis in a general hospital in Lima, Peru, 2008 to 2015. Rev Peru Med Exp Salud Pública. 2017; 34(2): 233-238.

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