Case Report
A term male baby born at 38 weeks gestation to a 26-year-old primi gravida mother by cesarean section was admitted on fifth day of life with seizures and jaundice. Antenatal period was normal with no history of fever or rupture of membranes. Baby was vigorous at birth, weighed 2800 grams and was breastfed. Bilirubin on third day of life was 16.4 mg/dL and baby received phototherapy. Baby had an episode of seizures on fourth day of life, controlled with phenobarbitone and was referred to our unit.
At admission, baby was febrile (101.90F), deeply icteric, sick looking and anterior fontanelle was full. Laboratory investigations showed haemoglobin of 12.5 gm/dL, leucopenia (WBC: 3200/mm3), thrombocytopenia (platelets: 1.1 lakhs/mm3) and positive septic screen (CRP: 65.4 mg/l). Bilirubin was 24.6 mg/dL with direct fraction of 1.2 mg/dL and there was evidence of haemolysis due to blood group incompatibility (baby’s group: B+; mother’s group: O+; reticulocyte count 12%; direct Coombs test positive). Baby was given intensive phototherapy, antibiotics (cefotaxime, amikacin) and ionotropic support. Head ultrasound at admission showed multiple cerebral abscesses in bilateral frontal and parietal lobes [Table/Fig-1]. Cerebrospinal Fluid (CSF) was turbid and showed 720 cells (neutrophils 90%; lymphocytes 10%), proteins 382 mg/dL and glucose 10 mg/dL (blood glucose: 64 mg/dL). Gram-stain showed Gram-negative intracellular diplococci.
Ultrasound brain at admission showing multiple cerebral abscesses
Double volume exchange transfusion was done at four hours after admission with fresh O+ whole blood. Baby had six episodes of seizures, controlled with phenobarbitone and phenytoin. Blood culture was negative. CSF culture grew N. meningitidis B which was sensitive to ceftriaxone, cefotaxime, meropenem and penicillin and resistant to ciprofloxacin. CSF analysis repeated after 48 hours showed 280 cells (neutrophils 80%; lymphocytes 20%), proteins 146 mg/dL and glucose 34 mg/dL. Serial head ultrasound scans (done twice weekly) showed multiple cerebral abscesses and mild ventricular dilatation [Table/Fig-2]. CT scan of brain done at three weeks of age showed mild hydrocephalus and few abscesses [Table/Fig-3]. Neurosurgeon’s consultation was taken and no surgical intervention was required till three weeks of age. Repeat cultures (blood and CSF) were sterile and baby received antibiotics (penicillin, cefotaxime) for three weeks. Head circumference remained static measuring 34 cm at discharge.
Ultrasound brain showing increase in number of abscesses.
CT scan brain at three weeks showing mild hydrocephalus and cerebral abscesses.
Unfortunately, mother and her family members were not screened for N. meningitidis before rifampicin prophylaxis was given. CT scan of brain repeated at five weeks of age showed hydrocephalus and a VP shunt was placed [Table/Fig-4]. Child is 18 months of age now, weighed 10.9 kg with height of 79 cm. Child has motor delay (truncal weakness and walking with support) without any recurrence of seizures. Child’s vision and hearing were normal.
CT scan brain done after placement of VP shunt.
Discussion
Neisseria meningitidis is a Gram-negative, aerobic, encapsulated intracellular diplococcus primarily transmitted by close contact with respiratory secretions but can colonize maternal genital tract leading to intrauterine infections. N. meningitidis causes significant morbidity and mortality in children but is uncommon in neonates, possibly due to transplacental transmission of maternal antibodies [1]. The incidence of neonatal meningococcal infection is estimated to be 2- 9/100,000 newborn infants in the developed world [1-4].
Both sporadic infections and wide spread epidemics of N. meningitidis were reported [5-8]. The route of transmission could be intrauterine or acquired during perinatal or postnatal period and is often difficult to ascertain [3,9-12].
Literature search of Pubmed, EMBASE, MEDLINE and Google scholar was done using the words: neonate, sepsis, N. meningitidis and meningitis. WHO bulletins and cross references of all articles were reviewed. Infants < 30 days of age and those reported as newborn or neonate were included in the review. Early and late onset infections were defined as development of symptoms during first 7 days of life and between 8 to 30 days of life respectively.
In our literature review, though we found 127 reported cases of infection (from 55 articles) with N. meningitidis in the neonatal period, we believe it may be an underestimate of the true burden of this infection [Table/Fig-5] [1-55]. Invasive meningococcal disease can have a fulminant course with fatality rates of 5%-20%. Infection was early in onset in 17.9% of cases (n=23 cases, from 16 citations) with mortality of 34.8% [1,2,5,6,10-14,17,24,30,35,43,46,51]. Two neonates in early onset group developed hydrocephalus [13,36]. Serogroups were reported in 13 cases: serogroup B being the most common with five cases, serogroup A-2 cases, serogroup C-3 cases, serogroup W135-2 cases and one case of serogroup Y.
Characteristics of neonates with meningitis caused by Neisseria meningitides [1-55].
| Author | Year | No. of cases | Age in days | Group | Complications | Outcome |
|---|
| Koplik H [13] | 1916 | 1 | 3 | ND | Hydrocephalus | Survived |
| Barron M [14] | 1916 | 1 | Newborn* | ND | - | Unknown |
| Miller DJM [15] | 1917 | 1 | 14 | ND | | Died |
| White TW [16] | 1917 | 1 | 29 | ND | - | Survived |
| Root JH [17] | 1921 | 1 | Newborn* | ND | | Died |
| Cooke JV [18] | 1922 | 1 | 17 | ND | | Died |
| Neal JB [19] | 1927 | 2 | 21, 21 | ND | | Both died |
| McLean S [20] | 1928 | 1 | 23 | ND | - | Unknown |
| Brown A [21] | 1933 | 1 | 22 | ND | - | Survived |
| Ravid JM [22] | 1935 | 1 | 27 | ND | - | Unknown |
| Garrow DH [23] | 1951 | 1 | 10 | ND | - | Died |
| Carmona EM[24] | 1953 | 2 | 2, 4 | ND, ND | - | Survived |
| Smith ES [25] | 1954 | 1 | 30 | ND | - | Unknown |
| Yung-en K [26] | 1956 | 5 | 8, 22, 25, 26, 28 | ND | | 1 Died / 4 Survived |
| Watson DG [27] | 1957 | 1 | 24 | ND | Subarachnoid haemorrhage | Died |
| Ziai M [28] | 1958 | 1 | Newborn* | ND | | Unknown |
| Stiehm ER [29] | 1966 | 1 | 7 | B | - | Survived |
| Wherle P [30] | 1976 | 1 | Newborn* | ND | | Unknown |
| Sunderland WA [9] | 1972 | 1 | 2 | C | | Died |
| Jones RN [10] | 1976 | 1 | 15 | ND | | Died |
| Manginello FP [31] | 1979 | 1 | 15 | B | - | Survived |
| Clegg HW [32] | 1980 | 1 | 25 | B | | Survived |
| Mulder CJJ [33] | 1984 | 3 | Newborn* | B, B, A# | | Unknown |
| Donald PR [34] | 1986 | 4 | Newborn* | ND | | Unknown |
| Embree J [35] | 1987 | 1 | 1 | W135 | - | Survived |
| Chugh K [36] | 1988 | 1 | 3 | A | Cerebral abscess, hydrocephalus | Died |
| Bhutta ZA [11] | 1991 | 1 | 1 | ND | | Died |
| J de Louvois [37] | 1991 | 11 | ≤28 days | ND | - | Survived |
| Ellis M [12] | 1992 | 2 | 2,3 | C, W135 | - | Survived |
| Sapan N [38] | 1993 | 1 | 20 | ND | | Died |
| Kirkpatrick M [39] | 1994 | 1 | 21 | B | Spinal dysfunction | Survived |
| Chiu CH [40] | 1994 | 2 | 28, 16 | ND,ND | - | Survived |
| Arango CA [41] | 1996 | 2 | 21, 13 | B, B | | Survived |
| Falero GMP [42] | 1999 | 1 | 25 | C | - | Survived |
| Campagne G [8] | 1999 | 11 | < 1 month | ND | - | Unknown |
| Casanova RM [43] | 2000 | 1 | 3 | B | - | Survived |
| Shepard LW [5] | 2003 | 6 | < 7 days | ND | | Unknown |
| Shepard CW [5] | 2003 | 16 | 8 - 30 days | ND | | Unknown |
| Lo WT [2] | 2003 | 1 | 1 | C | | Survived |
| Katier N [44] | 2003 | 1 | 12 | C | | Survived |
| Huang HR [6] | 2006 | 2 | 28, 28 | -/B | -, Subdural empyema | Survived |
| Falcao MC [1] | 2007 | 1 | 15 | C | | Survived |
| Arya S [3] | 2007 | 1 | 1 | A | | Died |
| Tinsa F [45] | 2008 | 1 | 20 | B | | Survived |
| Ahmareen O [4] | 2008 | 1 | 12 | B | - | Survived |
| Kurlenda J [46] | 2010 | 1 | 1 | B | - | Survived |
| Cho HK [47] | 2010 | 2 | < 1 month | ND | | Unknown |
| Fuentes AD [48] | 2011 | 3 | 9,15,15 | B,B,B | - | Survived |
| Gaschignard J [7] | 2011 | 14 | 5 - 28 | ND | | Unknown |
| Smith A [49] | 2013 | 1 | 7 | B | | Died |
| Ramsamy Y [50] | 2013 | 1 | 21 | W135 | Subdural empyema, hydrocephalus | Survived |
| Bosman M [51] | 2013 | 1 | 3 | Y | - | Survived |
| Shah S [52] | 2013 | 1 | 12 | B | | Died |
| Kumar D [53] | 2014 | 1 | 9 | ND | - | Survived |
| Devi U [54] | 2014 | 1 | 14 | Y | - | Survived |
| Kiray Bas E [55] | 2014 | 1 | 10 | ND | | Died |
| Present report | 1 | 5 | B | Cerebral abscesses, hydrocephalus | Survived |
Newborn: age not specified; ND: not done, Unclusterable or not disclosed early neonatal period
Serotypes A, B
In 2003, Lo WT et al published a review on early-onset meningococcal infection and reported a mortality rate of 50% [2]. In 2014, two cases of uncomplicated late onset meningococcal meningitis were reported from India [53,54]. In the same year, Kiray Bas E et al., reported a fatal case of meningococcal infection in a 10 day old neonate and reviewed the literature [55]. There are few published case reports of neonatal meningococcal meningitis complicated by subdural empyema, cerebral abscess and hydrocephalus [6,13,36,50].
Chugh K et al., reported a case of meningococcal meningitis in a three-day-old neonate which had complications of cerebral abscess and hydrocephalus at three weeks of age [36]. We did not find any other case reports of multiple cerebral abscesses presenting in the neonatal period.
The possible mode of transmission of infection in this patient is either intrauterine or perinatal, because of development of cerebral abscesses by the fifth day of life. Unfortunately, neither were we able to obtain a culture of the placenta or high vaginal swabs nor screen the health care personnel of the referral hospital. In this patient, there was evidence of motor delay without vision or hearing impairment or recurrence of seizures. Despite prompt diagnosis at admission and treatment, baby developed hydrocephalus requiring a VP shunt.
Conclusion
Meninogoccal meningitis should be suspected in neonates who present with sepsis and seizures even in the absence of rash. Establishing the aetiological diagnosis and identifying cerebral abscesses early was vital for treating meningitis and the associated complication of hydrocephalus. To the best of our knowledge, this is the youngest reported case of neonatal meningococcal meningitis with multiple cerebral abscesses.
*Newborn: age not specified; ND: not done, Unclusterable or not disclosed early neonatal period
#Serotypes A, B
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