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Risk factors for community-acquired bacterial meningitis in adults
Adriani, K.S.
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Adriani, K. S. (2015). Risk factors for community-acquired bacterial meningitis in adults.
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Download date: 23 Dec 2020

Kirsten S. Adriani
for community-acquired
bacterial meningitis
in adults
Risk factors
Risk factors for community-acquired bacterial meningitis in adults Kirsten S. Adriani

Risk factors for community-acquired
bacterial meningitis in adults
Kirsten S. Adriani
Officieel_Kirsten.indd 1 19-8-2015 9:15:27

The research described in this thesis is supported by grants from the Netherlands Organi-
zation for Health Research and Development (ZonMw; NWO-Veni grant 2006 [916.76.023]
(D. van de Beek), NWO-Vidi grant 2010 [917.11.358] (D. van de Beek), ZonMw NWO-
Veni grant 2012 (916.130.78) (M.C. Brouwer) and the Academic Medical Center (AMC
Fellowship 2008) (D. van de Beek) and European Research Council Starting Grant 281156
(D. van de Beek).
The printing of this thesis was financially supported by: Stichting Cirion, Pfizer BV, University
of Amsterdam, and ABN AMRO.
Cover Esther Ris, Proefschriftomslag.nl

Layout Renate Siebes, Proefschrift.nu
Printed by Ridderprint, Ridderkerk
ISBN 978-94-90791-37-7
© Kirsten S. Adriani, 2015

All rights reserved. No part of this publication may be reproduced, stored in a retrieval
system, or transmitted, in any form or by any means, electronically, mechanically, by pho-
tocopying, recording or otherwise, without the prior written permission of the author. The
copyright of the articles that have been published, has been referred to the respective journals.

ACADEMISCH PROEFSCHRIFT
ter verkrijging van de graad van doctor

aan de Universiteit van Amsterdam
op gezag van de Rector Magnificus
prof. dr. D.C. van den Boom
ten overstaan van een door het College voor Promoties ingestelde
commissie, in het openbaar te verdedigen in de Aula der Universiteit
op vrijdag 16 oktober 2015, te 11.00 uur
door
Kirsten Saskia Adriani

geboren te Amsterdam

Promotiecommissie
Promotor: Prof. dr. D. van de Beek, Universiteit van Amsterdam
Co-promotor: Dr. M.C. Brouwer, Universiteit van Amsterdam
Overige leden: Prof. dr. P. Portegies, Universiteit van Amsterdam

Prof. dr. I.N. van Schaik, Universiteit van Amsterdam
Prof. dr. B.M.J. Uitdehaag, Vrije Universiteit Amsterdam
Prof. dr. T. van der Poll, Universiteit van Amsterdam
Prof. dr. C.M. Vandenbroucke-Grauls, Vrije Universiteit Amsterdam
Prof. dr. M. Vermeulen, Universiteit van Amsterdam
Faculteit der Geneeskunde

Voor Nora, Linde en Fenna

Contents
Chapter 1 Introduction 9
Chapter 2 Community-acquired recurrent bacterial meningitis in adults 15
Chapter 3 Bacterial meningitis in adults after splenectomy and in 29

hyposplenic states
Chapter 4 Bacterial meningitis in pregnancy: report of six cases and review 45

of the literature
Chapter 5 Common polymorphisms in the complement system and 61

susceptibility to bacterial meningitis
Chapter 6 Genetic variation in the β2-adrenoceptor gene and association 81

with susceptibility to bacterial meningitis in adults
Chapter 7 General discussion: risk factors for community-acquired bacterial 95

meningitis in adults
Summary 115
Samenvatting 119
Dankwoord 125
About the author 133
Curriculum vitae 134
List of publications 135
TableOfContents_kirsten.indd 7 20-8-2015 8:50:20

TableOfContents_kirsten.indd 8 20-8-2015 8:50:20
Chapter 1
Introduction
Chapter_1_Kirsten.indd 9 19-8-2015 9:15:55

Chapter 1 Introduction
Bacterial meningitis is an inflammation of the meninges and occurs when bacteria invade
the subarachnoid space. The meninges are the protective membranes that surround the
brain and the spinal cord.
Bacterial meningitis is a life-treatening disease because the proximity of the infection to

the brain and still has a high mortality. Bacterial meningitis is described as early as the 5th
century B.C. in Hippocratic writings.1
Thomas Willis (1621–1675) – a neuroanatomist whose name is still connected to the vascular
structure in the brain “the circle of Willis” – was probably the first who described an early
epidemic of meningitis (1661). Gaspard Vieusseux (1746–1814) was the first who described
the clinical features of bacterial meningitis on the basis of epidemic (meningococcal)
meningitis in Geneva in 1805.2 And in 1891, Heinrich Quincke (1842–1922) developed
a new technique of lumbar puncture and provided therefore the diagnostic procedure to
confirm bacterial meningitis.1
Since than, major changes in diagnosis and treatment of bacterial meningitis are made –
and also – changes in epidemiology of the disease occured. Antibiotics became available;
childhood vaccinations are administered and changed epidemiology and reduced cases of
bacterial meningitis. Dexamethasone proved to be important adjunctive therapy because
of reduction of neurological sequela like hearing loss.3
Still, there is more to improve and identification of patients who are at increased risk for
bacterial meningitis is amongst this. By this identification, patients and physicians can be
aware of the risk and preventive measures can be taken by administration of vaccinations
or – in some cases – antibiotics on demand.
Susceptibility and risk factors – outline of this thesis

Organisms causing meningitis were identified in the late 19th century. The most common
pathogens were Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influen-
zae. After introduction of the Hib vaccine there is has been a 99% reduction of H. influenzae
type B as causative organism, and is currently rarely identified.4
Streptococcus pneumoniae and Neisseria meningitidis are common bacteria and are also
commensal in the human respiratory tract without causing disease. It is unclear why some
persons develop bacterial meningitis and others colonized with the same bacteria do not. The
10

Chapter 1
aim of my PhD project was to identify risk factors for adult bacterial meningitis and identify
Introduction
which protective measures can be taken to prevent bacterial meningitis in these risk groups.
In chapter 2 a nation-wide prospective cohort study in adults with recurrent bacterial

meningitis is presented. Predisposing factors, clinical findings, complications and outcome
in a cohort of 31 patients is described. An important acquired condition that increases
susceptibility to pneumococcal infections is loss of spleen function and in chapter 3 we
describe bacterial meningitis in patients after splenectomy or with hyposplenia. We studied
occurrence, disease course, prognosis, and vaccination status of 24 patients. In chapter 4
we present 6 cases of bacterial meningitis in pregnant women in a prospective cohort study.
We reviewed the medical literature on bacterial meningitis during pregnancy and identified
42 cases of bacterial meningitis.
Chapter 5 describes a prospective nationwide genetic association study in adults with

community-acquired bacterial meningitis. We genotyped 17 common single nucleotide
polymorphisms (SNPs) in genes coding for complement components and evaluated
functional consequences by measuring complement levels in the cerebrospinal fluid. In
1
chapter 6 a prospective genetic association study is presented to determine or genetic
variation in the β2-adrenoceptor gene (ADRB2) influences susceptibility to bacterial
meningitis. We genotyped 542 patients with community acquired bacterial meningitis and
376 matched controls for 2 functional SNPs in the β2-adrenoceptor gene (ADRB2). Also,
we analyzed if the use of non-selective beta-blockers, which bind to the β2-adrenoceptor,
influenced the risk of bacterial meningitis.
This thesis concludes with a general discussion in chapter 7, which gives an overview of
risk factors and patient risksgroups for bacterial meningitis.
References
1. Tyler KL. Chapter 28: a history of bacterial meningitis. Handb Clin Neurol 2010; 95: 417–433.
2. Vieusseux G. “Mémoire sur le Maladie qui a regne à Génève au printemps de 1805”. Journal de
Médecine, de Chirurgie et de Pharmacologie (article in French) 1806; 11: 50–53.
3. de Gans J, van de Beek D. European Dexamethasone in Adulthood Bacterial Meningitis Study

Investigators. Dexamethasone in adults with bacterial meningitis. N Eng J Med 2002; 347: 1549–
1556.
11

Chapter 1 Introduction
4. Brouwer MC, Tunkel AR, van de Beek D. Epidemiology, diagnosis and antimicrobial treatment
for acute bacterial meningitis. Clin Microbiol Rev 2010; 23: 467–492.
12

Chapter 1
Introduction
1
13

Chapter 2
Community-acquired recurrent
Kirsten S Adriani, Diederik van de Beek, Matthijs C Brouwer,
Lodewijk Spanjaard, Jan de Gans
Clinical Infectious Diseases 2007; 45(5): e46-51.

Chapter 2 Recurrent bacterial meningitis
Abstract
Community-acquired recurrent bacterial meningitis in adults is a relatively rare disease. All
previous data were derived from small retrospective case series. We prospectively evaluated
episodes of recurrent bacterial meningitis in a nationwide cohort study in The Netherlands.
Thirty-four episodes of recurrent bacterial meningitis were identified among 31 patients; 3
patients experienced 2 episodes during the study period. The mean age was 43 years, and
25 (74%) of 34 episodes occurred in men. Predisposing conditions were involved in 26
(77%) of 34 episodes; the most common predisposing conditions were remote head injury
(17 (53%) of 32 episodes) and cerebrospinal fluid (CSF) leakage (9 (32%) of 28 episodes).
Lumbar puncture revealed an individual CSF indicator of bacterial meningitis for almost
all episodes (88%). The outcome was death for 5 (15%) of 34 episodes; 1 additional patient
had a suboptimal score on the Glasgow Outcome Scale. We conclude that most patients
with recurrent meningitis are male and have predisposing conditions, which, in most cases,
are remote head injury or CSF leakage.
16

Chapter 2
Introduction
Recurrent bacterial meningitis

Community-acquired bacterial meningitis is a serious and life-threatening disease. The
estimated incidence is 2.6–6 cases per 100,000 adults per year in developed countries, and
Streptococcus pneumoniae and Neisseria meningitidis are the leading causes.1-3 Recurrent
bacterial meningitis has been estimated to occur in 4%–9% of all patients with community-
acquired bacterial meningitis; cases have been described after head trauma and neurosurgical
procedures, even after several years, and have also been described in patients with congenital
malformations or immunocompromised state.2,4-9 Most previous data were derived from
small retrospective case series.10,11 We performed the first prospective nationwide cohort
study involving adults with community-acquired bacterial meningitis.12 In this article, we
describe the incidence, clinical features, complications, and outcome in adults with recurrent
community-acquired bacterial meningitis.
Methods
In the Dutch Meningitis Cohort Study, a nationwide observational cohort study in The
Netherlands, 696 episodes of community-acquired acute bacterial meningitis were assessed 2
prospectively. All causative organisms were identified by CSF culture, which yielded S.
pneumoniae in 352 episodes (51%), N. meningitidis in 257 episodes (37%), and other bacteria
in 87 episodes (12%). Inclusion and exclusion criteria have been described elsewhere.12 In
summary, eligible patients were aged >16 years, had bacterial meningitis confirmed by culture
of CSF, and were listed in the database of The Netherlands Reference Laboratory for Bacterial
Meningitis from October 1998 through April 2002. The treating physician was contacted,
and informed consent was obtained from participating patients or their legal representatives.
The study was approved by our ethics committee. Patients with hospital-acquired meningitis
(defined as meningitis that occurred during hospitalization or within 1 week after hospital
discharge), neurosurgical devices, and a history of a recent (within <1 month) head trauma
or neurosurgical procedure were excluded. Recurrent meningitis was defined as a second or
subsequent episode of meningitis in a patient that was caused by a different organism than the
organism that caused the first episode or by the same organism >3 weeks after the completion
of therapy for the first episode. Patients with an altered immune status owing to the use of
immunosuppressive drugs or splenectomy, diabetes mellitus, or alcoholism were considered
to be immunocompromised. We defined predisposing factors for developing bacterial
meningitis, such as otitis, sinusitis, pneumonia, CSF leakage, immunocompromised state,
17

remote neurosurgerical procedure, and remote head trauma. Neurosurgerical procedures

and head trauma were classified as remote when they occurred >1 month before the onset
of meningitis. All patients underwent a neurological examination at hospital discharge, and
outcome was graded using the Glasgow Outcome Scale. This measurement scale is well
validated, with scores varying from 1 (indicating death) to 5 (indicating good recovery).
A favorable outcome was defined as a score of 5, and an unfavorable outcome was defined
as a score of 1–4. Focal neurological abnormalities were divided into focal cerebral deficits
(e.g., aphasia, monoparesis, or hemiparesis) and cranial nerve palsies.
Results
During the 3.5-year period, 34 (4.8%) of 696 episodes of community-acquired bacterial
meningitis were classified as recurrent meningitis (Table 2.1). The calculated annual incidence
Table 2.1 Clinical characteristics and laboratory findings at hospital admission for 31 patients who
experienced 34 episodes of recurrent community-acquired meningitis
Variable Value
Mean age, years (range) 43 (17–83)

Male sex 25/34 (74)
Duration of symptoms, <24 h 19/30 (63)
Seizures 6/32 (19)
Previously treated with antimicrobials 2/34 (6)
Predisposing factors 26/34 (77)
Immunocompromised state 3/34 (9)
Pneumonia 4/34 (12)
Otitis or sinusitis 4/34 (12)
Remote neurosurgical procedure 3/27 (11)
Remote head trauma 13/32 (41)
History of CSF leakage 9/28 (32)
Symptoms on presentation
Headache 28/31 (90)
Nausea 25/30 (83)
Neck stiffness 25/32 (78)
Temperature, ≥38 º C 25/31 (81)
Score on Glasgow Coma Scalea
Median ± SD 12 ± 3
≤14 24/34 (71)
≤8 6/34 (18)
Triad of fever, neck stiffness, altered mental status 11/34 (32)
Table 2.1 continues on next page
18

Chapter 2
Table 2.1 Continued

Variable Value
Focal neurological deficits 10/34 (30)

Cranial nerve palsy 8/34 (24)
Indexes of CSF inflammationb
WBC count
Median cells/mm3 (range) 3467 (0–56320)
<100 cells/mm3 3/30 (10)
100–999 cells/mm3 2/30 (7)
>999 cells/mm3 25/30 (83)
Protein concentration, median g/L (range) 2.57 (0.37–9.15)
Median CSF: blood glucose ratio (range) 0.24 (0.0–1.0)
CSF Gram stain results
Negative 6/31 (19)
Gram-positive cocci 23/31 (74)
Gram-negative cocci 2/31 (6)
Causative organism
Streptococcus pneumoniae 28/34 (85)
Haemophilus influenzae 3/34 (9)
Neisseria meningitidis 2/34 (6)
Staphylococcus aureus 1/34 (3)
Blood chemical test resultc
ESR, median mm/h (range)
C-reactive protein concentration, median mg/L (range)
13 (1–112)
104 (4–286) 2
Trombocyte count, median 109 cells/L (range) 221 (53–350)
Note. Data are no. (%) of episodes, unless otherwise indicated. ESR = erythrocyte sedimentation rate.
a
A score ≤14 indicates a change in mental status and a score ≤8 coma.
b
CSF pressure was measured in 13 episodes, CSF WBC count was evaluated in 30 episodes, CSF protein in 26
episodes, CSF blood: glucose ratio in 27 episodes.
c
ESR was evaluated in 26 episodes, C-reactive protein concentration in 18 episodes, and trombocyte count
in 31 episodes.
of recurrent bacterial meningitis was 0.12 cases per 100,000 adults. The mean age was 43
years, and 25 episodes (74%) occurred in men. The 34 episodes occurred among 31 patients;
the studied episode was the second episode of bacterial meningitis in 25 patients (81%), the
third episode in 4 (13%), and the fifth and sixth episodes in 1 patient (3%). Three patients
experienced 2 episodes during the study period. The duration between the first episode and
the studied episode was known for 22 episodes; the median duration was 4 years (range, 0–29
years). Seven (23%) of 31 patients had neurologic sequelae from a previous episode, which
consisted of hearing impairment in 2 patients, cognitive impairment in 2, epilepsy in 1, and
an unknown sequelae in 2. Most episodes occurred during winter (38%) and autumn (32%).
19

Predisposing conditions were involved in 26 episodes (77%). The most common predisposing
factors were remote head injury (17 (53%) of 32 episodes) and CSF leakage (9 (32%) of
28 episodes); 6 episodes involved both of these predisposing factors. Of the 17 episodes
involving remote head injury, 15 (88%) occurred in men. In the 3 patients with CSF leakage
who did not experience previous trauma, 2 had undergone surgical procedures involving
the dura mater, and in 1 patient, the cause was unidentifiable. An immunocompromised
state was involved in only 3 (9%) of 34 episodes; 1 of these episodes was in a patient who
was HIV positive, 1 in a patient who had a splenectomy, and 1 in a patient who was known
to have alcoholism.
At presentation, symptoms were present for <24 h for 21 (58%) of 30 episodes. Most patients
presented with classic symptoms and signs of bacterial meningitis (Table 2.1); however, the
triad of neck stiffness, fever, and altered mental status was present in patients only for 11
(32%) of 34 episodes. For 6 (18%) of 34 episodes, the patients presented with a Glasgow
Coma Score of ≤8, indicating coma. For 4 (12%) of 34 episodes, rhinorrhoea (nasal CSF
leakage) was reported at hospital admission.
CT of the brain was performed at hospital admission for 27 (79%) of 34 episodes and
revealed the potential causes of recurrent meningitis that were involved in 6 episodes (22%).
Overall, CT abnormalities were found for 16 of these 27 episodes (67%) and consisted
of posttraumatic abnormalities for 5 episodes, cerebral edema for 3, hydrocephalus and
brain infarction for 2; sinusitis, mastoiditis, and pneumatocephalus each were involved in
1 episode. Posttraumatic abnormalities included localized posttraumatic brain atrophy in
4 patients and skull fractures in 2 (1 patient had both abnormalities on CT). Congenital
malformations were not reported.
Cranial CT was performed before lumbar puncture for 12 (44%) of 27 episodes; antimicrobial
therapy was started before CT for only 3 (25%) of these episodes. At hospital admission,
cranial CT was repeated for 10 (37%) of 27 episodes. New abnormalities were found to be
involved in 5 episodes, including cerebral edema and cerebral infarctions in 2 episodes each
and a subarachnoid hemorrhage in 1 episode. MRI was performed at hospital admission
for 1 patient and revealed a defect of the cribriform plate and accumulation of CSF in the
nasal cavity.
Lumbar puncture was performed for all episodes. Opening pressure was recorded for 13
(38%) of 34 episodes and revealed a median pressure of 370 mm of water. At least 1 individual
CSF finding that was indicative of bacterial meningitis (glucose concentration, <1.9
20

Chapter 2
mmol/L; ratio of CSF glucose concentration to blood glucose concentration, <0.23; protein

concentration, >2.20 g/L; WBC count, >2000 cells/mL; or CSF neutrophil count, >1180 cells/
mL)13 was found for 28 (88%) of 32 evaluated episodes. Gram staining of CSF samples was
performed for 31 (91%) of 34 episodes and correctly identified the causative microorganism
involved in 25 episodes; for 6 episodes, Gram staining revealed no microorganisms.
The causative microorganisms, as identified by CSF culture, were S. pneumoniae in 28

(85%) of 34 episodes, Haemophilus influenzae in 3 (9%), N. meningitidis in 2 (6%), and
Staphylococcus aureus in 1 (3%). This last episode occurred in a patient who had CSF leakage
under the facial skin. The causative bacterial species of the previous episode of meningitis
was known for 12 episodes and was similar to the causative bacterial species of the current
episode for 11 episodes (92%). S. pneumoniae was the causative microorganism of meningitis
in all 3 immunocompromised patients.
The causative bacterial species in the patient who had 6 episodes of bacterial meningitis were
S. pneumoniae (episodes 1 and 2), group A streptococci (episode 4), and N. meningitidis
(episode 5 and 6); CSF culture results were negative during episode 3. One additional patient
experienced 2 episodes of meningococcal meningitis during the study period.
The distribution of serotypes of S. pneumoniae was type 14 in 5 (18%) episodes; types 6B 2

and 35F in 6 (11%) episodes each; types 6A, 9V, 10A, 16F, and 22F in 10 (7%) episodes each;
types 3, 4, 15C, 19A, 22F, and 23F in 6 (4%) episodes each, and unknown in 1 episode. The
causative organism was one of the serotypes included in the 7-valent conjugated vaccine
in only 13 episodes (46%); the coverage of the 23-valent pneumococcal polysaccharide
vaccine was 61%.
Initial antimicrobial treatment consisted of penicillin or amoxicillin for 17 (50%) of 34

episodes, a third-generation cephalosporin for 12 (35%) episodes, and a combination of
amoxicillin and third-generation cephalosporin for 1 (3%) episode; other regimens were
used for 4 episodes (12%). Data on antimicrobial therapy were missing for 1 episode. Initial
therapy was microbiologically adequate for all evaluated episodes. Adjunctive steroids
were administered to 2 patients after clinical deterioration during the clinical course. One
patient was included in the European Dexamethasone Study and was randomized to the
placebo group.14
During the clinical course, neurologic complications occurred during 23 (67%) of 34

episodes, and systemic complications developed during 6 (18%) of 34 episodes (Table 2.2).
21

Table 2.2 Complications during hospital admission and outcome of recurrent bacterial meningitis
Complication or outcome No. (%) of episodes
Seizures 7/34 (21)

Cardiorespiratory failure 6/34 (18)
Required mechanical ventilation 5/34 (15)
Sepsis 3/34 (9)
Hyponatriemia 6/32 (18)
Fevera 96/436 (22)
Recurrent 6/34 (18)
Persistent 1/34 (21)
Impaired consciousness 16/34 (47)
Hemiparesis 1/34 (3)
Hearing impairment 2/34 (6)
Pneumonia 1/16 (6)
Score on Glasgow Outcome Scale
1 – death 5/34 (15)
2 – vegetative state 0/34
3 – severe disability 0/34
4 – moderate disability 1/34
5 – good recovery 27/34 (82)
Sequelae at discharge
Focal cerebral deficit 0/34
Cranial nerve palsyb 2/34 (6)
a
Recurrent fever was defined as fever reoccurring after at least 1 afebrile day, and persistent fever was defined
as a temperature ≥38 °C for >10 days after the initiation of appropriate antimicrobial treatment.
b
Hearing impairment and sixth cranial nerve palsy each occurred during 1 episode.
The outcome was death for 5 (16%) of 31 patients; 1 additional patient had a suboptimal
score on the Glasgow Outcome Scale (score, 4). One patient with pneumococcal meningitis
died of subarachnoid hemorrhage. Neurological examination was performed at hospital
discharge for all surviving patients. New neurological sequelae were found in 2 patients and
consisted of hearing impairment and sixth cranial nerve palsy.
The vaccination status of many patients was unknown. Two patients were vaccinated with the
23-valent pneumococcal vaccine (pneumovax-23) after a second episode of pneumococcal
meningitis. Both patients experienced recurrence of pneumococcal meningitis despite
vaccination. Two patients experienced recurrent meningococcal meningitis, 1 of whom was
vaccinated with an unknown meningococcal vaccine after the first episode of meningococcal
meningitis (i.e., the patient’s fifth episode of meningitis). Despite this vaccination, a
recurrence of meningococcal meningitis occurred, which was the patient’s sixth episode
of bacterial meningitis.
22

Chapter 2
Discussion

Our study reveals that recurrent bacterial meningitis occurs in 5% of community-acquired
bacterial meningitis episodes. This frequency is somewhat lower than that found in a
retrospective study evaluating 275 patients with community-acquired bacterial meningitis
in a tertiary referral center.2 In this case series, 33 (11%) of 296 episodes occurred in patients
who had ≥2 episodes of community-acquired meningitis.2 Our prospective study was
performed nationwide and carefully excluded cases of nosocomial meningitis; therefore,
our study provides an accurate estimate of the incidence of community-acquired recurrent
bacterial meningitis.
Most patients with recurrent meningitis had predisposing conditions. Common predisposing
conditions in our series were remote head injury (in 53% of episodes) and CSF leakage (in
38% of episodes); only a small minority of patients had an impaired humoral immunity. This
is comparable to the previously mentioned retrospective study, which reported a remote
history of head trauma or neurosurgerical procedures in 47% of patients with recurrent
meningitis. Although overt CSF leakage was seldom present at presentation, anatomical
defects after head trauma can be regarded as the principal pathophysiological mechanism
leading to recurrent bacterial meningitis and may have delayed onset until years after 2
trauma.5,6,8
The predominant causative organism was S. pneumoniae. This bacterium is a frequent

cause of nonrecurrent community-acquired bacterial meningitis and is a part of the normal
nasopharyngeal flora. The predominance of S. pneumoniae as a cause of recurrent meningitis
has been reported previously.1-3
An interesting finding is that 75% of the patients were male. The male-to-female ratio in the
whole group of patients with community-acquired pneumococcal meningitis was 50 : 50.15
One explanation for the predominance of male sex among patients having recurrent
meningitis is that head trauma is more likely to occur in male individuals than in female
individuals. A recent Dutch prospective multicenter study evaluating minor head injury
revealed a male predominance of 71%.16 Remote head injury is an important predisposing
condition for recurrent community-acquired bacterial meningitis. However, there might
be other unidentified factors as well. A recent study revealed that male sex is an individual
risk factor for developing meningitis after a craniotomy, although most patients had
staphylococcal meningitis.17
23

Two patients (6%) had recurrent meningitis caused by N. meningitidis. One of these patients
experienced 6 episodes involving different causative organisms and CSF leakage; the
previous causative organism was unknown for the other patient. In the literature, recurrent
meningococcal meningitis is frequently associated with complement deficiencies.18-20 The
recurrence of meningococcal meningitis occurs in ~45% of patients with a complement
deficiency.20 However, N. meningitidis is a pharyngeal commensal in 9% of the population;18
therefore, meningococcal meningitis is also possible when CSF leakage is the predisposing
condition.
The mortality rate was substantial (15%) but much lower than that for non-recurrent
pneumococcal meningitis (34%).12 This difference in mortality rate might be explained
by early symptom recognition by patients and their families, because they may recognize
symptoms of previous episodes. This may also explain the relatively high proportion of
patients presenting after having symptoms for <24 h and the low proportion of patients
having the triad of neck stiffness, fever, and altered mental status. Another explanation might
be competing risks between mortality and recurrence of illness; there is no recurrence of
meningitis when a patient has died.
Our study has several important limitations. First, only patients who had a positive CSF
culture result were included. Negative CSF culture results occur among 11%–30% of patients
with bacterial meningitis.2,12 However, the clinical presentation in patients with positive and
negative CSF culture results was closely similar in several studies.2,4 Furthermore, patients
with space-occupying lesions on CT, such as hemorrhages, associated with the infection
may not undergo lumbar puncture.12 For patients with coagulation disorders or severe septic
shock, lumbar puncture might be postponed, which can result in negative CSF culture results,
as well.12 Therefore, these patient groups were probably only partly represented in our study,
which might have caused an underestimation of the mortality rate. Finally, patients were
not routinely tested for complement deficiency; this was an observational cohort study.
In patients with no apparent cause of recurrent meningitis or known history of head

trauma, the high prevalence of remote head injury and CSF leakage in our series justifies
an active search for anatomical defects and CSF leakage in patients with recurrent bacterial
meningitis.8-11 Detection of β-2-transferrine in nasal discharge in cases of rinorrhoea is a
sensitive and specific method to confirm the presence of a CSF leak.21-23 Optimum imaging
is performed using thin-slice CT of the skull base and is the initial imaging of choice.5,9,24 It
is important to take into account that small bone defects on CT do not prove CSF leakage.24
24

Chapter 2
T2-weighted MRI may detect a small CSF leak but lacks fine bone detail.25,26 Because CSF leaks

are often intermittent, the administration of intrathecal contrast will not be more accurate
to prove leakage and depends on the timing of imaging.24,27 Anatomical defects and CSF
leakage might require the consultation of a neurosurgeon or otolaryngologist to evaluate
the necessity of surgical repair, which has an overall high success rate and low mortality
and morbidity.8,24,28 In patients with recurrent meningococcal meningitis, it depends on the
patient’s history whether a complement or immunoglobulin deficiency should be excluded
before a search for anatomical defects and CSF leakage is initiated.18-20
The vaccination status was largely unknown in our series, which is an important short
coming of our study. Only 2 patients in our study were known to be vaccinated after
recurrent episodes of meningitis. In previous literature, the role of vaccination to prevent
recurrence of meningitis was only investigated in patients with meningococcal infection
caused by complement or immunoglobulin deficiency or after splenectomy.19,29 This group
of patients and their possible affected family members should be vaccinated to prevent
meningitis.19 Both vaccinated patients in our study experienced recurrence after vaccination;
however, vaccination should be routine for patients with persistent CSF leakage. The
efficacy of prophylactic antibiotics in patients with CSF leakage remains controversial in
the literature.5,6,17,30,31 2
We conclude that most patients with recurrent meningitis are male individuals with
predisposing conditions, which, in most cases, are remote head injury or CSF leakage. The
high prevalence of remote head injury and CSF leakage in our series justifies an active search
for anatomical defects and CSF leakage in a patient with recurrent bacterial meningitis.
References
1. van de Beek D, de Gans J, Tunkel AR, Wijdicks EF. Community-acquired bacterial meningitis in
adults. N Engl J Med. 2006; 354: 44–53.
2. Durand ML, Calderwood SB, Weber DJ, et al. Acute bacterial meningitis in adults: a review of 493
episodes. N Engl J Med. 1993; 328: 21–28.
3. Schlech WF III, Ward JI, Band JD, Hightower A, Fraser DW, Broome CV. Bacterial meningitis in
the United States, 1978 through 1981.The National Bacterial Meningitis Surveilliance Study. JAMA.
1985; 253: 1749–1754.
4. Sigurdardottir B, Bjornsson OM, Jonsdottir KE, Erlendsdottir H, Gudmundsson S. Acute bacterial

meningitis in adults: a 20-year overview. Arch Intern Med. 1997; 157: 425–430.
25

5. Pappas DG, Hammerschlag PE, Hammerschlag M. Cerebrospinal fluid rinorrhea recurrent

meningitis. Clin Infect Dis. 1993; 17: 364–368.
6. Choi D, Spann R. Traumatic cerebrospinal fluid leakage: risk factors the use of prophylactic
antibiotics. Br J Neurosurg. 1996; 10: 571–575.
7. Whittet HB, Barker S, Anslow P, Leighton S. Heterotopic brain tissue: a rare cause of adult recurrent
meningitis. J Laryngol Otol. 1990; 104: 328–330.
8. Giunta G, Piazza I. Recurrent bacterial meningitis occurring five years after closed head injury
caused by an intranasal post-traumatic meningo-encephalocele. Postgrad Med J. 1991; 67: 377–379.
9. Carrol ED, Latif AH, Misbah SA, et al. Recurrent bacterial meningitis: the need for sensitive imaging.
BMJ. 2001; 323: 501–503.
10. Ford H, Wright J. Recurrent bacterial meningitis in adults: a case series. J Infect. 1996; 33: 131–133.
11. Hoşoğlu S, Ayaz C, Cevic A, Çümen B, Geyik MF, Kökoğlu OF. Recurrent bacterial meningitis: a
six year experience in adult patients. J Infect. 1997; 35: 55–62.
12. van de Beek D, de Gans J, Spanjaard L, Weisfelt M, Reitsma JB, Vermeulen M. Clinical features
prognostic factors in adults with bacterial meningitis. N Engl J Med. 2004; 351: 1849–1859.
13. Spanos A, Harrell FE Jr, Durack DT. Differential diagnosis of acute meningitis: an analysis of the
predictive value of initial observations. JAMA. 1989; 262: 2700–2707.
14. de Gans J, van de Beek D. European Dexamethasone in Adulthood Bacterial Meningitis Study
Investigators. Dexamethasone in adults with bacterial meningitis. N Eng J Med. 2002; 347:
1549–1556.
15. Weisfelt M, van de Beek D, Spanjaard L, Reitsma JB, de Gans J. Clinical features, complications,
outcome in adults with pneumococcal meningitis: a prospective case series. Lancet Neurol. 2006;
5: 123–129.
16. Smits M, Dippel DW, de Haan GG, et al. External validation of the Canadian CT head rule the New
Orleans criteria for CT scanning in patients with minor head injury. JAMA. 2005; 294: 1519–1525.
17. Korinek AM, Baugnon T, Golmard JL, van Effenterre R, Coriat P, Puybasset L. Risk factors for
adult nosocomial meningitis after craniotomy: role of antibiotic prophylaxis. Neurosurgery. 2006;
59: 126–133.
18. Swart AG, Fijen CAP, te Bulte MT, Daha MR, Dankert J, Kuijper EJ. Prevalence in The Netherlands
of complement deficiency in patients having experienced a meningococcal infection. Ned Tijdschr
Geneeskd. 1993; 137: 1147–1152.
19. Stephens D, Hajjeh R, Baughman W, Harvey R, Wenger J, Farley M. Sporadic meningococcal disease
in adults: results of a 5-year population-based study. Ann Intern Med. 1995; 123: 937–940.
20. Andreoni J, Kayhty H, Densen P. Vaccination the role of capsular polysaccharide antibody in
prevention of recurrent meningococcal disease in late complement component-deficient individuals.
J Infect Dis. 1993; 168: 227–231.
26

Chapter 2
21. Nandapalan V, Watson ID, Swift AC. Beta-2-transferrin cerebrospinal fluid rinorrhoea. Clin

Otolaryngol. 1996; 21: 259–264.
22. Ryall RG, Peacock MK, Simpson DA. Usefulness of beta-2-transferrin assay in the detection of
cerebrospinal fluid leaks following head injury. J Neurosurg. 1992; 77: 737–739.
23. Bateman N, Jones NS. Rhinorrhoea feigning cerebrospinal fluid leak: nine illustrative cases. J
Laryngol Otol. 2000; 114: 462–464.
24. Lund VJ, Lloid S, Lloyd G, et al. Optimum imaging diagnosis of cerebrospinal fluid rhinorrhoea.
J Laryngol Otol. 2000; 114: 988–992.
25. Stafford Johnson DB, Brennan P, Toland J, O’Dwyer AJ. Magnetic resonance imaging in the
evaluation of cerebrospinal fluid fistulae. Clin Radiol. 1996; 51: 837–841.
26. Gupta V, Goyal M, Mishra NK, Sharma A, Gaikwad SB. Positional MRI: a technique for confirming
the site of leakage in cerebrospinal fluid rhinorrhoea. Neuroradiology. 1997; 39: 818–820.
27. Stone JA, Castillo M, Neelon B, Mukherji SK. Evaluation of CSF leaks: high-resolution CT compared
with contrast-enhanced CT radionuclide cisternography. Am J Neuroradiol. 1999; 20: 706–712.
28. Friedman JA, Ebersold MJ, Quast LM. Post-traumatic cerebrospinal fluid leakage. World J Surg.
2001; 25: 1062–1066.
29. Omlin A, Muhlemann K, Fey M, et al. Pneumococcal vaccination in splenectomised cancer patients.
Eur J Cancer. 2005; 41: 1731–1734.
30. Brody HA. Prophylactic antibiotics for posttraumatic cerebrospinal fluid fistulae, a meta-analysis. 2
Arch Otolaryngol Head Neck Surg. 1997; 123: 749–752.
31. Villalobos T, Arango C, Kubilis P, Rathore M. Antibiotics after basilar skull fractures: a meta-analysis.
Clin Infect Dis. 1998; 27: 364–369.
27

Chapter 3
Bacterial meningitis in adults after
splenectomy and hyposplenic states
Kirsten S Adriani, Matthijs C Brouwer, Arie van der Ende,
Diederik van de Beek
Mayo Clinic Proceedings 2013; 88(6): 571-578.

Chapter 3 Bacterial meningitis after splenectomy
Abstract
Objective: To examine the occurrence, disease course, prognosis, and vaccination status of
patients with community-acquired bacterial meningitis with a history of splenectomy or
functional hyposplenia.
Patients and methods: Patients with bacterial meningitis proven by cerebrospinal fluid
culture were prospectively included in a nationwide cohort study between March 1, 2006,
and September 1, 2011. Splenectomy or diseases associated with functional hyposplenia
were scored for all patients. Vaccination status, clinical features, and outcome of patients
with a history of splenectomy or functional hyposplenia were analyzed and compared with
patients with normal spleen function.
Results: Twenty-four of 965 patients (2.5%) had an abnormal splenic function: 16 had a
history of splenectomy and 8 had functional hyposplenia. All patients had pneumococcal
meningitis. Pre-illness vaccination status could be retrieved for 19 of 21 patients (90%),
and only 6 patients (32%) were adequately vaccinated against pneumococci. Pneumococcal
serotype was known in 21 patients; 52% of pneumococcal isolates had a serotype included in
the 23-valent vaccine. Vaccine failure occurred in 3 patients. Splenectomized patients more
often presented with signs of septic shock compared with patients with a normal spleen (63%
vs. 24%; p = 0.02). Outcome was unfavorable in 14 patients (58%), and 6 patients died (25%).
Conclusion: Splenectomy or functional hyposplenia is an uncommon risk factor for bacterial

meningitis but results in a high rate of mortality and unfavorable outcome. Most patients
were not adequately vaccinated against Streptococcus pneumoniae.
30

Chapter 3
Introduction
Bacterial meningitis after splenectomy

Bacterial meningitis is associated with high mortality and morbidity rates, despite available
treatment with antibiotics and adjunctive dexamethasone.1 Streptococcus pneumoniae is
identified in 70% patients with community-acquired bacterial meningitis,2 with case fatality
rates ranging from 16 to 37%,2,3 and neurological sequelae, including hearing loss,4 focal
neurological deficits, and cognitive impairment, occurring in 30–52 % of surviving patients.5
Invasive pneumococcal disease – including bacterial meningitis – has been associated

with deficiencies in the immune system, which can be determined by genetic risk factors
or acquired conditions.6 An important acquired condition that increases susceptibility to
pneumococcal infections is loss of spleen function.1,7 Patients with splenic dysfunction lose
a major site of humoral and cellular immunity, cannot filter blood born bacteria and lose
the ability to mount a coordinated attack by different cell types.8 Causes of dysfunctional
splenic function are congenital hyposplenism, asplenia following splenectomy or acquired
functional hyposplenism, for example due to sickle cell disease, after allogeneic bone
marrow transplantation, coeliac disease and HIV infection.8-10 Splenic dysfunction may
result in an overwhelming post-splenectomy infection.7,11-13 Because of the high risk of
pneumococcal infections, adults with splenic dysfunction should be vaccinated with the
23-valent polysaccharide pneumococcal vaccine (PPV-23) and, if the immune response to
the vaccine is still insufficient, receive prophylactic antibiotic treatment.14 The incidence of
asplenia and hyposplenia in bacterial meningitis is unknown. We studied occurrence, disease 3
course, prognosis, and vaccination status of adult patients with asplenia or hyposplenia who
had community-acquired bacterial meningitis.
Methods
In a nationwide prospective cohort study we included bacterial meningitis patients older
than 16 years with positive cerebrospinal fluid (CSF) cultures who were identified by The
Netherlands Reference Laboratory for Bacterial Meningitis (Academic Medical Center,
Amsterdam) from March 1, 2006 to September 1, 2011.15 The Netherlands Reference
Laboratory for Bacterial Meningitis receives bacterial isolates from approximately 85% of
bacterial meningitis patients in the Netherlands and provided the names of the hospitals
where patients with bacterial meningitis had been admitted 2 to 6 days previously. The
treating physician was contacted, and informed consent was obtained from all participating
31

patients or their legally authorized representatives. Patients could also be included by

physicians familiar with the study through a 24/7-telephone service. Patients with hospital-
associated meningitis (defined as meningitis that occurred during hospitalization or within
1 week of discharge) including neurosurgery patients, patients with a neurosurgical device,
or neurotrauma within 1 month of the onset of meningitis and patients with negative CSF
culture results were excluded. The study was approved by the ethical committee of the
Academic Medical Center.
Data on patient history, symptoms and signs on admission, laboratory findings, radiologic
examination, treatment, and outcome were prospectively collected by means of a case record
form (CRF). The CRF included a standard question on spleen function and all discharge
letters were evaluated to confirm asplenism or hyposplenism. Vaccine status, previous
infections, medical history associated with hyposplenism (e.g. allogeneic bone marrow
transplantation) or splenectomy, clinical characteristics on admission and predisposing
factors for bacterial meningitis and complications during admission were all evaluated.
Patients who underwent autologous bone marrow transplantation were not considered to
be hyposplenic.8
All patients underwent a neurological examination at hospital discharge, and outcome was
graded using the Glasgow Outcome Scale. This measurement scale is well validated, with
scores varying from 1 to 5. A score of 1 on this scale indicates death; a score of 2 a vegetative
state (the patient is unable to interact with the environment); a score of 3 severe disability
(the patient is unable to live independently but can follow commands); a score of 4 moderate
disability (the patient is capable of living independently but unable to return to work or
school); and a score of 5 mild or no disability (the patient is able to return to work or school).
A favorable outcome was defined as a score of 5, and an unfavorable outcome was defined
as a score of 1–4. Focal neurological abnormalities were divided into focal cerebral deficits
(e.g., aphasia, monoparesis, or hemiparesis) and cranial nerve palsies.
The Mann-Whitney U test was used to identify differences between episodes with and
without spleen dysfunction with respect to continuous variables, and dichotomous variables
were compared with use of the χ2 test. All tests were 2-tailed and a p-value <0.05 was
considered significant. Statistical analyses were performed with the use of SPSS statistical
software, version 19 (SPSS Inc).
32

Chapter 3
Results

Of 965 patients with community-acquired bacterial meningitis, 24 patients (2.5%) had
splenic dysfunction: 16 had a history of splenectomy and 8 hyposplenism (Table 3.1). Reasons
for splenectomy were as follows: blunt spleen trauma in 5 patients (31%), lymphoma or
immunocytoma in 5 (31%), hypersplenism due to portal hypertension in liver cirrhosis
patients in 2 (13%), pyruvate kinase deficiency and spherocytosis in 1 each (6%), and
unknown in 2 patients (13%). Functional hyposplenia was caused by allogeneic bone marrow
transplantation in 5 patients and was newly diagnosed during the current disease episode
in 3 patients (on autopsy in 1, imaging in 1, and functional hyposplenia with splenomegaly
caused by hepatitis B-induced liver cirrhosis in 1 patient). All 24 patients had pneumococcal
meningitis and comprised 3.7% of all pneumococcal meningitis patients in the cohort.
Recurrent pneumococcal infections were present in 7 of 24 patients with splenic dysfunction

(29%; 3 of 16 with a history of splenectomy, and 4 of 8 patients with hyposplenism). One
splenectomized patient had 12 episodes of invasive pneumococcal disease despite vaccination
with PPV-23 and the conjugate 7-valent vaccines (PCV-7). Two patients with hyposplenia
were treated with prophylactic antibiotics at time of meningitis (one patient was taking
trimethoprim-sulfamethoxazole, and the other was taking levofloxacin).
Preadmission pneumococcal vaccination status could be retrieved for 19 of 21 patients

with splenic dysfunction identified before admission (14 of 16 splenectomized patients,
all 5 patients with known hyposplenia) and 6 of 19 patients (32%) were vaccinated against
3
pneumococci. Only 3 of 14 patients after splenectomy (21%) received pneumococcal
vaccinations according to local guidelines (repeated every 5 years; PPV-23 only in 3, PPV-23
and PCV-7 in 2 patients). One additional patient was immunized once with PPV-23 after an
episode of pneumococcal meningitis. Of the 5 patients with known hyposplenism, 2 received
PPV-23 one year after bone marrow transplantation and 2 patients were on preventive
antibiotics, as vaccinations were not yet administered because of immunosuppressive
medication. One patient was in between revaccinations and used amoxicillin on demand.
Pneumococcal serotypes of the current meningitis episodes were available for 21 of 24

patients (88%; Table 3.2). In 3 of 6 fully vaccinated patients (4 splenectomy, 2 hyposplenia)
vaccine failure occurred, defined as an infection by a pneumococcus with a serotype
included in a vaccine administered to the patient. The other 3 patients were infected by
pneumococci with a serotype not included in PPV-23 or PCV-7. The coverage rate of the
33

34
Chapter 3
Chapter_3_Kirsten.indd 34
Table 3.1 Demographics, clinical characteristics, and outcomes of 24 patients with bacterial meningitis and abnormal splenic functiona,b
Variable All patients (n = 24) Splenectomy (n = 16) Hyposplenism (n = 8)
Mean age, y (range) 54 (24–77) 56 (24–77) 49 (25–72)

Male/female sex 12/12 8/8 4/4
Time between spleen dysfunction and meningitis - y (range)c 19 (1–54) 23 (3–54) 5 (1–14)
Duration of symptoms <24 h 11/22 (50) 8/16 (50) 3/8 (38)
Predisposing conditions
Otitis / sinusitis 2 (8) 1 (6) 1 (13)
Pneumonia 5 (21) 2 (13) 3 (38)
Immunocompromised, other than spleen dysfunctiond 9 (38) 6 (25) 3 (38)

Headache 17/20 (85) 12/13 (92) 5/7 (71)
Nausea 13/15 (87) 9/11 (82) 4/7 (57)
Neck stiffness 17/23 (74) 12/14 (86) 5/8 (63)
Temperature ≥38°C 17/23 (74) 12/15 (80) 5/8 (63)
Signs of septic shocke 8 (33) 3 (19) 5 (63)
GCS scoref , median (IQR) 11 (10–14) 13 (9–14) 13 (10–15)
Altered mental status (GCS score <14) 18 (75) 13 (81) 5 (63)
Coma (GCS <8 ) 4 (17) 4 (25) 0
Triad of fever, neck stiffness, altered mental status 10 (42) 7 (44) 3 (38)
Blood chemical test result, median (IQR)
C-reactive protein (mg/L) 294 (206–370) 303 (213–370) 249 (116–433)
Trombocyte count (109 cells/L) 147 (89–222) 200 (107–292) 94 (61–129)
19-8-2015 9:16:15
Indexes of CSF inflammation
Leukocyte count (cells/mm3) 392 (144–5141) 421 (150–2864) 392 (144–5291)
Leukocyte count <1000/mm3 16/23 (70) 12/16 (75) 4/7 (57)
Protein (g/L) 4.84 (2.26–6.61) 5.05 (1.75–7.50) 4.71 (3.99–5.64)
CSF-Blood glucose ratio 0.6 (0.3–2.4) 0.6 (0.2–2.6) 0.6 (0.4–0.6)
Positive CSF Gram stain result 18/22 (82) 13/14 (93) 7/8 (88)
Positive bloodculture result 17/21 (81) 13/15 (87) 4/6 (67)
Required mechanical ventilation 11 (46) 7 (44) 4 (50)
Circulatory shock 2 (8) 1 (6) 1 (13)
Hemiparesis 7 (29) 4 (25) 3 (38)
Hearing impairment 5 (21) 4 (25) 1 (13)
Pneumonia 7 (29) 4 (25) 3 (38)
Score on the Glasgow Outcome Scale
Death 6 (25) 4 (25) 2 (25)
Vegetative state 0 0 0
Severe disability 2 (8) 1 (6) 1 (13)
Moderate disability 6 (25) 4 (25) 2 (25)
Minor or no disability 10 (42) 7 (44) 3 (38)
Mortality 6 (25) 4 (25) 2 (25)
Unfavorable outcome 14 (58) 9 (56) 5 (63)
Neurologic sequelaeg 8/18 (44) 5/12 (42) 3/6 (50)
a
CSF = cerebrospinal fluid; GCS = Glasgow Coma Scale; IQR = interquartile range.
b
Data are presented as No./total No. evaluated (percentage), unless otherwise indicated.
c
Unknown in 1 of 16 patients with splenectomy and in 2 of 8 patients with hyposplenism.
d
Immunocompromised other than spleen dysfunction was defined as the use of immunosuppressive drugs, the presence of diabetes mellitus or alcoholism, and patients
with the human immunodeficiency virus (HIV).
e
Defined as a systolic blood pressure ≤90 mmHg, a diastolic blood pressure <60 mmHg and/or heart rate ≥120 beats/min.
f
A score ≤14 indicates a change in mental status, and a score <8 indicates coma.
g
Sequelae consisted of critical illness polyneuromyopathy in 2 patients (11%), hearing loss in 2 patients (11%), cognitive impairment in 2 patients (11%), cranial nerve
palsy in 1 patient (6%), and hemiparesis in 1 patient (6%).
35
Bacterial meningitis after splenectomy Chapter 3
3
19-8-2015 9:16:15
Table 3.2 Pneumococcal serotypes and vaccinationsa
S. pneumoniae All patients Splenectomy Hyposplenism Vaccine failure

serotypeb (n = 21) (n = 14) (n = 7) (n = 3)
6A13 3 (14%) 3 (43%)

6B7,10,13,23 1 (5%) 1 (7%) 1 (33)
7F10,13,23 3 (14%) 2 (14%) 1 (14%) 1 (33)
10A23 3 (14%) 2 (14%) 1 (14%) 1 (33)
15C 1 (5%) 1 (7%)
19A13,23 1 (5%) 1 (7%)
22F23 1 (5%) 1 (7%)
23B 2 (10%) 2 (14%)
23F7,10,13,23 2 (10%) 2 (29%)
24F 1 (5%) 1 (7%)
31 1 (5%) 1 (7%)
35F 2 (10%) 2 (14%)
a
Total strains covered by vaccine: 11 (52%) by PPV-23, 3 (14%) by PCV-7, 6 (28%) by PCV-10, and 10 (48%) by
PCV-13.
b
Inclusion in vaccine: 7 = PCV-7, 10 = PCV-10, 13 = PCV-13, and 23 = PPV-23.
available vaccines was: PPV-23 52%, PCV-7 14%, PCV-10 28%, PCV-13 48%, and the
combination of PPV-23 and PCV-13, 67%. Serotypes of pneumococci causing meningitis
in patients with hyposplenia were more often covered by PCV-13 compared to serotypes of
pneumococci causing meningitis in splenectomized patients (86% vs. 28%; p = 0.02). For 517
of 662 pneumococcal meningitis patients with a normal splenic function the serotype of the
pneumococcal isolate was available: the coverage rate of PPV-23 among these pneumococci
was higher as compared to those causing infection in patients with splenic dysfunction
(88% vs. 52%; p = 0.002).
Median time between splenectomy or the diagnosis of functional hyposplenism and

meningitis was 16 years (range 1–54 yr). This period was shorter for patients diagnosed
with functional hyposplenism as compared with patients who underwent a splenectomy
(median 5 vs. 23 years; p = 0.003). In patients who were not adequately vaccinated, the time
between splenectomy and pneumococcal meningitis was significantly longer (median time
from splenectomy to infection in vaccinated patients 10 year vs. 28 years in non-vaccinated
patients; p = 0.03). Distant foci of infection were identified on admission in 7 of 24 patients
(29%) and consisted of pneumonia in 5 (21%) and otitis or sinusitis in 2 patients (8%). Six
patients (25%) had additional causes of immunodeficiency, consisting of immunosuppressive
medication in 4 (17%), and alcoholism and HIV infection each in 1 (4%). Patients with
splenic dysfunction less frequently presented with ear- and sinus infections as compared
36

Chapter 3
with 662 patients with pneumococcal meningitis with presumed normal spleen function

(Table 3.3; p = 0.001).
Most patients presented with classic symptoms and signs of bacterial meningitis (Table 3.1).
The triad of fever, neck stiffness and altered mental status was present in 10 of 24 patients
(42%). Signs of septic shock at presentation (defined as systolic blood pressure ≤90 mm Hg,
diastolic blood pressure <60 mm Hg and/or heart rate ≥120/min) were present in 8 patients
(33%). Splenectomized patients tended to present more often with septic shock compared to
those with functional hyposplenism (63% vs. 19%; p = 0.06) and more often presented with
signs of septic shock compared to patients with a normal spleen (63% vs. 24%; p = 0.02).
Lumbar puncture was performed in all patients. Independent predictors of bacterial

meningitis (CSF leucocyte count >2000 cells/mL, neutrophil count >1180 cells/mL, glucose
Table 3.3 Comparison among 24 patients with pneumococcal meningitis and abnormal splenic function
and 662 patients with pneumococcal meningitis and normal splenic functiona,b
Abnormal spleen Normal spleen

Characteristicc (n = 24) (n = 662) p-value
Mean age, y (range) 54 (24–77) 59 (17–93) 0.20

Male/female sex 12/12 328/334 0.97
Ear or sinus infection
Pneumonia
2 (8)
5 (21)
283 (43)
69 (10)
0.01
0.12
3
Signs of septic shockc 8 (33) 156 (24) 0.27
Index of CSF inflammation
WBC count; median cells/mm3 (IQR) 392 (144–5141) 2818 (604–7700) 0.08
WBC <1000/mm3 16/23 (70) 185/608 (30) <0.001
Complications
Required mechanical ventilation 11 (46) 250 (38) 0.42
Circulatory shock 2 (8) 69 (10) 0.54
Hemiparesis 7 (29) 48 (7) 0.001
Hearing impairment 5 (21) 163 (25) 0.67
Pneumonia 7 (29) 57 (9) 0.004
Blood cultures positive for S. pneumoniae 16 (67) 470 (71) 0.64
Serotype not covered by PPV23 or PCV7 10/21 (48) 62/517 0.002
Mortality 7 (29) 116 (18) 0.16
Unfavorable outcome 14 (58) 271 (41) 0.09
Sequelae at discharge 8/18 (44) 56/546 (10) 0.002
a
CSF = cerebrospinal fluid; IQR = interquartile range; PCV7 = 7-valent pneumococcal conjungate vaccine;
PPV23 = 23-valent pneumococcal vaccine; WBC = white blood cell.
b
Data are No./total No. evaluated (%) unless otherwise indicated.
c
Defined as a systolic blood pressure ≤90 mmHg, a diastolic blood pressure <60 mmHg and/or heart rate
≥120/min.
37

level <1.9 mmol/L, protein level >2.2 g/L or CSF-blood glucose ratio <0.23) were present in 20
of 24 (83%) patients.16 A CSF white blood cell count less than 1000 per mm3, was found in 70%
of patients with splenic dysfunction compared to 30% of pneumococcal meningitis patients
with normal spleen function (p < 0.001). The CSF Gram staining revealed pneumococci in
19 of 22 patients (86%) in whom Gram staining was performed.
Cranial computed tomography (CT) was performed on admission in 19 patients and revealed
abnormalities in 13 patients (68%): sinus and mastoid opacification in 7, hypodensity suspect
for cerebral infarction in 4, brain edema in 3, and hydrocephalus in 1 patient. Antibiotics
were started before CT in 9 of 19 patients (47%). The delay of initiation with antibiotics
due to cranial imaging was not associated with unfavorable outcome (p = 0.46). Antibiotics
with adequate microbiological coverage were started in all but one patient. This patient was
initially treated with ciprofloxacin, which is considered inadequate for S. pneumoniae;17
therapy was switched to amoxicillin after culture results became available, but this patient
died 11 days after admission. Adjunctive dexamethasone therapy was administered in 21
patients (88%); all started with the first dose of antibiotics, 40 mg per day for 4 days. Two
patients were not treated with high dose steroids because of septic shock.
Neurologic complications developed in 7 patients (29%; Table 3.3). A high proportion of

patients developed pneumonia (29%) during admission and required mechanical ventilation.
Patients with splenic dysfunction more frequently had pneumonia during clinical course and
neurological deficits at discharge as compared to patients without splenic dysfunction (p =
0.004 and p = 0.016; Table 3.3). Outcome was unfavorable in 14 patients (58%), of whom 6
patients died (25%). In 2 patients care was withdrawn because of a poor neurologic prognosis,
in 3 patients cause of death was cardiorespiratory failure, and 1 patient died of multiorgan
failure. Three of 12 surviving patients (25%) were vaccinated after their current episode of
pneumococcal meningitis: all received PPV-23 and 1 patient additionally received PCV-7.
Three patients (25%) did not receive vaccinations despite their episode of pneumococcal
meningitis and history of splenectomy.
Discussion
Splenectomy or functional hyposplenia is an uncommon risk factor for bacterial meningitis
but it results in a high rate of mortality and unfavorable outcome (58.3%). All patients had
pneumococcal meningitis and most patients were not adequately vaccinated against S.
38

Chapter 3
pneumoniae. Therefore, vaccination coverage and education about infectious risks in patients

with an absent or dysfunctional spleen should be stressed in these patients.
The proportion of patients with splenic dysfunction in our cohort (overall, 2%; pneumococcal
meningitis, 4%) was lower than previously identified. A retrospective study including 269
patients with community-acquired bacterial meningitis reported rates of 3.5% overall, and
10% among patients with pneumococcal meningitis.18 A retrospective study in a tertiary
hospital reported splenic dysfunction in 10 of 87 patients with pneumococcal meningitis
(12%).19 Our study was performed prospective and nationwide and, therefore, we were able
to study a representative sample of bacterial meningitis patients.
Patients after splenectomy or with functional hyposplenia have a well-known risk for severe
invasive pneumococcal infections. Nevertheless, many of our patients were not adequately
vaccinated against S. pneumoniae. According to current guidelines, adults with asplenia of
hyposplenia should be vaccinated with PPV-23 every 5 years.14,20,21 The additional benefit
of PCV vaccines for adults remains unclear, although some experts advise combined
use of PPV-23 and PCV.14,22 A study in the United Kingdom, including 77 patients with
fulminant invasive pneumococcal disease after splenectomy, found only 30% of patients
were adequately vaccinated against S. pneumoniae, which is similar to our study’s finding.23
A recent survey study showed that about 85 to 90% of the Dutch patients receive the PPV-23
after splenectomy.24 Studies have found up to 50% of splenectomized patients are unaware
of their increased risk of infections.23,25 A workgroup of the British Committee for Standards 3
in Haematology recommends to provide patients with splenic dysfunction medical alert
carts or bracelets with mention of diminished or absent splenic function and vaccination
status.14 Furthermore, prophylactic antibiotics should be offered to patients considered at
continued high risk of pneumococcal infection and all patients are advised to carry a supply
of antibiotics for emergency use.14
In our study, 3 three patients were infected with a pneumococcus with a serotype included
in the vaccine despite multiple immunizations. Two of these patients were splenectomized
and 1 was hyposplenic after bone marrow transplantation. Pneumococcal vaccination is
recommended for all patients after allogeneic bone marrow transplantations,26 but the
optimal timing is unclear. A survey among 107 European hospitals showed the time of first
vaccination varied between 6 and 12 months after transplantation.27 Early vaccination is
possible, although only useful when the host immune response is restored after transplant.28
In our study, 2 bone marrow transplant patients developed meningitis within the first year
39

after transplantat and before vaccination was initiated. In the 3 other bone marrow transplant
patients, meningitis developed 5 to 14 years after transplantation.
Hyposplenism was diagnosed during admission in 2 patients and by post-mortem

examination in 1. In 1 of these 3 patients the pneumococcal meningitis episode was a
recurrence of pneumococcal disease. Although splenic dysfunction has been described as an
uncommon cause of recurrent invasive pneumococcal disease and recurrent meningitis,29,30
functional hyposplenia should be considered in patients with recurrent pneumococcal
meningitis without anatomical defect or disorder affecting the immune system.31 Hyposplenia
can be diagnosed by identification of Howell-Jolly bodies in blood, a small spleen on CT or
ultrasound, and by functional imaging with Tc99m-radiolabelled erythrocytes.32
Patients with splenic dysfunction were more often found to have less than 1000 leukocytes
in the CSF compared to patients with normal spleen function. Previously, a low CSF white
blood cell count has been associated to signs of sepsis and systemic complications.33 This
was also noted in patients with splenic dysfunction that had an increased risk of developing
pneumonia during admission, and in patients with hyposplenism who more often presented
with signs of septic shock. This resulted in a high rate of unfavourable outcome (58%).
Our study has several limitations. First, patients with splenic dysfunction are prone to
develop overwhelming postsplenectomy infection (OPSI), and in these patients concomitant
meningitis may be overlooked. Patients with severe septic shock may not undergo lumbar
puncture, as sepsis is frequently associated with coagulation disorders, such as disseminated
intravascular coagulation. Therefore, these patients are probably only partly represented
in our cohort, which can lead to an underestimation of the rate of sepsis and unfavorable
outcome among this population. Furthermore, not all conditions that may lead to acquired
functional hyposplenism (e.g. sickle cell disease, allogeneic bone marrow transplantation,
celiac disease) were scored in our case-record forms. Although all discharge letters were
screened for these conditions, patients may have been missed and the incidence may be an
underestimation.
Conclusion
Splenic dysfunction is a relatively uncommon cause of pneumococcal disease that can be
prevented with adequate vaccination and education, although vaccine failures also occur. In
our study, a substantial part of episodes were caused by serotypes not included in vaccines.
40

Chapter 3
Increased awareness of patients with splenic dysfunction and their physicians about the risk

of pneumococcal meningitis and preventive measures is needed to reduce the mortality and
morbidity in this patient population.
References
1. Brouwer MC, Tunkel AR, van de Beek D. Epidemiology, diagnosis, and antimicrobial treatment
of acute bacterial meningitis. Clin Microbiol Rev. 2010; 23: 467–492.
and prognostic factors in adults with bacterial meningitis. N Engl J Med. 2004; 351: 1849–1859.
4. Heckenberg SG, Brouwer MC, van der Ende A, Hensen EF, van de Beek D. Hearing loss in adults
surviving pneumococcal meningitis is associated with otitis and penumococcal serotype. Clin
Microbiol Infect. 2012; 18: 849-855.
5. Hoogman M, van de beek D, Weisfelt M, de Gans J, Schmand B. Cognitive outcome in adults after
bacterial meningitis. J Neurol Neurosurg Psychiatry. 2007; 78: 1092-1096.
6. Brouwer MC, de Gans J, Heckenberg SG, Zwinderman AH, van der Poll T, van de Beek D. Host
genetic susceptibility to pneumococcal and meningococcal disease: a systematic review and meta-
analysis. Lancet Infect Dis. 2009; 9: 31–44.
3
7. Aavitsland P, Froholm LO, Hoiby EA, Lystad A. Risk of pneumococcal disease in individuals without
a spleen. Lancet. 1994; 344: 1504.
8. DiSabatino A, Carsetti R, Corazza GR. Post-splenectomy and hyposplenic states. Lancet. 2011;
378: 86-97.
9. Cuthbert RJ, Iqbal A, Gates A, Toghill PJ, Russell NH. Functional hyposplenism following allogeneic
bone marrow transplantation. J Clin Pathol. 1995; 48: 257-259.
10. William BM, Corazza GR. Hyposplenism: a comprehensive review, part I: basic concepts and
causes. Hematology. 2007; 12: 1-13.
11. Jenks PJ, Jones E. Infections in asplenic patients. Clin Microbiol Infect. 1996; 1: 266-272.
12. Kyaw MH, Holmes EM, Toolis F, et al. Evaluation of severe infection and survival after splenectomy.
Am J Med. 2006; 119: 276-277.
13. Morris DH, Bullock FD. The importance of the spleen in resistance to infection. Ann Surg. 1919;
70: 513-521.
41

14. Davies JM, Lewis MP, Wimperis J, Rafi I, Ladhani S, Bolton-Maggs PH. Review of guidelines
for the prevention and treatment of infection in patients with an absent or dysfunctional spleen:
prepared on behalf of the British Committee for Standards in Haematology by a working party of
the Haemato-Oncology task force. Br J Haematol. 2011; 155: 308-317.
15. Brouwer MC, Heckenberg SG, de Gans J, Spanjaard L, Reitsma JB, van de Beek D. Nationwide
implementation of adjunctive dexamethason therapy for pneumococcal meningitis. Neurology.
2010; 75: 1533-1539.
16. Spanos A, Harrel FE Jr, Durack DT. Differential diagnosis of acute meningitis: an analysis of the
predictive value of initial observations. JAMA. 1989; 262: 2700-2707.
17. Hoban DJ, DoernV, Fluit AC, Roussel-Delvallez M, Jones RN. Worldwide prevalence of antimicrobial
resistance in Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis in
the SENTRY Antimicrobiol Surveillance Program, 1997-1999. Clin Infect Dis. 2001; 32: S81-S93.
18. Benca J, Lesnakova A, Holeckova K, et al. Pneumococcal meningitis in community is frequent

after craniocerebral trauma and in alcohol abusers. Neuro Endocrinol Lett. 2007; 28: 16-17.
19. Kastenbauer S, Pfister HW. Pneumococcal meningitis in adults: spectrum of complications and
prognostic factors in a series of 87 cases. Brain. 2003; 126: 1015-1025.
20. Davidson RN, Wall RA. Prevention and management of infections of patients without a spleen.
Clin Microbiol Infect. 2001; 7: 657-660.
21. Newland A, Provan D, Myint S. Preventing severe infection after splenectomy. BMJ. 2005; 331:
417-418.
22. Meerveld-Eggink A, de Weerdt O, Rijkers GT, van Velzen-Blad H, Biesma DH. Vaccination
coverage and awareness of infectious risks in patients with an absent or dysfunctional spleen in
the Netherlands. Vaccine. 2008; 26: 6975-6979.
23. Waghorn DJ. Overwhelming infection in asplenic patients: current best practice preventive measures
are not being followed. J Clin Pathol. 2001; 54: 214-218.
24. Lammers J, Veninga D, Speelman P, Hoekstra J, Lombarts K. Perfomrance of Dutch hospitals in

the management of splenectomized patients. J Hosp Med. 2010; 5: 466-470.
25. Kinnersley P, Wilkinson CE, Srinivasan J. Pneumococcal vaccination after splenectomy: survey of
hospital and primary care records. BMJ. 1993; 307: 1398-1399.
26. Ljungman P, Engelhard D, de la Camara R, et al. Vaccination of stem cell transplant recipeints:
recommendations of the Infectious Diseasses Working Party of the EBMT. Bone Marrow Transplant.
2005; 35: 737-746.
27. Ljungman P, Cordonnier C, de Bock R, et al. Immunisations after bone marrow transplantation:
results of a European survey and recommendations from the infectious diseases working party of
the European Group for Blood and Marrow Transplantation. Bone Marrow Transplant. 1995; 15:
455-460.
28. Meerveld-Eggink A, van der Velden AMT, van de Loosdrecht AA, Ossenkoppele GJ. Vaccination
after stem cell transplantation: is it worthwhile? Ned Tijdschr Hematol. 2010; 7: 275-281.
42

Chapter 3
29. Adriani KS, van de Beek D, Brouwer MC, Spanjaard L, de Gans J. Community-acquired recurrent

bacterial meningitis in adults. Clin Infect Dis. 2007; 45: e46-e51.
30. Mufson MA, Hao JB, Stanek RJ, Norton NB. Clinical features of patients with recurrent invasive
Streptococcus pneumoniae disease. Am J Med Sci. 2010; 343: 303-309.
31. Tebruegge M, Curtis N. Epidemiology, etiology, pathogenesis, and diagnosis of recurrent bacterial
meningitis. Clin Microbiol Rev. 2008; 21: 519-537.
32. William BM, Thawani N, Sae-Tia S, Corazza GR. Hyposplenism: a comprehensive review, part II:
clinical manifestations, diagnosis, and management. Hematology. 2007; 12: 89-98.
33. Weisfelt M, van de Beek D, Spanjaard L. Reitsma JB, de Gans J. Attenuated cerebrospinal fluid
leukocyte count and sepsis in adults with pneumococcal meningitis: a prospective cohort study.
BMC Infect Dis. 2006; 6: 149.
43

Chapter 4
Bacterial meningitis in pregnancy:
report of 6 cases and review of the
literature
Kirsten S Adriani, Matthijs C Brouwer, Arie van der Ende,
Clinical Microbiology and Infection 2012; 18: 345-351.

Chapter 4 Bacterial meningitis in pregnancy
Abstract
Few cases of bacterial meningitis during pregnancy have been reported in the literature,
and the causative microorganisms and prognosis of bacterial meningitis during pregnancy
are unclear. In a 6-year period we identified 6 cases of bacterial meningitis in pregnant
women. All were multigravida and gestational age at presentation ranged from 5 to 39 weeks.
Predisposing factors were present in 5 patients and consisted of otitis in 4 patients. The
causative organism was Streptococcus pneumoniae in all patients. Two patients died, both due
to florid septic shock and brain herniation. Fetal outcome was good in 5 cases; 1 woman had
a miscarriage 3 weeks after the episode of bacterial meningitis. We reviewed the literature
on bacterial meningitis during pregnancy and identified 42 cases of bacterial meningitis.
Twenty-five of these patients had pneumococcal meningitis and 7 had meningitis caused by
L. monocytogenes. We found that pneumococcal meningitis during pregnancy can be rapidly
fatal and is associated with fetal death, especially in the first trimester. L. monocytogenes
meningitis was associated with a high rate of neonatal deaths.
46

Chapter 4
Introduction
Bacterial meningitis in pregnancy

Community-acquired bacterial meningitis is a serious and life-threatening disease. The
estimated incidence is 2.6–6 per 100,000 adults per year in developed countries and
Streptococcus pneumoniae and Neisseria meningitidis are the leading causes.1-3 Few cases of
bacterial meningitis have been described during pregnancy, and the causative microorganisms
and prognosis of bacterial meningitis during pregnancy are unclear. During pregnancy,
immunosuppressive cytokines are produced by the placenta and foetus to avoid immunological
attack by the mother.4 This does not lead to increased susceptibility to most infectious diseases,
including pneumococcal disease, and usually infections in pregnant woman are no more
serious than in non-pregnant women.4,5 An exception is infection by Listeria monocytogenes,
which seems to have a predilection for pregnant women and may result in pregnancy loss.6 In
a 6-year period we identified 6 cases of bacterial meningitis during pregnancy and combined
these data with cases identified in a review of the literature. In this review we describe
epidemiology, clinical characteristics and outcome of bacterial meningitis during pregnancy.
Cases
From 2005 to 2010 we identified 6 episodes of bacterial meningitis in pregnant women
(Table 4.1). Four patients were aged over 35 years and all were multigravida. Gestational age
at presentation ranged from 5 to 39 weeks, and pregnancies had been without complications
up to the development of bacterial meningitis. Predisposing factors for meningitis were
present in 5 patients and consisted of otitis in 4. One patient had remote head injury 5 years
before the episode of meningitis for which a craniotomy was performed. Five patients had
4
symptoms for <24 h and all presented with a decreased level of consciousness. One patient
had a 2-week history of malaise and otitis, for which she was treated with oral antibiotics.
Neurological examination revealed neck stiffness in all but one.
Lumbar puncture was performed in all patients and CSF analyses were indicative of bacterial
meningitis in all patients. CSF-Gram stain of all patients showed Gram-positive cocci and
CSF cultures grew penicillin-susceptible Streptococcus pneumoniae. Initial therapy consisted
of monotherapy with third-generation cephalosporin in 3 patients and penicillin in 2
patients. One patient received a combination of amoxicillin and ceftriaxone. Four patients
were treated with adjunctive dexamethasone 4 dd 10 mg QID and 1 patient was treated with
betamethasone for fetal lung maturation.
47

48
Chapter 4
Table 4.1 Clinical characteristics and laboratory findings for 6 pregnant patients with bacterial meningitis
Characteristics Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6
Age (year) 43 36 28 40 30 38
Parity G12P9 G2P2 G2P1 G4P2 G3P2 G2P1
Gestational age at presentation (weeks) 29 36 5 39 36 37
Predisposing factor Otitis Otitis None Otitis Remote head injury Otitis
Symptoms on admission
Temperature (°C) 39.1 38.9 38.2 38.7 39.3 39.6
Neck stiffness Yes Yes Yes Yes No Yes
Score on GCSa 11 11 13 15 11 13
Signs of circulatory shockb No No No No Yes No
Computed tomography (CT) brain on Diffuse brain Diffuse brain Normal Mastoid Remote craniotomy Normal
admission swelling swelling opacification,
intracranial air
CSF indexes of inflammation

White cell count (per mm3) 200 1213 4500 13300 1930 8688
Protein (g/l) 4.2 2.6 2.5 3.9 1.1 2.5
Glucose (mM) <0.1 0.2 0.2 0.1 0.5 <0.1
Gram stain Gram-positive Gram-positive Gram-positive Gram-positive Gram-positive Gram-positive
cocci cocci cocci cocci cocci cocci
Culture S. pneumoniae S. pneumoniae S. pneumoniae S. pneumoniae S. pneumoniae S. pneumoniae
19-8-2015 9:16:28
Initial antibiotic therapy Ceftriaxone Penicillin Amoxicillin, Ceftriaxone Penicillin Cefotaxim
ceftriaxone
Adjunctive dexamethasone No Yes Yes No Yes Yes
Complications during admission Sepsis, brain Sepsis, brain None None Sepsis, herpes Hemiparesis
herniation herniation stomatitis
Maternal outcome Death Death Good recovery Good recovery Good recovery Good recovery
Fetal outcome Preterm birth, Good Miscarriage Good Good Good

good
Mode of delivery Emergency Emergency - Spontaneous Emergency Emergency

caesarian section caesarian section vaginal delivery caesarian section caesarian section
a
GCS = Glasgow Coma Scale, scores range from 3 to 15, with 15 indicating a normal level of consciousness.
b
Defined as a systolic blood pressure ≤90 mmHg, a diastolic blood pressure <60 mmHg and/or heart rate ≥120/min.
49
Bacterial meningitis in pregnancy Chapter 4
4
19-8-2015 9:16:28
Complications developed during admission in 4 patients and consisted of septic shock in 2

patients (patients 1 and 2). These 2 patients also developed clinical signs of brain herniation
(deterioration of consciousness, bradycardia and fixed and dilated pupils) and died shortly
after admission. Cranial computed tomography (CT) showed generalized cerebral oedema
in both patients. Time from disease onset to death was <6 h in both patients. The patient
presenting with septic shock (patient 5) developed a deterioration of consciousness
during admission, but finally recovered without sequelae. Patient 6 developed a left-sided
hemiparesis without abnormalities on cranial CT and recovered without sequelae.
Emergency Caesarean section was performed in 4 patients (gestational age 29, 36, 36 and
37 weeks) and all children were in good health. One patient gave birth to a healthy child
2 days after meningitis was diagnosed. The patient in the first trimester of pregnancy had
a miscarriage at 9 weeks gestation, 3 weeks after the meningitis episode. Another specific
cause of the miscarriage was not identified. In 2 of 4 patients with otitis an otolaryngologist
was consulted (patient 2 and 6), who performed paracentesis.
Review of the literature

PubMed was searched using Entrez for articles published to 20 September 2010 using search
terms ‘bacterial meningitis’ and ‘pregnancy’ in the English, French and German language.
Additional studies were identified by a search of references listed in those published studies.
The search retrieved 136 studies and 18 were relevant to our review. A total of 42 cases
of bacterial meningitis during pregnancy were reported. The most common causative
microorganisms were S. pneumoniae (25 cases; 60%) and L. monocytogenes (7 cases; 17%).7-
19
Pathogens in other cases were Neisseria meningitidis (2 cases), Haemophilus influenzae (1
case), Group A streptococci (2 cases), Group B streptococci (2 cases), Neisseria gonorrhoea
(2 cases) and Pasteurella multocida (1 case).20-29
Six of the 25 cases of pneumococcal meningitis during pregnancy were included in a previous
review study,7 and 15 were reported in a Nigerian case series performed from 1958 to 1962
(Table 4.2).15 Combining these patients with those from our case series, we found the average
age was 33 years and all 31 patients were multigravida. Otitis and sinusitis were the most
common predisposing conditions, present in nine of 15 reported patients (60%). Five patients
presented in the first trimester of pregnancy (17%), eight in the second trimester (27%) and
17 episodes occurred in the third trimester (57%). Overall maternal mortality rate was 28%
50

Chapter 4
and 11 pregnancies (37%) resulted in miscarriage, stillbirth or neonatal death. No maternal

deaths occurred when pneumococcal meningitis occurred in the first trimester.
We identified 7 cases of L. monocytogenes meningitis during pregnancy in the literature

(Table 4.3).18,19 The average age of pregnant women with L. monocytogenes meningitis was
26 years. All of the reported cases were diagnosed at the end of the second trimester or at
the beginning of the third trimester. One patient was diagnosed with tuberculous meningitis
and developed a superinfection with L. monocytogenes.18 No predisposing conditions for
L. monocytogenes infection were identified other than pregnancy. There was a high rate of fetal
loss: 4 of 7 (56%) pregnancies ended in neonatal death. There were 2 maternal deaths (29%).
Although meningococcal meningitis is the most frequent cause of invasive disease in

adolescents,30 only 2 cases of meningococcal meningitis were reported during pregnancy.20,21
The first patient was a 34-year-old primigravida in her second trimester, presenting with
Waterhouse-Friderichsen syndrome.20 Eight days after admission she delivered a stillborn
baby and 1 day later she died. The second case report concerned a 19-year-old primigravida
in the third trimester, who developed meningococcal meningitis after an episode of sinusitis.21
The clinical course was complicated by multiple epileptic seizures, and she recovered
incompletely with a facial palsy. The child was born healthy at term.
Neisseria gonorrhoeae meningitis during pregnancy was reported in 2 cases.27,28 Although

most cases of gonococcal meningitis were reported before antibiotics were available, the
cases in pregnant women were reported recently (2006 and 2008).31 In both cases mother
and child were well after treatment.
Meningitis due to H. influenzae, group A and B streptococci, has been described in a few 4
case reports only.22-26 These microorganisms infrequently cause bacterial meningitis in adults
and an increased frequency during pregnancy can not be established. None of these patients
had specific characteristics predisposing to bacterial meningitis due to these pathogens.
One patient with group B streptococcal meningitis was found to have an ectopic pregnancy
during admission for which she received surgery.
One case of Pasteurella multocida meningitis in pregnancy is described.29 This patient

was infected by her cat or dog, in whom P. multocida was cultured from saliva. Pasteurella
multocida is part of the commensal flora of the respiratory and gastrointestinal tracts of cats
and dogs, and is not a common cause of infections in humans.
51

52
Chapter 4
Table 4.2 Patients reported in the literature with pneumococcal meningitis during pregnancy
Author Lucas15 Landrum7 Bakaya17 Vives13 Felisati16 Iinuma14 Present study Total
Study period 1958–1962 1962–2006 1967 1996 2004 2007 2005–2010 1958–2010
Study type Case series Case report and Case report Case report Case report Case report Case series
review
No. of cases 15 6 1 1 1 1 6 31
Mean age (range) Not reported 30 (21–38) 31 36 39 30 36 (28–43) 33 (21–43)
Predisposing factors Not reported 1 otitis Multiple Sinusitis Mastoiditis, None 4 otitis 9/16 otitis/sinusitis (56%)
1 pneumonia pneumococcal sinusitis and 1 remote head 1/16 pneumonia (6%)
2 sinusitis infections otitis injury 1/16 remote head injury (6%)
1/16 pneumococcal infections (6%)
Gestational age at
presentation
1st trimester 3 1 0 0 0 0 1 4 (14%)
2nd trimester 5 1 0 1 0 1 0 8 (28%)
3rd trimester 7 4 1 0 1 0 5 17 (59%)
Multigravida Not reported All Yes Yes Not reported Yes All All reported
19-8-2015 9:16:29
Maternal outcome 8 deaths (28%)
1st trimester 3 recovered 1 recovered 1 recovered 5 recovered (100%)
2nd trimester 2 deaths 1 recovered 1 death 1 recovered 1 death 4 deaths (50%)
3 recovered 4 recovered (50%)
3rd trimester 7 recovered 2 deaths 1 recovered 2 deaths 4 deaths (22%)
2 recovered 3 recovered 14 recovered (78%)
Fetal outcome 11 deaths (38%)

1st trimester 2 miscarriages 1 term birth 1 miscarriage 3 miscarriages (60%)
1 term birth 2 term births (40%)
2nd trimester 2 miscarriages 1 term birth 1 preterm birth 1 miscarriage 3 miscarriages (38%)
2 term births 1 preterm birth (13%)
1 patient died 1 patient died undelivered (13%)
undelivered 3 term births (38%)
3rd trimester 1 stillbirth 2 neonatal deaths 1 term birth 1 preterm birth 1 preterm birth 1 stillbirth (5%)
1 neonatal death 1 preterm birth 4 term births 3 neonatal deaths (17%)
1 preterm birth 1 term birth 4 preterm births (22%)
4 term births 10 term births (56%)
a
The patient had a miscarriage shortly before admission and died on the 16th day of admission.
53
Bacterial meningitis in pregnancy Chapter 4
4
19-8-2015 9:16:29
54
Chapter 4
Table 4.3 Patients reported in the literature with bacterial meningitis during pregnancy due to microorganisms other than S. pneumoniae
Neisseria Haemophilus Group A Group B Listeria Neisseria Pasteurella

Causative organism meningitidis20,21 influenzae22 streptococci23,24 streptococci25,26 monocytogenes18,19 gonorrhoea27,28 multocida29 Total
No. of cases 2 1 2 2 7 2 1 17
Age (year) 19 and 34 22 33 and 30 27 and 28 26 (average) 21 and 14 35 26 (average)
a
Predisposing factors 1 sinusitis, 1 URI URI None None 1 tuberculous None None 4/17 (24%)
meningitis
Gestational age at presentation

1st trimester 0 0 0 1 0 0 0 1/10 (10%)
2nd trimester 1 0 0 0 All 2nd or 3rd 1 1 3/10 (30%)
3rd trimester 1 1 2 1 trimester 1 0 6/10 (60%)
Multigravida 0/2 NRb 2/2 NR 2/7 0/2 NR 2/13 (31%)
Maternal outcome
Death 1 2 3/17 (18%)
Neurological sequelae 1 1 2/17 (11%)
Complete recovery 1 2 1 5 2 1 12/17 (70%)
Fetal outcome
Fetal death 1c 1c 4/7 (57%)c 6/16 (38%)
Preterm birth 1 1/16 (6%)
Term birth 1 1 1 1 3 1 1 9/16 (56%)
a
URI = upper respiratory infection. b NR = not reported. c Neonatal death.
19-8-2015 9:16:29
Chapter 4
Discussion

Bacterial meningitis during pregnancy is an uncommon disease, with substantial mortality
for both mother and child. In a 6-year period we identified 6 cases of community-acquired
pneumococcal meningitis during pregnancy in the Netherlands. No episodes of bacterial
meningitis due to other microorganisms were found in a nationwide cohort study
performed from 2006 to 2009, in which 4 out of 6 pneumococcal meningitis episodes were
identified.32 Combining our data with previous reports we found S. pneumoniae in 52% and
L. monocytogenes in 16% of bacterial meningitis episodes during pregnancy.
Patients in our cases-series were relatively old compared with previous studies of pneumo-
coccal meningitis during pregnancy:7-17 4 of 6 women were over 35 years. This is probably
explained by the higher age of childbearing in the Netherlands.33
All patients in our study and all patients reported after 1962 with pneumococcal meningitis
were multigravida, in contrast to meningitis in pregnancy caused by other bacteria.
Maternal age and parity have previously not been associated with an increased rate of other
pneumococcal infections such as pneumonia.34 Otitis was found to be the most important
risk factor in developing pneumococcal meningitis in pregnant women. Combining our
results with previous reports, the incidence of otitis and sinusitis in pregnant patients was
54%.15 The incidence of otitis and sinusitis during pregnancy is unclear, but has not been
reported to be increased compared with the normal population.
A previous study suggested pregnancy to be a predisposing condition for pneumococcal

meningitis.14 However, as B-cell immunity during pregnancy is normal, susceptibility to
infections by S. pneumoniae is unchanged.4 The small number of reported cases in the
4
literature does not support a higher incidence of pneumococcal meningitis in pregnancy. The
annual birth rate in the Netherlands is approximately 200,000/year,33 resulting in an estimated
incidence of 0.5 cases of pneumococcal meningitis per 100,000 successful pregnancies. This
rate is lower than the overall incidence of pneumococcal meningitis in adults (1.3/100,000).35
In our patients and previous studies pneumococcal meningitis occurring in the first trimester
appears to have a relatively good prognosis, as no deaths occurred in a total of 5 reported
patients.7,9,15 However, miscarriages are common in these women as 3 of 5 had spontaneous
abortions (60%). The cause of spontaneous abortion in these women was unknown. Miscar-
riages have been described following other pneumococcal infections such as pneumonia but
the incidence and mechanism are unknown.34 Septic shock and multi-organ failure in the
55

mother have been described as possible mechanisms for fetal death, but these conditions
do not apply to the patient in our case series.9
In our literature review, we identified L. monocytogenes as the second most common cause of
bacterial meningitis during pregnancy.18,19 Pregnancy has been identified as a risk factor for
Listeria monocytogenes infection and maternal infection may result in fetal loss, stillbirth or
invasive disease in the newborn.36 It is estimated that 16% of invasive L. monocytogenes infec-
tions occur in pregnant women.36 Maternal illness is usually mild, and often asymptomatic
or self-limiting.37 The mortality rate in pregnant patients with bacterial L. monocytogenes
meningitis was, however, substantial, with 2 deaths in 7 patients (29%). This is higher than
the 17% described in non-pregnant adults with L. monocytogenes meningitis.38 The rate of
fetal loss was high: in 4 of 7 cases (57%) there was a neonatal death, which is considerably
higher than the reported 23% neonatal mortality in L. monocytogenes infections in general.36
The incidence of L. monocytogenes meningitis in pregnant women is unclear. In our

literature review we identified only 7 case reports.18,19 However, a study of 283 episodes of
L. monocytogenes infections, including 128 cases of meningitis and encephalitis, included
15 pregnant women.37 This study did not specify how many of the pregnant women had
meningitis and could therefore not be included in our review. In a nationwide prospective
study on L. monocytogenes meningitis none of the included 30 episodes occurred during
pregnancy.38 Although the incidence is probably low, empirical therapy in pregnant women
with bacterial meningitis should cover L. monocytogenes based on our literature review.
Pathogens other than S. pneumoniae and L. monocytogenes causing bacterial meningitis

during pregnancy are rare and only reported in isolated cases. Some of these cases were
associated with specific risk factors, such as sexually transmitted disease (N. gonorrhoea) or
exposure to animal saliva (P. multocida). However, no specific risk factors could be identified
in meningitis cases due to Group A and B streptococci, H. influenzae and N. meningitidis. No
cases of bacterial meningitis during pregnancy due to organisms other than S. pneumoniae
were identified in a nationwide prospective cohort study in the Netherlands, including
518 episodes.32 The risk of meningitis due to organisms other than S. pneumoniae and
L. monocytogenes is therefore considered to be very low.
Current standard therapy for bacterial meningitis includes adjunctive dexamethasone.39 Two
out of six patients with pneumococcal meningitis in our study did not receive adjunctive
dexamethasone; one patient because of antibiotic use prior to admission and the second
patient for unknown reasons. Physicians might be hesitant to administer dexamethasone
56

Chapter 4
in pregnant women as it has been associated with oral clefts when administered in the first

trimester.40 In late pregnancy few side effects have been reported and corticosteroids are
frequently used to improve fetal lung maturation in impending preterm birth. Because of
the beneficial effect of adjunctive dexamethasone on survival in pneumococcal meningitis
and its limited side-effects, its use in pregnant woman seems appropriate.39
Conclusion
We conclude that bacterial meningitis during pregnancy is rare and mostly caused by
S. pneumoniae. Otitis and sinusitis are important predisposing conditions in these patients.
Miscarriages are frequent in pregnant women with pneumococcal meningitis in their first
trimester. The second most common cause is L. monocytogenes, which is associated with a
high rate of neonatal death. Empirical therapy for bacterial meningitis in pregnant women
should therefore cover S. pneumoniae and L. monocytogenes. Despite optimal antibiotic
treatment bacterial meningitis during pregnancy can have a rapidly fatal outcome for mother
and child.
Acknowledgements
We thank the many physicians in the Netherlands for their cooperation and Dr. B.B. Mook-
Kannamori for his assistance.
4
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11. Steiner ZP, Manor Y, Smorjik J, Yaretzky A, Klajman A. Successful postmortem cesarean section
in a case of fulminant pneumococcal meningitis. Isr J Med Sci 1978; 14: 287–288.
12. Tempest B. Pneumococcal meningitis in mother and neonate. Pediatrics 1974; 53: 759–760.
13. Vives A, Carmona F, Zabala E, Fernandez C, Cararach V, Iglesias X. Maternal brain death during
pregnancy. Int J Gynaecol Obstet 1996; 52: 67–69.
14. Iinuma Y, Hirose Y, Tanaka T et al. Rapidly progressive fatal pneumococcal sepsis in adults: a report
of two cases. J Infect Chemother 2007; 13: 346–349.
15. Lucas AO. Pneumococcal meningitis in pregnancy and the puerperium. Br Med J 1964; 1: 92–95.
16. Felisati G, Di Berardino F, Maccari A, Sambataro G. Rapid evolution of acute mastoiditis: three
case reports of otogenic meningitis in adults. Am J Otolaryngol 2004; 25: 442–446.
17. Bakaya R, Astin TW. Pneumococcal meningo-encephalitis in pregnancy. J Obstet Gynaecol Br

Commonw 1967; 74: 71–73.
18. Boucher M, Yonekura ML. Listeria meningitis during pregnancy. Am J Perinatol 1984; 4: 312–318.
19. Seeliger H, Leineweber R. Listeria-Meningitis in der schwangerschaft. Munch Med Wochenschr

1952; 94: 2318–2321.
20. Polayes SH, Ohlbaum C, Winston HB. Meningococcus meningitis with massive hemorrhage of
the adrenals’ (Waterhouse-Friderichsen syndrome) complicating pregnancy with pre-eclamptic
toxemia. Am J Obstet Gynecol 1953; 65: 192–196.
21. Williams M. Meningitis and encephalitis in pregnancy. Nurs Mirror Midwives J 1969; 129: 33.
22. Sandberg T, Dahlberg T. Meningitis and septicaemia due to Haemophilus influenzae type b in
pregnancy. BMJ 1981; 282: 946.
23. Ferrazzini G, Peduzzi R, Balestra B. Group A beta-hemolytic streptococcal meningitis in a pregnant

woman. Schweiz Med Wochenschr 1996; 126: 1842–1844.
24. Verhulsdonk MT, Hassell DR, Oei SG. Septic shock as a result of group A beta-hemolytic
streptococcal meningitis with empyema in pregnancy. Int J Gynaecol Obstet 2007; 97: 197–198.
58

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25. Sabadell J, Sanchez-Iglesias JL, Ferrer R, Higueras T, Alijotas J, Cabero L. Cervical pregnancy

complicated with group B streptococcal meningitis. J Matern Fetal Neonatal Med 2007; 20: 423–425.
26. Braun TI, Pinover W, Sih P. Group B streptococcal meningitis in a pregnant woman before the
onset of labor. Clin Infect Dis 1995; 21: 1042–1043.
27. Burgis JT, Nawaz H III. Disseminated gonococcal infection in pregnancy presenting as meningitis
and dermatitis. Obstet Gynecol 2006; 108: 798–801.
28. Martin MC, Pérez F, Moreno A et al. Neisseria gonorrhoeae meningitis in pregnant adolescent.
Emerg Infect Dis 2008; 14: 1672–1674.
29. Rollof J, Johansson PJH, Holst E. Severe Pasteurella multocida infections in pregnant women. Scand
J Infect Dis 1992; 24: 453–456.
30. Stephens DS, Greenwood B, Brandtzaeg P. Epidemic meningitis, meningococcaemia, and Neisseria
meningitidis. Lancet 2007; 369: 2196–2210.
31. Cachay E, Mathewa WC, Reed SL, Swancutt MA, Fierer J. Gonococcal meningitis diagnosed by
DNA amplification: case report and review of the literature. AIDS Patient Care STDS 2007; 21:
4–8.
implementation of adjunctive dexamethasone therapy for pneumococcal meningitis. Neurology
2010; 75: 1533–1539.
33. van Nimwegen N, Beets GCN, van der Erf RF. Bevolking van Europa [Europe’s population]. Demos
2008; 21: 44–48.
34. Shariatzadeh MR, Marrie TJ. Pneumonia during pregnancy. Am J Med 2006; 11: 872–876.
and prognostic factors in adults with bacterial meningitis. N Engl J Med 2004; 351: 1849–1859.
4
36. Jackson KA, Iwamoto M, Swerdlow D. Pregnancy-associated listeriosis. Epidemiol Infect 2010;
138: 1503–1509.
37. Doorduyn Y, de Jager CM, van der Zwaluw WK et al. Invasive Listeria monocytogenes infections
in the Netherlands, 1995–2003. Eur J Clin Microbiol Infect Dis 2006; 25: 433–442.
38. Brouwer MC, van de Beek D, Heckenberg SG, Spanjaard l, de Gans J. Community-acquired Listeria
monocytogenes meningitis in adults. Clin Infect Dis 2006; 43: 1233–1238.
of acute bacterial meningitis. Clin Microbiol Rev 2010; 23: 467–492.
40. Carmichael SL, Shaw GM. Maternal corticosteroid use and risk of selected congenital anomalies.
Am J Med Genet 1999; 86: 242–244.
59

Chapter 5
Common polymorphisms in the
complement system and susceptibility
to bacterial meningitis
Kirsten S Adriani, Matthijs C Brouwer, Madelijn Geldhoff, Frank Baas,
Aeilko H Zwinderman, B Paul Morgan, Claire L Harris, Arie van der Ende,
Journal of Infection 2013; 66(3): 255-262.

Chapter 5 Polymorphisms in complement system and bacterial meningitis
Abstract
Risk factors for susceptibility to bacterial meningitis have been identified, but basic causes
of inter-individual differences in susceptibility are largely unknown.
To determine the effect of genetic variation in the complement system on susceptibility to

bacterial meningitis we performed a prospective nationwide genetic association study in
patients with community-acquired bacterial meningitis. We genotyped 17 common SNPs
(minor allele frequencies >5%) in genes coding for complement components and evaluated
functional consequences by measuring complement levels in the cerebrospinal fluid.
From March 2006 to June 2009 we included 636 adults with community-acquired bacterial
meningitis. DNA was available for 439 patients and 302 controls. Rs1047286 (Pro314Leu) in
complement component 3 was associated with reduced susceptibility to bacterial meningitis
after correction for multiple testing: the protective Leu/Leu genotype was found in 5 of 435
patients (1%) compared to 15 of 302 controls (5%; odds ratio [OR] 4.50, 95% confidence
interval [CI] 1.62–12.50, p = 0.0017). Rs1047286 is in strong linkage disequilibrium with
Rs2230199 (C3 Arg102Gly), of which the Arg/Arg genotype was associated with higher
CSF levels of C3 and lower levels of C5a and terminal complement complex (TCC; soluble
C5b-9), indicating decreased consumption of C3 and less activation of the complement
system. Rs1047286 was associated with susceptibility albeit not significantly after Bonferroni
correction (OR 1.37, 95% CI 1.01–1.87; p = 0.04).
This study shows an association between a common single nucleotide polymorphism in C3

and susceptibility for community-acquired bacterial meningitis.
62

Chapter 5
Introduction
Polymorphisms in complement system and bacterial meningitis

Community-acquired bacterial meningitis is a devastating and life-threatening disease,
even in developed countries, despite effective antibacterial agents and implementation of
childhood vaccination programmes.1,2 Streptococcus pneumoniae and Neisseria meningitidis
are the leading causes of bacterial meningitis, with the first responsible for two thirds of cases
in Europe and the United States.1,3 The fatality rates in patients with meningitis caused by
these microorganisms are substantial, at 26% and 9% respectively, and long-term sequelae,
including hearing loss, focal neurological deficits and cognitive impairment, develop in
about half of the survivors.1-7
Several risk factors for increased susceptibility to infections by pneumococci and menin-
gococci have been identified.1 Invasive meningococcal disease has been related to smoking
and living in the same household as a patient, while pneumococcal disease is associated
with distant foci of infection and immunocompromised state.1,8-10 However, in the majority
of patients the cause for increased susceptibility is unknown.2
Studies in patients with extreme phenotypes, for example patients with recurrent or familial
infections, showed that genetic variation could explain increased susceptibility to pneumo-
coccal or meningococcal infections. Several of these studies identified genetic variants in
genes coding for proteins in the complement system.11
The complement system is an important part of the innate immune system that can be
activated by three distinct activation pathways: the lectin (triggered by mannose binding
lectin; MBL or ficolins), classical (CP) and alternative (AP) pathways.12 The first common
step after activation is cleavage of complement component C3 by the C3 convertase into
C3a and C3b, which eventually results in the formation of the membrane attack complex.12
Genetic variation in the activation pathway proteins C2 (CP), factor D (AP) and properdin 5
(AP) were identified to cause a substantial increase in susceptibility to meningococcal and/
or pneumococcal disease in patients with extreme phenotypes.13-16 Most of these genetic
variations consisted of single nucleotide polymorphism (SNPs).11
Case-control studies on pneumococcal and meningococcal disease have also been performed
although most of the studies lacked power to detect true associations.11 Polymorphisms in
MBL and complement factor H (fH) were associated with an increase in susceptibility.11
In 2010 the first genome wide association study in meningococcal disease described an
SNP (rs1065489) in the gene encoding fH (CFH) associated with increased susceptibility
63

to meningococcal disease.17 fH is an important regulator of the AP and is utilized by N.

meningitidis to escape the host immune response.12,17 This study unambiguously proved a role
for genetic variation in the complement system on susceptibility to meningococcal disease.17
To determine the effect of genetic variation in complement genes on susceptibility to bacterial

meningitis we performed a prospective nationwide genetic association study in patients
with community-acquired bacterial meningitis. By analysing cerebrospinal fluid (CSF),
we examined the potential impact and functionality of two SNPs that were associated with
susceptibility. This study is the first genetic association study focussing on common genetic
variance in complement genes and susceptibility to bacterial meningitis.
Methods
Dutch bacterial meningitis cohort
In the nationwide prospective cohort study we included bacterial meningitis patients older
than 16 years of age with positive cerebrospinal fluid (CSF) cultures who were identified
by the Netherlands Reference Laboratory for Bacterial Meningitis (NRLBM) from March
2006 to June 2009.18 The NRLBM provided the names of the hospitals where patients with
bacterial meningitis had been admitted two to six days previously. The treating physician was
contacted, and informed consent was obtained from all participating patients or their legally
authorized representatives. Physicians familiar with the study could also include patients
through a 24/7-telephone service. Patients with hospital-acquired bacterial meningitis and
negative CSF cultures were excluded. Controls for exposure/susceptibility were patients’
partners or their non-related proxies living in the same dwelling, as household members are
exposed to similar bacteria.18 Controls were excluded if related to the patient. These controls
guaranteed similar socio-economic background of patients and controls. Data on age, sex
and ethnicity of patients and controls were collected. Blood from patients and controls for
DNA extraction was collected in sodium/EDTA. DNA was isolated with the Gentra Puregene
isolation kit (Qiagen) and quality control procedures were performed to determine the yield
of isolation. The research ethics committees of all participating hospitals approved the study.
Genotyping
We selected all SNPs with a minor allele frequency >5% in genes coding for complement
components (C1QA, C1QB, C1QC, C2, C3, C5, C6, C7, C8B, C9, CFD, CFH, CFI and CFP)
64

Chapter 5
for which a commercial genotyping assay was available. A total of 17 common SNPs in

the complement system were genotyped using TaqMan SNP Genotyping Assays (Applied
Biosystems) with 96 × 96 Dynamic Arrays (Fluidigm) by Service XS, Leiden, the Netherlands,
and the Genetics Core Facility in the Academic Medical Center, Amsterdam, the Netherlands.
Laboratory personnel were blinded to clinical information.
To provide 90% power or more for a low frequent (10%) risk genotype with an odds ratio of
2.5 or more the calculated sample size was 400 patients and 300 controls, using a Bonferroni
corrected p-value of 0.0025.
CSF complement analysis
CSF of patients was obtained with the diagnostic lumbar puncture. Subsequently, CSF
and WBC were stored separately at -80 °C. CSF complement component C3 levels were
determined using the C3 Luminex xMAP technology with a Milliplex MAP kit obtained
from Millipore Corp. (St. Charles, MO). CSF complement component C3a, iC3b, C5a and
terminal complement complex (TCC; sC5b-9) levels were determined using the Microvue
C3a, iC3b, C5a and TCC Quidel ELISA kits according to the manufacturer’s instructions.
Strength of relationships between C3, C3a, iC3b, C5a and TCC levels was assessed by
Spearman’s correlation tests.
Statistics
The Mann–Whitney U test was used to identify differences in baseline characteristics

between groups with respect to continuous variables, and dichotomous variables were
compared with use of the χ2 test. These statistical tests were two-tailed, and a p-value of <0.05
was regarded as significant. Differences in genotype frequencies were analysed with the χ2
or Fishers’ exact tests by use of the programs R-statistics and PASW18. For the SNP analysis 5
we used a Bonferroni correction for multiple testing (17 SNPs, p < 0.0029). We calculated
whether the genotype frequencies in white controls concurred with the Hardy–Weinberg
equilibrium (HWE) by use of a χ2 and exact test with one degree of freedom with a p < 0.001
to indicate significance. SNPs deviating from the HWE were excluded from the analysis.
Subgroup analyses were performed for pneumococcal and meningococcal meningitis.
65

Results
From March 2006 to June 2009, 827 episodes of bacterial meningitis were reported by
the Netherlands Reference Laboratory for Bacterial Meningitis and 110 by physicians
(Figure 5.1). A total of 642 episodes of community-acquired CSF culture-proven bacterial
meningitis were included in 636 patients. The distribution of causative bacteria was: S.
pneumoniae in 468 (73%), N. meningitidis in 80 (13%), and other bacteria in 94 (14%). DNA
samples were obtained from 439 patients (68%) and 302 controls. Common reasons for not
collecting DNA were: patient already deceased, blood withdrawal for DNA isolation not
performed, no informed consent, and transfer of the patient between wards or hospitals.
The median age of patients was 59 years (interquartile range [IQR] 41–68) and that of
controls 58 years (IQR 45–66). 210 patients were male (48%) and the ethnicity of majority
937 episodes identified

- 827 reported by reference laboratory
- 110 reported by physician
12 patients were untraceable

17 patients declined consent
20 physicians declined to participate
98 episodes in hospitals with pending
approval by ethics committee
790 episodes evaluated for inclusion
54 negative CSF culture

94 hospital acquired meningitis
642 episodes in 636 patients

- 468 (73%) S. pneumoniae
- 80 (13%) N. meningitidis
- 94 (14%) other micro-organisms
197 patients no DNA available (32%)
DNA available for 439 patients (68%)

- 346 (79%) S. pneumoniae
- 56 (12%) N. meningitidis
- 39 (9%) other micro-organisms
DNA available for 302 matched controls
Figure 5.1 Flowchart of prospective nationwide cohort study of 642 episodes of bacterial meningitis.
66

Chapter 5
of patients was white (415 patients; 94%); demographic characteristics between patients

and controls were similar (Table 5.1). Clinical characteristics and outcome are presented in
Table 5.2 (previously published).19 Genotyping was over 95% successful for all assays. In 16
of 17 assays, genotype frequency of controls concurred with the HWE (Table 5.3). The C8b
rs12067507 SNP did not concur with the HWE and was excluded from further analysis.
We identified the uncommon allele of rs1047286 in complement component C3 (Pro314Leu)

to be associated with a reduced susceptibility to bacterial meningitis. The protective Leu/Leu
genotype was found in 5 of 435 patients (1%) compared to 15 of 302 controls (5%; odds ratio
[OR] 4.50, 95% confidence interval [CI] 1.62–12.50, p = 0.0017). Rs1047286 has previously
been shown to be in strong linkage disequilibrium (LD) with rs2230199 (Arg102Gly;
r2 ~ 0.53)20 and this latter polymorphism was previously shown to influence complement
activation.21,22 Homozygotes for the common allele of rs2230199 (Arg/Arg) were found to
have an increased susceptibility to bacterial meningitis, but this association did not reach
significance after correction for multiple testing (Arg/Arg genotype frequency patients 68%
vs. 60% in controls; OR 1.37, 95% CI 1.01–1.87, p = 0.04). Other SNPs were not associated
with susceptibility to disease after Bonferroni correction. The genotype frequency of the
rs1065489 SNP in CFH, which was previously identified in the genome wide association study
on meningococcal disease,17 did not differ between patients and controls in our study. The
risk allele was present in 99 (12.5%) patients with meningococcal meningitis and 42 (11.6%)
controls (OR 0.82, 95% CI 0.27–2.82, p = 0.73). In the subgroup analyses for pneumococcal
or meningococcal meningitis no significant associations with susceptibility were identified
(Supplementary Tables S5.1 and S5.2).
CSF was available for 349 of 636 included (55%) patients and for 231 of 437 (53%) in whom
genotyping was performed (52%). CSF levels of C3, C3a, iC3b, C5a and TCC were measurable
in over 95% of available CSF samples (Table 5.4). CSF was available for only six patients 5
Table 5.1 Baseline characteristics of patients and controls
Characteristic Patients with DNA (n = 439) Controls (n = 302) p-valuea
Age (median – IQRb) 59 (41–68) 58 (45–66) 0.64

Male sex 210 (48%) 148 (49%) 0.77
Ethnicity
White 415 (94%) 287 (95%) 0.57
African 17 (4%) 13 (4%) 0.89
Asian 7 (2%) 2 (1%) 0.25
a
Mann-Whitney U or Chi2. b IQR – interquartile range.
67

Table 5.2 Clinical characteristics of 439 patients with community-acquired bacterial meningitis (adapted
from Woehrl et al.19)a
Characteristic Values
Age – years 56 ± 18
Male sex – no 208 (47%)
Predisposing conditions 253/436 (58%)
Otitis or sinusitis 156/436 (36%)
Pneumonia 57/436 (13%)
Immunocompromise 96/436 (22%)
Symptoms and signs on presentationb
Headache 340/394 (86%)
Neck stiffness 325/421 (77%)
Systolic blood pressure – mmHg 145 ± 29
Heart rate – beats/min 99 ± 21
Body temperature – ºC 38.7 ± 1.3
Score on Glasgow Coma Scalec 11 ± 3
< 8 indicating coma 58/434 (13%)
Focal neurologic deficits 140/436 (32%)
Indexes of CSF inflammationd
White blood cell count (/mm3) 6708 ± 11964
Protein – g/L 4.3 ± 3.1
CSF: blood glucose ratio 0.15 ± 0.16
Score on Glasgow Outcome Scale
1 – death 35/435 (8%)
2 – vegetative state 1/435 (0.2%)
3 – severe disability 15/435 (3%)
4 – moderate disability 55/435 (13%)
5 – good recovery 329/435 (76%)
a
Data are number/number evaluated (percentage), continuous data are mean ± SD. b Systolic blood pressure
was evaluated in 426 patients, heart rate in 421, temperature in 432. c CSF WBC count was evaluated in 409
patients, CSF protein in 412, CSF blood: glucose ratio in 408.
with the protective rs1047286 genotype (Leu/Leu). No significant differences in levels of

complement components were found between rs1047286 genotypes.
However, C3 CSF levels were significantly higher for patients with the rs2230199 Arg/Arg
genotype compared to carriers of the Gly allele (median 2.0 μg/ml vs. 1.1 μg/ml; p = 0.006).
These patients had lower levels of C5a (median 6.0 μg/ml vs. 23.6 μg/ml; p = 0.049),
indicating less complement activation. The differences were more pronounced in patients
with pneumococcal meningitis (C3 1.7 μg/ml vs. 0.6 μg/ml, p = 0.001; C5a 28 ng/ml vs.
14 ng/ml, p = 0.019; TCC 3.5 μg/ml vs. 2.3 μg/ml, p = 0.037: Figure 5.2). Correlation analysis
of C3, C3a, iC3b, C5a and C5b-9 showed that C3 levels were negatively correlated to C3a,
68

Table 5.3 Alleles, genotypes and risk alleles in common complement factor polymorphisms for susceptibility in patients with bacterial meningitis and in controls
Allele/genotype patients Allele/genotype controls

Odds ratio
Gene SNP A B AA AB BB A B AA AB BB Model p-value (95% CIa)
C3 rs1047286 719 151 289 141 5 477 127 190 97 15 Recessive 0.0017 4.50 (1.62–12.50)
C3 rs2230199 717 151 293 131 10 464 134 180 104 15 Dominant 0.04 1.37 (1.01–1.87)
C5 rs17611 503 373 149 205 84 338 264 93 152 56 Dominant 0.37 1.15 (0.84–1.58)
C6 rs1801033 562 306 186 190 58 414 190 142 130 30 Recessive 0.16 1.40 (0.88–2.23)
C7 rs1063499 523 349 167 189 80 392 212 132 128 42 Recessive 0.11 1.39 (0.93–2.09)
C7 rs13157656 630 226 219 192 17 454 138 173 108 15 Dominant 0.05 1.34 (1.00–1.81)
C7 rs60714178 746 130 322 102 14 505 99 212 81 9 Dominant 0.32 1.18 (0.85–1.63)
C8Bb rs12067507 816 56 395 26 15 568 36 272 24 6 Recessive 0.24 1.76 (0.67–4.58)
C8B rs12085435 815 45 387 41 2 570 32 269 32 0 Dominant 0.78 1.07 (0.66–1.74)
C9 rs700233 502 332 148 206 63 361 225 112 137 44 Dominant 0.46 1.12 (0.83–1.54)
C9 rs34882957 809 59 377 55 2 560 34 263 34 0 Dominant 0.50 1.16 (0.74–1.85)
CFH rs505102 611 257 218 175 41 428 176 153 122 27 Recessive 0.82 1.06 (0.64–1.77)
CFH rs1065489 726 146 312 102 22 495 105 211 73 16 Dominant 0.72 1.06 (0.77–1.47)
CFH rs1410996 464 410 123 218 96 331 273 86 159 57 Recessive 0.31 1.21 (0.84–1.75)
CFH rs3753396 741 133 314 113 10 504 100 213 78 11 Recessive 0.28 1.61 (0.68–3.85)
CFH rs6677604 679 191 261 157 17 481 119 195 91 14 Dominant 0.17 1.23 (0.91–1.67)
CFH rs3753394 651 223 248 155 34 447 153 168 111 21 Recessive 0.69 1.12 (0.64–1.97)
a
Confidence interval. b Control population did not comply with HWE.
69
Polymorphisms in complement system and bacterial meningitis Chapter 5
19-8-2015 9:16:38
Table 5.4 Complement levels in CSF in patients with meningitisa
Complement component All patients (n = 344) S. pneumoniae (n = 277)
C3 1.5 (0.5–4.0) μg/ml 1.3 (0.4–3.7) μg/ml

C3a 0.48 (0.13–1.04) μg/ml 0.55 (0.19–1.16) μg/ml
iC3b 19.8 (9.4–41.3) ng/ml 23.1 (10.6–43.1) ng/ml
C5a 13.4 (3.0–55.2) ng/ml 23.6 (4.9–68.7) ng/ml
C5b-9 1.9 (0.3–5.9) μg/ml 2.6 (0.7–6.4) μg/ml
a
Data are medians (interquartile range).
Table 5.5 Correlation of complement components in cerebrospinal fluid of bacterial meningitis patients
C3 C3a iC3b C5a
TCC r = -.358 a
r = .634 a
r = .476 a
r = .760a
C5a r = -.277a r = .418a r = .350a
iC3b r = 0.094b r = .596a
C3a r = -.265a
Correlation analysis showing co-efficient (r) for interaction between complement factors.
a
p < 0.001, b p = 0.064.
Total C3 102R/R C3 102G

160%
p=0.04
140% p=0.001
p=0.02
120%
100%
80%
60%
40%
20%
0%
C3 C3a iC3b C5a C5b-‐9
Figure 5.2 Complement levels in patients with pneumococcal meningitis. Median level C3, C3a, iC3b, C5a
and C5b-9 of all pneumococcal meningitis patients (n = 247) is set at 100%, followed by the normalized median
of patients with the C3 102 R/R genotype (n = 112) and C3 102G allotype (n = 49).
70

Chapter 5
C5a and C5b-9 (Table 5.5), indicating that C3 is consumed during complement activation.

C3a, iC3b, C5a and C5b-9 were all positively correlated with each other.
Discussion
We identified a common variant in C3 to be associated with susceptibility to bacterial
meningitis. Individuals with the rs1047286 Leu/Leu genotype had a 4.5 fold decreased
risk for contracting bacterial meningitis as compared to those with the Pro/Leu or Pro/
Pro genotype. Therefore, the rs1047286 Leu/Leu genotype appeared to be a protective
genotype against bacterial meningitis. Our genetic association study was nationwide and,
therefore, we were able to study a representative sample of adults with acute bacterial
meningitis. The prospective approach allowed us to collect a well-defined group of patients
with microbiologically confirmed community-acquired bacterial meningitis. Our sample
size gave us the statistical power to perform a Bonferroni correction for multiple testing.
Our findings are in line with animal studies that also showed a role of C3 in susceptibility to
pneumococcal meningitis.23,24 Mice depleted of C3 by cobra venom factor (CoVF) developed
sepsis following intranasal pneumococcal challenge with serogroup 6B. This S. pneumoniae
strain was not pathogenic in the control mice: bacteraemia was absent in all controls.23
A study in rabbits showed C3 is essential for limiting pneumococcal outgrowth within the
CSF, the brain and blood. Rabbits depleted of C3 by CoVF had higher bacterial titers in the
CSF compared to complement-sufficient control animals after intracisternal inoculation
with S. pneumoniae.24 Other studies showed increased pneumococcal outgrowth in the
brain and blood in gene-targeted mice lacking functional C3 or the receptor for the opsonin
C3b/iC3b (CR3).25,26 In the latter study C3 deficiency led to diminished brain inflammation
paralleled by an attenuation of intracranial complications. 5
The main role of C3 in the susceptibility of bacterial meningitis can be found in first line
host defence in the bloodstream. Complement represents the first step of innate immunity
against bacteraemia. All three complement activation pathways are activated by streptococcal
species but the classical complement pathway plays a dominant role in pneumococcal
clearance.27,28 Pneumococci have developed two ways to minimize complement mediated
opsonization and subsequent phagocytosis. First, pneumococci undergo a phase variation
and become encapsulated. The polysaccharide capsule serves as nonspecific barrier, reducing
complement deposition on the bacterial surface and limiting subsequent interaction with
71

phagocytes.29,30 Second, pneumococcal surface proteins PspA, PspC and pneumolysin

target specific complement components thereby reducing complement mediated bacterial
clearance. PspA, which is ubiquitously expressed among pneumococci, inhibits C1q and
subsequent C3b deposition.27 PspC binds human fH, thereby blocking the formation of C3
convertase (C3bBb), leading to lower C3b production and limiting opsonophagocytosis.31
Recent in vitro studies showed that PspA and PspC work synergistically to limit complement
mediated adherence and transfer to phagocytes.31
The rs1047286 (Pro314Leu) polymorphism in C3 has previously been identified as a genetic

risk factor for age-related macular degeneration (AMD).20,22,32-34 The Leu/Leu genotype which
has been associated with increased risk for AMD was associated with reduced susceptibility
to bacterial meningitis in our cohort. Our study supports the hypothesis that genetic
variation in the complement system can influence the threshold for complement activation,
often referred to as a double edged sword: a more readily activated system will predispose
to chronic inflammation (AMD), while a less readily activated system will increase risk of
infection (bacterial meningitis).21
No data concerning the effect of rs1047286 on C3 function or concentration have been

published, although individuals carrying Leu/Gly or Leu/Leu alleles appear to have higher AP
activity compared to individuals with the Pro/Pro genotype.34,35 The Pro314Leu amino-acid
variation is located in the first ring of macroglobulin domains of the C3 protein, which are
key elements for correct orientation of the thioester-containing domain. The configuration
of the macroglobulin ring is hypothesized to be different for the genetic variants.32 This could
change the binding to pathogenic cell surfaces and other complement proteins. Another
explanation for the influence on susceptibility to bacterial meningitis could be through the
strong linkage disequilibrium between rs1047286 and rs2230199.
The rs2230199 Arg/Arg genotype has recently shown to be less effective in activating the
alternative complement pathway due to the enhanced binding to the regulator fH.21 In our
cohort the Arg/Arg genotype was found to increase susceptibility to bacterial meningitis,
albeit without significant p-value after applying a Bonferroni correction. Additional support
for a role of this SNP was the association of the risk genotype with higher levels of C3 and
lower levels of C5a and TCC in the CSF. C3 itself is inert until cleavage into C3a and C3b
after contact with pathogens.12 This activation leads to an amplification of the AP with
further activation (cleavage) of C3 and a reduction in C3 levels. The higher concentration of
C3 and lower concentration of C5a and C5b-9 in CSF of patients with the risk genotype fits
72

Chapter 5
with a reduced activation of the AP. Further support of consumption of C3 after activation

of the complement system was found in the inverse correlation between C3 and C3a, C5a
and C5b-9.
Since rs2230199 has been shown to have functional consequences on complement activation,
the function of rs1047286 can only be studied if patients are matched for rs2230199 genotype,
while having the opposite homozygous genotype for rs1047286. No patients within our
cohort could be matched like this due to the high level of linkage disequilibrium between
the two polymorphisms, preventing further functional studies to determine the effect of
rs1047286 on complement activation.
In contrast to the GWAS on meningococcal disease, we did not find the rs1065489 in CFH
to be associated with increased susceptibility to meningococcal meningitis.17,36 This is
probably due to a lack of power in our study as DNA was available for only 56 patients with
meningococcal disease. In our study there was no increase in susceptibility due to rs1065489
for bacterial meningitis with most cases consisting of pneumococcal meningitis. This might
imply that rs1065489 specifically increases susceptibility to meningococcal disease but not
pneumococcal meningitis.
Our study has certain limitations; first, a selection bias could have been introduced since
DNA was not available for a considerable number of patients (32%) in the cohort. However,
as all patients had CSF culture positive bacterial meningitis, this will probably not affect the
identified association with susceptibility. Furthermore, testing for multiple SNPs can result
in false-positive results (type 1 error). By using a Bonferroni correction for multiple testing
we have adequately addressed concerns regarding false positives. However, replication of the
association in a different cohort of bacterial meningitis patients is desirable to confirm the
identified association. Currently no such studies are at our disposal to replicate our findings.
In conclusion, we identified an association between a common SNP in C3 and susceptibility

5
for bacterial meningitis in a nation-wide prospective genetic association study. This is the
first report showing an association between susceptibility to invasive bacterial disease and
genetic variation in complement component C3. These results explain some of the differences
between individuals in susceptibility to bacterial meningitis.
73

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deficiency: molecular basis and disease association. Mol Immunol. 1999; 36: 863–867.
15. Jonsson G, Truedsson L, Sturfelt G, Oxelius VA, Braconier JB, Sjoholm AG. Hereditary C2 deficiency
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complement pathway activation due to factor D deficiency by 2 novel mutations in the complement
factor D gene in a family with meningococcal infections. Blood. 2006; 107: 4865–4870.
17. Davila S, Wright VJ, Khor CC, Sim KS, Binder A, Breunis WB, et al. Genome-wide association
study identifies variants in the CFH region associated with host susceptibility to meningococcal
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5 contributes to poor disease outcome in humans and mice with pneumococcal meningitis. J Clin
Invest. 2011; 121: 3943–3953.
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30. Kadioglu A, Weiser JN, Paton JC, Andrew PW. The role of Streptococcus pneumoniae virulence
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31. Li J, Glover DT, Szalai AJ, Hollingshead SK, Briles DE. PspA and PspC minimize immune adherence
and transfer of pneumococci from erythrocytes to macrophages through their effects on complement
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component C3 and risk of age-related macular degeneration. Ophthalmology. 2006; 116: 474–480.
33. Park KH, Fridley BL, Ryu E, Tosakulwong N, Edwards AO. Complement component 3 (C3)
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polymorphism increases risk of age-related macular degeneration. Hum Mol Genet. 2008; 17:
1821–1824.
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76

Supplementary material
Supplementary Table S5.1 Alleles, genotypes and risk alleles in common complement factor polymorphisms for susceptibility in white patients with pneumococcal
meningitis and controls

Odds ratio
Gene SNP A B AA AB BB A B AA AB BB Model p-value (95% CIa)
C3 rs1047286 486 110 193 100 5 335 97 130 75 11 Recessive 0.03 3.14 (1.08–9.19)
C3 rs2230199 482 112 194 94 9 326 102 124 78 12 Dominant 0.09 1.37 (0.95–1.96)
C5 rs17611 346 254 103 140 57 253 179 74 105 37 Recessive 0.59 1.14 (0.72–1.79)
C6 rs1801033 385 209 127 131 39 300 132 103 94 19 Recessive 0.13 1.56 (0.88–2.78)
C7 rs1063499 349 247 109 131 58 277 155 91 95 30 Recessive 0.10 1.50 (0.93–2.42)
C7 rs13157656 427 157 146 135 11 329 99 127 75 12 Dominant 0.04 1.46 (1.02–2.09)
C7 rs60714178 511 91 222 67 12 366 66 157 52 7 Dominant 0.66 1.24 (0.48–3.20)
C8Bb rs12067507 556 40 270 16 12 405 27 193 19 4 Recessive 0.16 2.22 (0.71–6.99)
C8B rs12085435 552 32 262 28 2 408 24 192 24 0 Dominant 0.09 1.09 (0.60–2.00)
C9 rs700233 344 220 99 146 37 259 161 82 95 33 Dominant 0.37 1.19 (0.82–1.72)
C9 rs34882957 560 34 264 32 1 402 26 188 26 0 Dominant 0.72 1.11 (0.63–1.98)
CFH rs505102 406 186 140 126 30 300 132 107 86 23 Dominant 0.62 1.10 (0.77–1.56)
CFH rs1065489 497 99 213 71 14 357 73 155 47 13 Dominant 0.50 1.30 (0.60–2.86)
CFH rs1410996 318 280 84 150 65 232 200 60 112 44 Recessive 0.71 1.09 (0.70–1.67)
CFH rs3753396 508 90 215 78 6 362 70 155 52 9 Recessive 0.15 2.13 (0.75–5.88)
CFH rs6677604 474 122 186 102 10 343 85 138 67 9 Recessive 0.62 1.26 (0.51–3.17)
CFH rs3753394 457 141 175 107 17 320 110 123 74 18 Recessive 0.23 1.52 (0.76–3.03)
a
77
Polymorphisms in complement system and bacterial meningitis Chapter 5
19-8-2015 9:16:39
78
Chapter 5
Supplementary Table S5.2 Alleles, genotypes and risk alleles in common complement factor polymorphisms for susceptibility in white patients with meningococcal
meningitis and controls

Risk allele Odds ratio
Gene SNP A B AA AB BB A B AA AB BB genotype p-value (95% CI)a
C3 rs1047286 98 14 42 14 0 41 9 17 7 1 Dominant 0.51 1.41 (0.50–3.98)

C3 rs2230199 99 13 44 11 1 38 10 15 8 1 Dominant 0.13 2.20 (0.77–6.25)
C5 rs17611 68 44 21 26 9 21 27 5 11 8 Dominant 0.14 2.28 (0.74–7.01)
C6 rs1801033 76 36 27 22 7 32 18 11 10 4 Dominant 0.73 1.33 (0.35–5.05)
C7 rs1063499 71 41 24 23 9 32 18 11 10 4 Dominant 0.92 1.05 (0.41–2.71)
C7 rs13157656 78 32 25 28 2 35 9 14 7 1 Dominant 0.15 2.10 (0.08–5.81)
C7 rs60714178 98 12 43 12 0 36 14 12 12 1 Dominant 0.007 3.85 (1.41–11.11)
C8Bb rs12067507 105 7 50 5 1 48 2 23 2 0 Dominant 0.71 1.38 (0.22–10.80)
C8B rs12085435 105 7 49 7 0 46 2 22 2 0 Dominant 0.72 1.56 (0.30–8.33)
C9 rs700233 67 45 21 25 10 33 15 10 13 1 Recessive 0.16 6.25 (0.60–50.00)
C9 rs34882957 99 13 44 11 1 45 1 22 1 0 Dominant 0.09 5.88 (0.73–50.00)
CFH rs505102 82 30 31 20 5 41 9 16 9 0 Dominant 0.47 1.43 (0.54–3.85)
CFH rs1065489 99 13 44 11 1 42 6 18 6 0 Dominant 0.73 1.22 (0.40–3.70)
CFH rs1410996 56 56 17 22 17 25 25 6 13 6 Dominant 0.56 1.40 (0.47–4.00)

CFH rs3753396 100 12 44 12 0 44 6 19 6 0 Dominant 0.80 1.16 (0.38–3.57)
CFH rs6677604 80 32 29 22 5 33 17 11 11 3 Dominant 0.52 1.37 (0.50–3.53)
CFH rs3753394 88 24 35 18 3 34 16 10 14 1 Dominant 0.06 2.50 (0.95–6.67)
a
19-8-2015 9:16:39
19-8-2015 9:16:40
5
79
Chapter 6
Genetic variation in the β2-adrenoceptor
gene is associated with susceptibility to
Kirsten S Adriani, Matthijs C Brouwer, Frank Baas, Aeilko H Zwinderman,
Arie van der Ende, Diederik van de Beek
Plos One 2012; 7(5): e37618.

Chapter 6 B2-adrenoceptor gene and meningitis
Abstract
Recently, the biased β2-adrenoceptor/β-arrestin pathway was shown to play a pivotal role in
crossing of the blood brain barrier by Neisseria meningitidis. We hypothesized that genetic
variation in the β2-adrenoceptor gene (ADRB2) may influence susceptibility to bacterial
meningitis. In a prospective genetic association study we genotyped 542 patients with
CSF culture proven community acquired bacterial meningitis and 376 matched controls
for 2 functional single nucleotide polymorphisms in the β2-adrenoceptor gene (ADRB2).
Furthermore, we analyzed if the use of non-selective beta-blockers, which bind to the
β2-adrenoceptor, influenced the risk of bacterial meningitis. We identified a functional
polymorphism in ADRB2 (rs1042714) to be associated with an increased risk for bacterial
meningitis (Odds ratio [OR] 1.35, 95% confidence interval [CI] 1.04–1.76; p = 0.026). The
association remained significant after correction for age and was more prominent in patients
with pneumococcal meningitis (OR 1.52, 95% CI 1.12–2.07; p = 0.007). For meningococcal
meningitis the difference in genotype frequencies between patients and controls was similar
to that in pneumococcal meningitis, but this was not statistically significant (OR 1.43, 95% CI
0.60–3.38; p = 0.72). Patients with bacterial meningitis had a lower frequency of non-selective
beta-blockers use compared to the age matched population (0.9% vs.1.8%), although this
did not reach statistical significance (OR 1.96 [95% CI 0.88–4.39]; p = 0.09). In conclusion,
we identified an association between a genetic variant in the β2-adrenoceptor and increased
susceptibility to bacterial meningitis. The potential benefit of pharmacological treatment
targeting the β2-adrenoceptor to prevent bacterial meningitis in the general population
or patients with bacteraemia should be further studied in both experimental studies and
observational cohorts.
82

Chapter 6
Introduction
B2-adrenoceptor gene and meningitis

Community-acquired bacterial meningitis is a disease with high mortality and morbidity,
despite effective antimicrobial agents, adjunctive dexamethasone and implementation
of childhood vaccination programmes. 1-3 Streptococcus pneumoniae and Neisseria
meningitidis are the leading causes of bacterial meningitis in adults, with the first responsible
for two thirds of cases in Europe and the United States.1,4 The disease is preceded by
nasopharyngeal colonization, which occurs in up to 100% of the normal population for
pneumococci and 18% for meningococci.5,6 Following nasopharyngeal colonization some
of the bacteria are able to invade the bloodstream, avoid host defences and reach the blood-
brain barrier.7 The mechanism by which the bacteria cross the blood-brain barrier is not
completely understood, but the interaction between host cell receptors and the bacteria is
thought to contribute to transcytosis into the subarachnoid space.8
Recently, Coureuil et al. showed an important role of the biased β2-adrenoceptor/β-arrestin

pathway in the pathophysiology of meningococcal meningitis in vitro. The authors showed
that N. meningitidis is able to use the β2-adrenoceptor/β-arrestin signalling pathway in
endothelial cells to cross the blood-brain barrier.9 The meningococcus was found to hijack
the β2-adrenoceptor and thereby stabilize its binding to the endothelium. Subsequently,
activation of the β-arrestin signalling pathway causes delocalization of junctional proteins,
resulting in gaps in the blood-brain barrier through which the meningococcus invades the
subarachnoid space. Previously, β-arrestin-1 was shown to participate in receptor-mediated
transcytosis of S. pneumoniae as well.10
The human β2-adrenoceptor has several functional variants determined by 2 single nucleo
tide polymorphisms (SNPs), rs1042713 and rs1042714 in the ADRB2 gene.11 Although the
genetic variant of the receptor displayed normal agonist binding and functional coupling
in a functional study, a markedly altered degree of agonist-promoted down regulation of
receptor expression was shown.11 Both SNPs have been associated with several diseases, such
as asthma.12,13 Familial aggregation and genetic association studies have suggested a genetic 6
influence on susceptibility to pneumococcal and meningococcal infections.14 SNPs have also
been suggested to influence the phenotype of disease, i.e. the development of meningitis
or sepsis.15 We hypothesized that crossing of the blood-brain barrier by microorganisms
such as N. meningitidis and S. pneumoniae, the two most common causative bacteria of
meningitis, may be influenced by these ADRB2 SNPs. We further analysed if the use of
beta-blockers influenced the risk of acquiring bacterial meningitis, as non-selective beta-
83

blockers may limit the availability of β2-adrenoceptors for bacteria to cross the blood-brain
barrier.
Methods
We performed a prospective nationwide genetic association study on the influence of ADRB2
SNP rs1042713 and rs1042714 on susceptibility to bacterial meningitis. In this study we
included bacterial meningitis patients older than 16 years of age with positive cerebrospinal
fluid (CSF) cultures who were identified by The Netherlands Reference Laboratory for
Bacterial Meningitis (NRLBM) from March 2006 to June 2010.3 The NRLBM receives
bacterial isolates from approximately 85% of bacterial meningitis patients in the Netherlands
and provided the names of the hospitals where patients with bacterial meningitis had
been admitted 2–6 days previously. The treating physician was contacted, and written
informed consent was obtained from all participating patients or their legally authorized
representatives. Patients could also be included by physicians familiar with the study through
a 24/7 telephone service. Patients with hospital-acquired bacterial meningitis and negative
CSF cultures were excluded. Controls for exposure/susceptibility were patients’ partners or
their non-related proxies living in the same dwelling, as household members are exposed to
similar bacteria.16 Furthermore, this choice of controls guaranteed similar socio-economic
background of patients and controls. Data on age, sex and ethnicity of patients and controls
were collected. For patients, information on medication use on admission was recorded. Use
of beta-blockers was categorized in selective and non-selective beta-blockers. We compared
the use of selective (β1) beta-blockers and non-selective (β1 and β2) blockers of bacterial
meningitis patients with that of the age corrected general population.
Blood from patients and controls for DNA extraction was collected in sodium/EDTA
tubes. DNA was isolated with the Gentra Puregene isolation kit (Qiagen, Hilden, Germany)
and quality control procedures were performed to determine the yield of isolation. The
rs1042713 and rs1042714 SNP were genotyped using TaqMan SNP Genotyping Assays
(Applied Biosystems, Foster City, California, USA) in a LightCycler480 (Roche, Basel,
Switzerland) using the Fast Start Universal Probe Mix (Roche) for rs1042713 and TaqMan
Genotyping Master Mix (Applied Biosystems) for rs1042714, by the Genetics Core Facility
in the Academic Medical Center, Amsterdam, the Netherlands. Laboratory personnel
were blinded to clinical information. The Mann-Whitney U test was used to identify
differences in baseline characteristics between groups with respect to continuous variables,
84

Chapter 6
and dichotomous variables were compared with use of the χ2 test. These statistical tests

were 2-tailed, and a p-value of <0.05 was regarded as significant. Differences in genotype
frequencies were analyzed with the χ2 or Fishers’ exact tests by use of PASW18. Logistic
regression analysis was used to analyse the difference in genotype frequency between patient
and controls corrected for age. Subgroup analyses were performed for pneumococcal and
for meningococcal meningitis patients. Furthermore, we separately compared the genotype
frequency of bacterial meningitis patients with and without otitis media and/or sinusitis to
controls. Since the ADRB2 SNPs are thought to influence the blood-brain barrier crossing
of bacteria, a potential effect is expected to be absent in patients with meningitis due to
continuous infection from otitis media and/or sinusitis. We calculated whether the genotype
frequencies in white controls concurred with the Hardy Weinberg equilibrium (HWE) by
use of a χ2 test with one degree of freedom with a p < 0.001 to indicate significance. The
study was approved by the research ethics committee of the Academic Medical Centre,
Amsterdam, the Netherlands.
Results
From March 2006 to June 2010, 734 patients with culture proven bacterial meningitis were
included: in 534 (73%) cases S. pneumoniae was the causative organism, in 91 (12%) N.
meningitidis and 109 (15%) were due to other microorganisms. DNA was available for 542
(74%) patients and 376 controls. The mean age of included patients was 55 years and 49.6%
of the patients were male. Sex, age, ethnicity and socio-economic background were similar
between patients and controls (Table 6.1). Clinical characteristics of the patient population
are presented in Table 6.2.
Table 6.1 Age, sex and ethnicity of 542 patients and 376 controls
Characteristic Patients Controls
Age (SD) 54.7 (±17) 55.7 (±15) 6

Male sex 269 (49.6%) 187 (49.7%)
Ethnicity
White 510 (94%) 361 (96%)
African 24 (4.4%) 13 (3.5)
Asian 8 (1.5) 2 (0.5%)
85

Table 6.2 Clinical characteristics 542 patients with bacterial meningitis on admission and outcome
Characteristics No./no. of patientsa
Mean age, year (range) 55 (17–93)

Male/female sex – no. 269/273
Duration of symptoms <24 hours 233/520 (45)
Otitis media/sinusitis 192/542 (35)
Pneumonia 49/535 (9)
Immunocompromised stateb 121/530 (23)
Headache 413/535 (77)
Nausea 290/535 (54)
Neck stiffness 400/535 (75)
Temperature ≥38°C 408/535 (76)
Signs of septic shockc 270/525 (51)
Score on Glasgow Coma Scaled 11 (9–14)
Altered mental status (Glasgow Coma Scale <14) 385/531 (73)
Coma (Glasgow Coma Scale <8 ) 69/531 (13)
Outcome
Unfavourabled 126/514 (23)
Death 36/514 (7)
a
Data are number/number evaluated (%), and median (interquartile range) unless otherwise stated.
b
Immunocompromised was defined as the use of immunosuppressive drugs, the presence of diabetes mellitus
or alcoholism, and patients with the human immunodeficiency virus (HIV).
c
Defined as a systolic blood pressure ≤90 mmHg, a diastolic blood pressure <60 mmHg and/or heart rate
≥120/min.
d
Unfavourable outcome was defined as a Glasgow Outcome Score (GOS) <5, a score of 1 indicates death, 2
indicates vegetative state, 3 indicates severe disability, 4 indicates moderate disability and 5 indicates mild
or no disability.
Genotyping was successful in 99.3% of the samples and the genotype frequency of controls
for both SNPs concurred with the Hardy-Weinberg Equilibrium. Genotype frequencies
were similar between patients of different ethnic background. The Gln/Glu genotype of the
rs1042714 was associated with increased susceptibility to bacterial meningitis (Table 6.3).
The genotype was found in 271 of 542 (50%) patients and 160 of 376 (42%) controls (odds
ratio [OR] 1.35, 95% confidence interval [CI] 1.04–1.76; p = 0.026). After correction for age,
rs1042714 was still significantly associated with susceptibility (OR 1.37, 95% CI 1.05–1.79;
p = 0.023). The results were similar when the analysis was limited to white patients and
controls (OR 1.36, 95% CI 1.04–1.79; p = 0.033). The genotype distribution of rs1042713 was
similar between patients and controls. Subgroup analysis showed that the Gln/Glu genotype
was found in 200 of 396 (51%) pneumococcal meningitis patients compared to 116 of 289
86

Table 6.3 Genotype frequencies rs1042713 (R16G) and rs1042714 (Q27E) in bacterial meningitis patients and controls

Risk Odds ratio
rs1042713 R G R/R R/G G/G R G R/R R/G G/G genotype p-value 95% (CIa)
All patients 666 408 207 252 78 475 275 158 159 58 R/G 0.176 1.20 (0.92–1.57)
S. pneumoniae 489 297 151 187 55 446 306 143 160 73 R/G 0.087 1.31 (0.96–1.78)
N. meningitidis 87 49 29 29 10 46 14 17 12 1 G/G 0.100 5.00 (0.61–42.0)
rs1042714 Q E Q/Q Q/E E/E Q E Q/Q Q/E E/E
All patients 625 459 177 271 94 446 306 143 160 73 Q/E 0.026 1.35 (1.04–1.76)
S. pneumoniae 452 340 126 200 70 348 230 116 116 57 Q/E 0.007 1.52 (1.12–2.07)
N. meningitidis 60 78 12 36 21 29 31 8 13 9 Q/E 0.419 1.43 (0.60–3.38)
a
Confidence interval.
87
B2-adrenoceptor gene and meningitis Chapter 6
19-8-2015 9:16:48
(40%) controls (OR 1.52, 95% CI 1.12–2.07; p = 0.007). For meningococcal meningitis the
risk genotype showed a similar distribution. It was found in 36 of 69 (52%) patients and 13
of 30 (43%) controls, but this did not reach statistical significance due to the low numbers
of patients (OR 1.43, 95% CI 0.60–3.38; p = 0.72). In the subgroup analysis of patients with
otitis media and/or sinusitis, there was no association of rs1072714 and susceptibility (p =
0.15), while in patients without otitis media and/or sinusitis the rs1072714 genotype was
still associated with increased susceptibility (OR 1.38, 95% CI 1.03–1.85; p = 0.030). Our
study, however, lacked power to meet the standard of demonstrating a statistically significant
interaction of otitis media and sinusitis by genotype. Both ADRB2 SNPs were not associated
the rate of unfavourable outcome or mortality rate.
Non-selective beta-blockers may present a means of preventing bacterial meningitis by

blocking the β2-adrenoceptor, and are used by a substantial part of the population for
hypertension and chronic heart failure.17 A total of 104 of 642 patients (16%) for whom
medication was specified used beta-blockers, of which 6 (0.9%) used non-selective beta-
blockers and 98 (15%) β1-selective beta-blockers (Table 6.4). Predisposing factors for
bacterial meningitis were present in all 6 patients using non-selective beta-blockers, 56 (57%)
patients using selective beta-blockers and 278 (52%) of patients using no beta-blockers (p =
0.041). Four of the patients on non-selective beta-blockers presented with otitis media and
four had a history of diabetes mellitus and were therefore immunocompromised. Data on
beta-blocker use in the control population was not available to assess if non-selective beta-
blocker use decreased the risk of bacterial meningitis. Data from the national pharmaceutical
registry (Foundation of Pharmaceutical Statistics) showed 12.9% of the age corrected
general population use β1-selective beta-blockers and 1.8% non-selective beta-blockers.17 A
statistical trend toward lower use of non-selective beta-blockers and higher use of selective
Table 6.4 Use of beta-blockers in study bacterial meningitis patients, the general Dutch population and
age corrected general population
Patients General populationa

Characteristic N = 638 N = 16,575,000 Age corrected populationb
Beta-blockers 103 (16%) 1,445,000 (8.7%) 2,480,000 (15.0%)

Selective 6 (0.8%) 191,000 (1.2%) 304,000 (1.8%)
Non-selective 97 (15.2%) 1,233,000 (7.4%) 2,140,000 (12.9%)
No beta-blockers 535 (84%) 15,130,000 (91.2%) 14,096,000 (85.0%)
a
Numbers do not add up to 100% as not all beta-blockers could be specified. Source: Foundation for
Pharmaceutical Statistics.18 Source: Statistics Netherlands.19
88

Chapter 6
beta-blockers was observed in the meningitis cohort compared to the general population

corrected for age (non-selective beta-blockers 0.9 vs. 1.8%; OR 1.96 [95% CI 0.88–4.39];
p = 0.09; selective beta-blockers 15.2% vs. 12.9%, OR 0.83 [95% CI 0.67–1.02], p = 0.08).18
Discussion
In a nationwide prospective genetic association study, we show an association of genetic
variation in G protein-coupled receptors with susceptibility to bacterial meningitis.14 The
effect of ADRB2 SNP rs1042714 was most clear for pneumococcal meningitis. We did not
identify an association of rs1042714 with susceptibility to meningococcal meningitis and
matched controls, although the difference in genotype frequencies between patients and
controls was similar to that seen in pneumococcal meningitis. Further studies are needed
to validate the identified associations in bacterial meningitis and pneumococcal meningitis,
and determine the role of rs1042714 in a larger population of meningococcal meningitis
patients. Furthermore, it would be interesting to compare meningitis patients with those
that had bacteraemia due to the same pathogens, who did not develop meningitis.
The importance of G protein-coupled receptors for microorganisms to cross the blood-

brain-barrier has been described in vitro in the binding of S. pneumoniae to the platelet
activating factor receptor (PAFr), which facilitates transcytosis.8 PAFr knockout mice
showed to be protected against pneumococcal meningitis after intravenous injection of
pneumococci.10 Binding of S. pneumoniae to the β2-adrenoceptor has not been studied so
far. The described molecular mechanisms of the interaction of S. pneumoniae and PAFr, and
that of N. meningitidis and the β2-adrenoceptor are quite different, but in both processes
β-arrestin-1 plays a crucial role.9 The identified association between the ADRB2 SNP and
susceptibility to pneumococcal meningitis in our study suggests this receptor may be of
similar importance for the pathophysiology of pneumococcal meningitis as was recently
shown for meningococcal meningitis. As no interaction between the β2-adrenoceptor and the
pneumococcus has been shown, our results must be interpreted with caution and regarded 6
as explorative. It is likely that micro-organisms need multiple receptors to achieve sufficient
adhesion to the endothelial cells and cross the blood-brain barrier.9 Further experimental
data are needed to determine the interaction of S. pneumoniae with the β2-adrenoceptor.
In this study we identified the β2-adrenoceptor as a potential target for therapy to prevent
bacteria crossing the blood-brain barrier. The availability of the β2-adrenoceptor can be
89

pharmacologically decreased by either binding of antagonists (beta-blockers) or down-

regulation of the receptor following catecholamine treatment.19 It has been suggested that
patients treated with catecholamines for meningococcal septic shock may benefit from
downregulation of the receptor, as this will interfere with crossing of the blood brain barrier
by the pathogen.19 Prevention of bacterial invasion of the central nervous system (CNS) in
sepsis patients is likely to reduce neurologic complications and improve outcome. The yield
of this treatment strategy is probably limited, as concomitant initiation of antimicrobial
treatment reduces the need for prevention of bacterial spread to the CNS. However, cases
due to multiresistant bacteria may benefit from this approach.
Patients using non-selective beta-blockers were underrepresented in our patient cohort,

while patients using selective beta-blockers were overrepresented, although this difference
was not statistically significant. The additional blocking of β2-adrenoceptor by non-selective
beta-blockers compared to selective beta-blockers may prevent bacteria crossing the blood-
brain barrier and explain that patients on non-selective beta-blockers only developed
meningitis when predisposing conditions such as otitis media or immunocompromised state
were present. The association of beta-blockers with susceptibility to bacterial meningitis
is however difficult to determine, since we have no data on the use of beta-blockers in the
matched control population. Furthermore, an interaction between beta-blocker efficacy and
rs1042714 has been reported that hinders a straightforward analysis.20 The potential benefit
of pharmacological treatment targeting the β2-adrenoceptor to prevent bacterial meningitis
in patients with bacteraemia should be further studied in both experimental studies and
observational case-control studies.
Our study has several limitations. First, the numbers of patients included in our study is
relatively small for a study of polymorphisms. However, this is the largest genetic association
study so far in bacterial meningitis patients, and provides interesting leads for further
clinical and experimental studies. Furthermore, we did not replicate our findings in other
case-control studies of adults with bacterial meningitis. Currently, no such studies are at
our disposal to validate our findings. Third, we did not have information on the medical
history of the control population and were therefore unable to correct for diseases that may
result in confounding. Finally, in this study we show an association between rs1042714 and
susceptibility but do functional demonstration this association is causal. Therefore, our
results must be interpreted with caution.
90

Chapter 6
In conclusion, we identified an association between rs1042714 ADRB2 and susceptibility to

bacterial meningitis. We have linked the β2-adrenoceptor/β-arrestin pathway with increased
susceptibility to bacterial meningitis in vivo.
References
implementation of adjunctive dexamethasone therapy for pneumococcal meningitis. Neurology.
2010; 75: 1533–1539.
5. Hausdorff WP, Siber G, Paradiso PR. Geographical differences in invasive pneumococcal disease
rates and serotype frequency in young children. Lancet. 2001; 357: 950–952.
6. Maiden MC, Stuart JM. Carriage of serogroup C meningococci 1 year after meningococcal C
conjugate polysaccharide vaccination. Lancet. 2002; 359: 1829–1831.
7. Weisfelt M, de Gans J, van der Poll T, van de Beek D. Pneumococcal meningitis in adults: new
approaches to management and prevention. Lancet Neurol. 2006; 5: 332–342.
8. Ring A, Weiser JN, Tuomanen EI. Pneumococcal trafficking across the blood-brain barrier.
Molecular analysis of a novel bidirectional pathway. J Clin Invest. 1998; 102: 347–360.
9. Coureuil M, Lecuyer H, Scott MG, et al. Meningococcus Hijacks a beta2-adrenoceptor/beta-Arrestin

pathway to cross brain microvasculature endothelium. Cell. 2010; 143: 1149–1160.
10. Radin JN, Orihuela CJ, Murti G, Guglielmo C, Murray PJ, Tuomanen EI. Beta-Arrestin 1 participates
in platelet-activating factor receptor-mediated endocytosis of Streptococcus pneumoniae. Infect
Immun. 2005; 73: 7827–7835.
11. Green SA, Turki J, Innis M, Liggett SB. Amino-terminal polymorphisms of the human beta
2-adrenergic receptor impart distinct agonist-promoted regulatory properties. Biochemistry. 1994;
33: 9414–9419.
6
12. Hall IP, Blakey JD, Al Balushi KA, et al. Beta2-adrenoceptor polymorphisms and asthma from
childhood to middle age in the British 1958 birth cohort: a genetic association study. Lancet. 2006;
368: 771–779.
13. Jalba MS, Rhoads GG, Demissie K. Association of codon 16 and codon 27 beta 2-adrenergic receptor
gene polymorphisms with obesity: a meta-analysis. Obesity (Silver Spring) 2008; 16: 2096–2106.
91

15. Brouwer MC, Read RC, van de Beek D. Host genetics and outcome in meningococcal disease: a
systematic review and meta-analysis. Lancet Infect Dis. 2010; 10: 262–274.
16. Gardner P. Clinical practice. Prevention of meningococcal disease. N Engl J Med. 2006; 355:
1466–1473.
17. Foundation for Pharmaceutical Statistics (SFK), Facts and Figures 2010, Basement Graphics, Den
Haag. Available: www.sfk.nl. Accessed 2011 Sept 1.
18. Statistics Netherlands. Statline, Voorburg/Heerlen. 2001. Available: www.cbs.nl. Accessed 2011
Sept 1.
19. Tourret J, Finlay BB. A receptor for meningococcus: eliciting beta-arrestin signaling for barrier
breaching. Dev Cell. 2011; 20: 7–8.
20. Petersen M, Andersen JT, Hjelvang BR, et al. Association of beta-adrenergic receptor polymorphisms
and mortality in carvedilol-treated chronic heart-failure patients. Br J Clin Pharmacol. 2011; 71:
556–565.
92

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93

Chapter 7
General discussion
Adapted from:
Kirsten S Adriani, Matthijs C Brouwer, Diederik van de Beek
The Netherlands Journal of Medicine 2015: 73(2); 53-60.

Chapter 7 General discussion
Abstract
Bacterial meningitis is a life-threatening infectious disease with high mortality and disability
rates, despite availability of antibiotics and adjunctive therapy with dexamethasone. Several
risk factors and predisposing conditions have been identified that increase susceptibility
for bacterial meningitis. Such risk factors can consist of medical conditions resulting in
immunodeficiency, host genetic factors or anatomical defects of the natural barriers of the
central nervous system. These factors can increase the risk of meningitis in general or result in
a specific risk of meningococcal or pneumococcal meningitis, the two most important causes
of bacterial meningitis, which are characterized by distinct host–pathogen interactions. In
this review we describe several risk factors for community-acquired bacterial meningitis in
adults and discuss what preventive measures can be taken in these populations.
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Chapter 7
Introduction
General discussion
Bacterial meningitis is a life-threatening infection of the central nervous system.1
Streptococcus pneumoniae and Neisseria meningitidis are the leading causative organisms,
with the first being responsible for two thirds of the cases in Western Europe and the United
States.2,3 Mortality is approximately 20% in high-income countries despite available treatment
with antibiotics and dexamethasone, and is several times higher in low-income countries.4,5
Approximately half of the survivors have neurologic sequelae such as hearing impairment,
focal motor deficits or cognitive impairment.6
Invasive disease by pneumococci and meningococci is preceded by nasopharyngeal colo-

nisation. Asymptomatic colonisation of pneumococci and meningococci occurs in up to
100% and 18%, respectively, of the normal population.7 In some persons these common
colonizers are able to breach the mucosal barrier, survive in the blood stream and cross the
blood-brain barrier to cause meningitis. Several factors have been identified that increase
the susceptibility for bacterial meningitis. These can consist of specific age groups, medical
conditions that cause immunodeficiency, host genetic factors and anatomical defects of the
natural barriers of the central nervous system.2 Patients with underlying conditions generally
have a higher risk of having a poor outcome, and therefore identification of these groups
and preventive measures like vaccination are of the utmost importance (Table 7.1).CHAPTER 3
Pneumococcal disease including meningitis is seen mostly in children below 2 years of

age or adults over 50 years. Furthermore, susceptibility is increased in individuals with
underlying conditions such as splenectomy or asplenic states and in children with cochlear
implants.CHAPTER 2,CHAPTER 3 The use of immunosuppressive drugs, the presence of diabetes
mellitus, a history of splenectomy, infection with HIV or alcoholism is found in 20% of adults
with pneumococcal meningitis.2 HIV infection affects the aetiology of acute meningitis,
and is especially important in lower-income countries.4 The meningococcus is the leading
pathogen of meningitis in young children beyond the neonatal period and in young adults.
Meningococcal disease has been associated with smoking, living in the same household
as a patient (including students), and meningococcal disease in proxies.8 Defects in innate
immunity have been described to be associated with susceptibility to both pneumococcal
and meningococcal infections within families.2 In this review we describe risk factors for 7
community-acquired bacterial meningitis, preventive measures and treatment options.
97

98
Chapter 7
Table 7.1 Acquired risk factors for bacterial meningitis and most common causative organisms
Prevalence or incidence Most common

Risk factor in Dutch population Relative frequencya causative organism Mortality
General discussion
Elderly >65 years 1,108,00061 37%14 S.pneumoniae 34%14

L. monocytogenes
Splenectomy / hyposplenic state Incidence ±1000 spleen removals a 3%39 S. pneumoniae 25%39
year62 Functional asplenia unknown
Alcoholism Prevalence 78,400 4–18%22, 26 S. pneumoniae 33%26

(adults between 18–65 year)63 L. monocytogenes
HIV/AIDS Prevalence 22,231 adults and In Western world : 1%3 S. pneumoniae, 24%43
children64 Salmonella spp.
Diabetes mellitus Prevalence 110,880 65 7–10%22, 23 S. pneumoniae, Unknown

L. monocytogenes
Cancer Incience 101,000 a year66 Unknown S. pneumoniae, Unknown

L. monocytogenes
Anatomical defect Unknown 5%22, 56 S. pneumoniae Prone to recurrent meningitis,

mortality in case of recurrent
meningitis 15%56
Organ transplant recipients Incidence 1200 a year67 5–10% of the patients S. pneumonia, Unknown
CNS infections38 L. monocytogenes, Nocardia
a
Frequency: percent of cases in adult patients with community-acquired bacterial meningitis.
20-8-2015 9:43:48
Chapter 7
Age
General discussion
The incidence of meningitis is highest in young children and elderly. 9 In infants the
waning passive immunity acquired from the mother and immature own immune system
results in an increased susceptibility to bacterial infections. Due to the introduction of
conjugated vaccines against Haemophilus influenzae type B and S. pneumoniae infants
have become protected against these infections, and the age distribution of bacterial
meningitis patients subsequently shifted. Whereas previously bacterial meningitis was
mostly a disease of children and adolescents, currently most patients are elderly with an
average age of 50.3 In children the common causative organisms have changed as a result of
vaccinations, but clinical characteristics have not. Young infants with bacterial meningitis
can present with nonspecific signs like lethargy, poor feeding or irritability. Older children
are more likely to present with typical signs and symptoms of bacterial meningitis.3 Most
common causative organisms are S. pneumoniae and N. meningitidis in infants older than
1 month (80% of cases in the Netherlands).10 The remainder of cases is caused by group
B streptococci, E. coli, H. influenzae, other Gram-negative bacilli, L. monocytogenes and
Group A Streptococci. Recommended treatment consists of a third generation cephalosporin
(cefotaxime or ceftriaxone).10 A meta-analysis of randomized trials showed a beneficial
effect of dexamethasone in children in high-income countries in respect to hearing loss, in
low-income counties this was not established.2
In elderly the function of the immune system declines, which has also been referred to as
“immunosenescence”.11 Immunosenescence leads to increased susceptibility to infections
in elderly patients, but also in reduced vaccine efficacy, and possibly autoimmune disease
and cancer.12,13 Elderly patients also frequently have comorbid conditions that affect the
immune system. Symptoms can be atypical, and neck stiffness and headache are less
frequently present, while focal neurological abnormalities occur more often.2 The spectrum
of causative bacteria is slightly different from younger adults, as L. monocytogenes is more
frequently identified.14 Vaccination of elderly with pneumococcal vaccines is currently not
recommended in Dutch national guidelines because of a lack of evidence of effectiveness
in the elderly.15 Recommended treatment consists of ceftriaxone and amoxicillin (to cover
for L. monocytogenes) in combination with adjunctive dexamethasone (Table 7.2).
7
99

100
Chapter 7
Table 7.2 Treatment and preventive measures of bacterial meningitis in adult patients with a risk fact
Risk group Treatment Preventive measures

General discussion
Splenectomy/hyposplenic Amoxicillin combined with a third generation cephalosporin Pneumococcal vaccination every 5 years (PVC-23),
states (ceftriaxone or cefotaxime). meningococcal vaccinations every 3–5 years and Haemophilus
Dexamethasone 10 mg 4 times a day, 4 days. influenzae type b vaccination (Hib) once.
Consider providing patients antibiotics on demand.68
HIV/AIDS Amoxicillin combined with a third generation cephalosporin Pneumococcal vaccination (controversial).
(ceftriaxone or cefotaxime).
If CD4 count >200 dexamethasone 10 mg 4 times a day, 4 days.
If CD4 count <200 no dexamethasone.
Diabetes mellitus (DM), Amoxicillin combined with a third generation cephalosporin In case of diabetes regulation of blood glucose levels.
Alcoholism, Cancer (ceftriaxone or cefotaxime)
Dexamethasone 10 mg 4 times a day, 4 days.
Anatomical defect Antibiotics: Amoxicillin combined with a third generation If possible: repair of the leakage.
cephalosporin (ceftriaxone or cefotaxime). Otherwise: pneumococcal vaccination every 5 years (PVC-23),
Dexamethasone 10 mg 4 times a day, 4 days. meningococcal vaccinations every 3–5 years and Haemophilus
influenzae type b vaccination (Hib) once.
Organ transplant recipients Antibiotics: Amoxicillin combined with a third generation Pneumococcal vaccinations preferably before transplantation,
cephalosporin (ceftriaxone or cefotaxime). type of vaccination depend on organ and organ disease.69
Dexamethasone 10 mg 4 times a day, 4 days (consider
differential diagnosis, in not all cases dexamethasone can be
safely administered).
a
These recommendations apply to areas with a low rate of penicillin/cephalosporine-resistance of pneumococci, like the Netherlands.
20-8-2015 9:43:49
Chapter 7
Immunodeficiency
General discussion
Life expectancy has increased due to advance of medical science and technology, and
diseases that were previously uniformly lethal now have become chronic illnesses.16,17
As a result the number of immunocompromised individuals has increased over the past
decades. Half of the patients with bacterial meningitis have predisposing conditions, one
third of these patients have an immunodeficiency.3 Splenectomy, alcoholism, HIV, diabetes
mellitus, cancer or the use of immunosuppressive medications have been recognized as risk
factors for invasive bacterial infections including meningitis.2,CHAPTER 3 The most common
causative organism of bacterial meningitis in patients with an immunocompromised state
is S. pneumoniae, although other causative organisms may be also encountered in patients
with specific risk factors.2,3,18
Diabetes mellitus
Diabetes mellitus has been reported as risk factor for bacterial infections, and infection is
an important cause of mortality in diabetic patients.29-21 In reports of community-acquired
bacterial meningitis in adults, diabetes was present before admission in 7–10%.22,23 Common
pathogens in diabetic patients with meningitis are S. pneumoniae and L. monocytogenes.18,22,23
As diabetes is a risk factor for invasive pneumococcal disease in general, physicians in the
United States and some European countries are advised to vaccinate diabetic patients with
the 23-valent polysaccharide pneumococcal vaccine.24 A large proportion of patients with
bacterial meningitis are hyperglycemic on admission, also in those without diabetes.23 In
these patients high blood glucose levels are probably an epiphenomenon of severe illness.
Blood glucose levels should be managed, although treatment-related hypoglycemia should
be avoided. Hypoglycemia in bacterial meningitis is associated with unfavourable outcome
and increased risk of major complications like seizures and brain damage.23 Adjunctive
treatment with dexamethasone can cause further dysregulation of blood glucose levels,25 so
follow-up of blood glucose concentrations in all bacterial meningitis patients is warranted.
Alcoholism
Excessive alcohol use results in increased susceptibility to infections; probably due 7

to decreased innate and adaptive immune response. It is unclear if alcoholism is an
26
independent risk factor for bacterial meningitis. Patients who suffer from alcoholism have
a worse general health, are more prone to head injury and more often have chronic liver
101

disease,26-28 all factors that have been associated with increased risk of bacterial meningitis. In
a prospective nationwide observational cohort study of 696 episodes of bacterial meningitis,
4% of the patients were alcoholics.26 Twenty-five patients with alcoholism suffered from
a second episode of meningitis during this study, suggesting an association between
alcoholism and bacterial meningitis, although causal relationship remains unclear due to
co-morbid conditions. The most common causative organisms of bacterial meningitis in
alcoholic patients were S. pneumoniae (70%) and Listeria monocytogenes (19%).26 Alcoholics
had a higher rate of complications compared to non-alcoholic patients (81% versus 62%)
and a higher rate of unfavourable outcome (67% versus 33%). Complications most often
consisted of cardiorespiratory failure due to underlying pneumonia or endocarditis. In a
recent study, patients with bacterial meningitis and endocarditis were more often found to be
alcoholics (17% vs. 4% in bacterial meningitis patient without endocarditis) and sometimes
presented with the Austrian syndrome, consisting pneumococcal meningitis, pneumonia
and endocarditis.29 Prognosis in these patients is generally poor.29 Treatment should consist
of amoxicillin and a third generation cephalosporin combined with dexamethasone (see
Table 7.2).
Cancer
Patients with cancer are more susceptible for infections due to several reasons;30 the disease
itself can predispose for infections (especially haematological malignancies such as multiple
myeloma) as does treatment with immunosuppressive chemotherapy, malnutrition and
presence of indwelling venous catheters.30-32 Patients with cancer were also found to have
an attenuated inflammatory response in the central nervous system.33
Susceptibility for meningitis is particularly increased in patients with leukemia and

lymphoma; one fourth of all CNS infections in cancer patients are found in this group.
Patients with cancer who recently underwent neurosurgery are also at risk for meningitis;
these patients account for 75% of the meningitis cases in cancer patients.34 In a retrospective
study in 77 patients with cancer, S. pneumoniae was the most common causative
organism, other relatively frequent causative organisms included L. monocytogenes and
Cryptococcus neoformans. Only 57% of these patients had a CSF pleiocytosis, reflecting the
immuncompromised state of cancer patients.33 Infections in these patients may go undetected
because signs and symptoms can be atypical resulting in a possible delay to diagnosis and
treatment.31,34 Another cause of diagnostic delay is deferral of lumbar puncture because of
thrombocytopenia or intracranial space occupying lesions.35 In high risk cancer patients
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Chapter 7
with severe immunocompromise, vaccination or even prophylactic antibiotic treatment
General discussion
may be warranted.
Organ transplant recipients
Invasive pneumococcal infections occur more frequently in organ transplant recipients

because of treatment with immunosuppressive therapy to prevent and treat rejection of the
graft.36 Liver transplant recipients have the highest incidence (354 per 100,000 persons per
year), possible due to a higher incidence of additional malfunction of the spleen. Time of
onset of invasive pneumococcal disease after organ transplant is variable and the risk persists
over time.37 Other causative organisms include Nocardia (especially in case of multiple brain
abscesses) and Listeria monocytogenes.38 Furthermore, it is important to consider there is
a wide range of differential diagnoses in case of suspected bacterial meningitis in these
patients, in not all cases adjunctive dexamethason can be safely administered.
The risk of invasive pneumococcal infections can be decrease by pneumococcal vaccination

prior to transplantation. Administration of prophylactic antibiotics in these patients remains
controversial, as there is a risk for resistance and recommendations in current guidelines
vary.37
Splenectomy or hyposplenic state
Dysfunction or absence of the spleen predisposes to infections with encapsulated bacteria

such as S. pneumoniae and Haemophilus influenzae.39, CHAPTER 3 A hyposplenic state can be
congenital or acquired after surgical removal of the spleen (splenectomy). Furthermore,
acquired functional hyposplenism occurs in 15–40% of the cases after allogeneic bone
marrow transplantation and other causes of hyposplenism are graft-versus-host disease,
sickle-cell anaemia, celiac disease and HIV infection.40 The spleen is the only site in the
human body where poorly opsonized bacteria like S. pneumoniae can be cleared from the
bloodstream and therefore hyposplenic patients are at risk for overwhelming sepsis caused
by these bacteria.39 Although this risk has been recognized for almost a century,43 patients
still do not receive adequate vaccination or information by their physicians about their risk
of infection and when to seek medical attention.39 Splenectomy or functional hyposplenia 7
is an uncommon risk factor for bacterial meningitis and was identified in 24 of 965 cases
(2.5%) of community-acquired meningitis in a prospective nation-wide cohort study, and
was associated with a high rate of mortality (25%) and unfavourable outcome (58%). In this
103

cohort study, all cases in patients with hyposplenia or asplenia were caused by S. pneumoniae.
The increased risk of infections by encapsulated bacteria is life-long, and the median time
between splenectomy or diagnosis of functional hyposplenia and the bacterial meningitis
episode was found to be 16 years, with a range from 1 to 54 years.39,CHAPTER 3 In the majority
of cases current guidelines for prevention of infection were not adhered to.39,42 Preventive
measures like sufficient and repeated vaccinations, patient education on how to recognize
meningitis, and prescription of prophylactic antibiotics could be used to reduce the number
of cases of bacterial meningitis in these individuals.39,42,CHAPTER 3
HIV/AIDS
HIV-infected individuals have a 6- to 324-fold increased susceptibility for invasive

pneumococcal disease.2 The increased susceptibility is caused by a decreased humoral
immunity: B-cell activation is impaired, resulting in decreased IgM synthesis and both
T-cell dependent and T-cell independent differentiation of B-cells is impaired. 43 This
results in a decreased humoral response to bacteria. In more advanced stages of HIV these
disturbances are more pronounced and therefore most episodes of bacterial meningitis
occur in individuals with a CD4 cell count of less than 200 cells per cubic millimetre.43 Most
of these patients are severely immunocompromised and do not take antiviral therapy. The
most common causative bacterial agent of bacterial meningitis in HIV-infected individuals
is S. pneumoniae, but Salmonella meningitis also occurs more frequently compared to
HIV negative controls.2 In case of low CD4 counts, the differential diagnosis of bacterial
meningitis is broad; tuberculous meningitis, cryptococcal meningitis and toxoplasma
meningoencephalitis should be considered.
Ninety percent of the worldwide HIV infected individuals live in low- income countries
and bacterial meningitis is at least ten times more common in these regions. Diagnosis
of bacterial meningitis in patients with HIV can be extremely difficult in resource-poor
settings, with no imaging available and limited laboratory facilities.4 Furthermore, antibiotic
resistance and partially treated bacterial meningitis is an increasing problem in Africa, where
antibiotics are often sold “over the counter”; approximately 5% of the S. pneumoniae isolates
have reduced susceptibility to ceftriaxone.4
A prospective cohort study in Spain performed in 2009 showed that there are several
differences between HIV-infected and HIV-uninfected meningitis patients in high resource
settings.43 In this study 32 episodes of bacterial meningitis in HIV-infected patients were
104

Chapter 7
compared to 267 episodes in HIV negative patients. HIV-infected patients with bacterial
General discussion
meningitis presented with more severe disease, reflected by a higher rate of altered mental
state, focal neurologic deficits and concomitant pneumonia. Leukocyte counts in the
cerebrospinal fluid (CSF) were lower in HIV infected patients, probably reflecting an
impaired immune response.43
In the United States national guidelines advice pneumococcal vaccinations in HIV infected
individuals.44 Because of a presumed low prevalence of pneumococcal infections in patients
with HIV in the Netherlands, Dutch national guidelines only advice pneumococcal vaccination
in case of concomitant use of intravenous drug and state that in other HIV infected individuals
vaccination can be considered.15 Studies that assessed vaccine efficacy of pneumococcal
vaccinations in case of HIV infection have varying and conflicting results.45 HIV-infected
patients with CD4+ T-lymphocyte counts less than 500 cells/uL often have lower responses
to pneumococcal vaccination.44 Despite these uncertainties, vaccination is considered safe in
this risk group and as the potential benefit is substantial, vaccination is advised.46,47
Host genetic susceptibility

The risk of acquiring bacterial infections is largely heritable, as shown by family-, twin- and
adoption studies.7,48 Several genetic traits for developing meningococcal and pneumococcal
disease have previously been described in extreme phenotype studies, of which most concerned
genetic deficits in genes coding for complement system proteins.7 An increased incidence of
invasive meningococcal meningitis was found in patients with a properdin deficiency and with
deficiencies in the complement system (C5, C6, C7, C8 and, possibly, C9) in extreme phenotype
studies.2 A review and meta-analysis of genetic risk factors for invasive pneumococcal and
meningococcal disease showed genetic variation in NFKBIA, NFKBIE, and TIRAP genes were
protective, whereas PTPN22 and MBL2 variants was associated with increased susceptibility
for pneumococcal disease.7 Increased susceptibility to invasive meningococcal disease was
associated with genetic variants in the CFH, SFTPA2, CEACAM3, and CEACAM6 genes,
whereas other CEACAM6 and SFTPA2 variants showed a protective effect.7
Recently, studies have addressed specific genetic risk factors for bacterial meningitis.25,49-51
A genetic association study in adult bacterial meningitis patients showed that a common
7
single nucleotide polymorphism the complement factor 3 gene (C3), was associated with
susceptibility for bacterial meningitis (OR 4.50, 95% CI 1.62–12.50).49,CHAPTER 5 Interestingly,
105

the protective genotype of this SNP was previously shown to increase the risk of age-related
macula degeneration, showing that a more readily activated complement system may
protect against bacterial infection while simultaneously increasing the risk for autoimmune
disease. In the same cohort, polymorphisms in mannose binding lectin (MBL2) resulting
in MBL deficiency were shown to increase the risk of pneumococcal meningitis.52 Patients
homozygous for variant alleles in exon1 of MBL2 had 8-fold (OR 8.21, 95% CI 1.05–64.1)
increased susceptibility for pneumococcal meningitis. Also, high CSF MBL levels were
associated with poor disease outcome and increased disease severity, suggesting that the
lectin pathway is a possible target for adjunctive therapy in pneumococcal meningitis.52
After an experimental meningitis model showed N. meningitidis passes the blood brain
barrier by using the beta2–adrenoceptor,53 genetic variation in the gene coding for this
receptor (ADRB2) was shown to influence the risk of bacterial meningitis (OR 1.35, 95%
CI 1.04–1.76).54,CHAPTER 6 Non-selective beta-blockers down-regulate this receptor, and
therefore could be tested as a target in experimental studies to see whether it may decrease
susceptibility to bacterial meningitis.54,CHAPTER 6
Two studies from a Dutch pediatric cohort showed that susceptibility to bacterial meningitis
was associated with genetic polymorphisms in Toll like receptor 2, 4, and 9 and nucleotide
oligomerization domain like receptor 2.50,51 Toll like receptors (TLRs) and nucleotide
oligomerization domain like receptor (NODs) are pathogen recognizing receptors and SNPs
in genes coding for this receptors are thought to influence susceptibility, but also disease
severity and outcome of bacterial meningitis by altering the inflammatory response.50,51
TLR4 and NOD2 SNPs were significantly associated with susceptibility to meningococcal
meningitis in children, and carriage of a combination of the risk alleles of in TLR2/TLR4
and TLR4/NOD2 SNPs showed an even stronger association.51 TLR9 SNPs were associated
with a reduced susceptibility to meningococcal meningitis in this study.50 Identification
of genetic risk factors for bacterial meningitis may be used in future study to identify
pathophysiological mechanisms and could change vaccination policy in patients with
established genetic risk factors.
Anatomical defects
The blood brain barrier (BBB) separates the central nervous system from the circulation and
is an important defence mechanism against bacteria invading the central nervous system.
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Chapter 7
It also maintains a stable environment inside the nervous system and potentiates molecular
General discussion
transport between blood and brain. Disruption of this barrier can occur following trauma,
surgery, congenital defects or ear and sinus infection and provides an entry for bacteria.55
When a patient has recurrent episodes of bacterial meningitis a disruption of the blood brain
barrier should be suspected, especially when the causative organism is S. pneumoniae, but
also N. meningitidis, S. aureus and H. influenzae are possible causative organisms in case of
a CSF leak.56,CHAPTER 2 In case of atypical causative organisms, or recurrent meningococcal
meningitis, an immunodeficiency (e.g. complement or properdin deficiency) should be
suspected. When no apparent cause of recurrent meningitis is identified on clinical grounds,
diagnostic procedures should be performed to identify anatomical defects because of the
high prevalence of this cause for recurrent meningitis (Figure 7.1).56,CHAPTER 2 Optimal imaging
consists of thin-slice CT of the skull base combined with MRI-3D constructive interference
in steady state (CISS) imaging. It is important to take into account that small bone defects
on CT do not prove CSF leakage.56,CHAPTER 2 Overt CSF leakage is seldom identified on
presentation and most leaks resolve spontaneously within the first 24–48 hours. In case of
a persistent CSF leak 7–30% of the patient develop meningitis, and this risk increases with
the duration of the leakage.55 There can be a delayed onset of several years between trauma
and bacterial meningitis.58-60 With an anatomical defect and/or CSF leakage present, a
neurosurgeon or otolaryngeologist should be consulted to evaluate the possibility to repair
the defect. Furthermore, vaccinations should be administered in case of persistent CSF
leakage. Treatment with prophylactic antibiotics in these patients remains controversial
but may be considered in patients with recurrent meningitis despite vaccination.56,CHAPTER 2
7

Figure 7.1 Computed tomographic imaging: Anatomical defect of the fovea ethmoidalis on the right side
in a 57-year old woman, with a history of 3 episodes of pneumococcal meningitis and prior sinus surgery.
107

Vaccination after bacterial meningitis

The risk of a recurrence of bacterial meningitis in patients with no anatomical defect or
known immunodeficiency is estimated to be 1–3%.56,CHAPTER 2 Most of these cases are caused
by S. pneumoniae. The risk of second meningitis episode is substantially increased compared
the risk of a first episode in the general population. Although the efficacy of pneumococcal
vaccination in this population has not been studied, it appears logical to vaccinate all patients
following an episode of pneumococcal meningitis, considering the substantially increased
risk and lack of side effects of vaccination. This paradigm shift needs follow-up evaluation
in cohorts of bacterial meningitis patients to determine whether the risk of recurrent
pneumococcal disease is reduced.
Conclusion
Bacterial meningitis is a potentially life-threatening disease and several conditions that
increase susceptibility are identified. Awareness of risk factors for meningitis may facilitate
early recognition and treatment of the disease, and vaccinations can prevent cases of bacterial
meningitis in various risk groups. Sufficient preventive measures in selected groups of
individuals with increased risk for bacterial meningitis may reduce the number of cases.
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112

Chapter 7
General discussion
113

Summary
Summary_Kirsten.indd 115 19-8-2015 9:17:09

Summary
Bacterial meningitis remains a life-threatening and serious infectious disease. Available

treatment with antibiotics and dexamethasone improved the prognosis, but mortality and
morbidity is still substantial. Because of preventive measures the epidemiology of bacterial
meningitis changed and reduced the number of cases – e.g. the childhood vaccinations
that are administered in the Netherlands. There are several risk factors and predisposing
conditions for bacterial meningitis and in this thesis we give an overview of these risk factors.
In Chapter 2 we describe a group of 31 patients and 34 episodes of recurrent bacterial

meningitis. These patients were included in a Dutch nation-wide prospective cohort study
from 1998–2002. Recurrent bacterial meningitis is relatively rare, but there was a substantial
mortality rate of 15% of 34 episodes. Most patients were male and predisposing conditions
were involved in 77% of 34 episodes. Most common were remote head injury and CSF
leakage which justifies an active search for anatomical defects and CSF leakage in patients
with a second episode of bacterial meningitis. If closure of the leak is not possible these
patients should receive vaccinations.
In Chapter 3 we investigate bacterial meningitis in patients with a history of splenectomy

or with a hyposplenic state. Loss of spleen function is an important acquired condition
that increases susceptibility for pneumococcal infection and Streptococcus pneumoniae
is the most common causative organism that causes bacterial meningitis. We identified
24 patients with bacterial meningitis. Sixteen of them had a history of splenectomy and 8
patients had functional hyposplenia. All of these patients had pneumococcal meningitis and
there was a high rate of mortality and unfavourable outcome (58%). Most patients presented
with classic symptoms and signs of bacterial meningitis, but there was more often a septic
shock at presentation compared to patients with normal spleen function. Only 6 patients
were adequately vaccinated against pneumococci. We concluded that splenic dysfunction is
uncommon as predisposing condition for bacterial meningitis, but that it can be prevented by
vaccinations – although vaccine failures occur. Furthermore, increased awareness of patients
with splenic dysfunction – but also of their physicians – about the risk for pneumococcal
meningitis is needed to reduce mortality and morbidity in this patient group.
Bacterial meningitis during pregnancy is rare and only a few cases previously have been
reported in literature. In Chapter 4 we identify 6 cases in a 6-year period (2005–2010)
and describe epidemiology, clinical characteristics and outcome. All of these patients were
multigravida and the causative organism was S.pneumoniae in all cases. Two of these 6
patients died, fetal outcome was good in 5 cases. Also, we reviewed the literature about
116

bacterial meningitis in pregnancy and found 42 cases. When we combine our cases and the
Summary
cases from literature the second most common causative organism was L.monocytogenes.
Otitis was found to be the most frequent predisposing condition for bacterial meningitis in
pregnancy. Furthermore, the women in our case-series are relatively old compared to the
cases in literature, 4 of 6 women over 35 years old. We concluded that empirical therapy for
bacterial meningitis in pregnant women should cover S. pneumoniae and L. monocytogenes.
Despite optimal antibiotic treatment, bacterial meningitis during pregnancy can have a rapid
fatal outcome for mother and child.
To determine the effect of genetic variation in the complement system and susceptibility for
bacterial meningitis we performed a prospective genetic association study. We genotyped
17 common SNPs in genes coding for complement components in patients and controls as
described in Chapter 5. Also we measured complement levels in cerebrospinal fluid of the
patients to evaluate functional consequences. We found an association between a common
SNP in C3 and susceptibility for bacterial meningitis, which explains some of the inter-
individual differences in susceptibility for bacterial meningitis.
After a report in literature about the biased β2-adrenoceptor/β-arrestin pathway that played
an important role in crossing the blood brain barrier by Neisseria meningitidis, we inves-
tigated in Chapter 6 whether SNPs in the β2-adrenoceptor/β-arrestin pathway influence
susceptibility for bacterial meningitis. We identified a functional polymorphism in ADRB2
to be associated with an increased risk for bacterial meningitis. Non-selective beta-blockers
bind to the β2-adrenoceptor, so we also analysed whether use of this medication influenced
the risk. We found that a lower frequency of patients with bacterial meningitis used these
compared to the age matched Dutch population, but this did not reach statistical significance.
To evaluate a potential benefit of non-selective betablockers as prevention for bacterial
meningitis more research is necessary.
To conclude, in Chapter 7 we give an overview of risk factors and risk groups for community-
acquired bacterial meningitis in adults, with preventive measures and treatment options.
117

Samenvatting
Samenvatting_Kirsten.indd 119 19-8-2015 9:17:23

Samenvatting
Bacteriële meningitis is nog steeds een levensbedreigende en gevaarlijke infectieziekte.

Tegenwoordig zijn er antibiotica en dexamethason beschikbaar, maar desondanks is er
nog steeds een relatief hoge mortaliteit en morbiditeit ten gevolge van deze aandoening.
Door preventieve maatregelen, zoals het vaccineren van kinderen, is de epidemiologie
veranderd en de hoeveelheid gevallen afgenomen. Er zijn verschillende risicofactoren en er
zijn risicogroepen die meer kans hebben op bacteriële meningitis. In dit proefschrift geven
we een overzicht van deze risicofactoren en risicogroepen.
In hoofdstuk 2 beschrijven we 31 patiënten die 34 episodes van recidiverende meningitis

tijdens de onderzoeksperiode doormaakten. Deze patiënten waren geïncludeerd in een
Nederlandse landelijke prospectieve cohortstudie van 1998–2002. Recidiverende bacteriële
meningitis is zeldzaam, maar er was een substantiële mortaliteit van 15% van de 34 episodes.
De meeste patiënten waren van het mannelijke geslacht en predisponerende factoren kwamen
vaak voor; in 77% van de 34 episodes. De vaakst voorkomende predisponerende factoren
waren een voorgeschiedenis van hoofdtrauma en liquorlekkage. Dit betekent dat er – als een
patiënt een tweede keer bacteriële meningitis krijgt – grondig gezocht moet worden naar
anatomische defecten en liquorlekkage. Als een liquorlek gevonden wordt dat niet gesloten
kan worden, dan moeten deze patiënten gevaccineerd worden.
In hoofdstuk 3 onderzoeken we patiënten met bacteriële meningitis en een splenectomie

in de voorgeschiedenis of een verminderde miltfunctie. Een verminderde miltfunctie is
een belangrijke vaak verworven aandoening die resulteert in een verhoogde gevoeligheid
voor pneumokokkeninfecties en Streptococcus pneumoniae is de meest voorkomende
veroorzakende bacterie van bacteriële meningitis. In ons cohort vonden we 24 patiënten met
bacteriële meningitis met een splenectomie (16 patiënten) of verminderde miltfunctie (8
patiënten). Alle patiënten hadden pneumokokkenmeningitis en er was een hoge mortaliteit
en slechte uitkomst (58%). De meeste patiënten presenteerden zich met klassieke symptomen
van meningitis, maar vaker dan patiënten met een normale miltfunctie presenteerden ze zich
met tekenen van een septische shock. Slechts 6 patiënten bleken adequaat te zijn gevaccineerd
tegen pneumokokken. We concludeerden dat een verminderde miltfunctie een zeldzame
predisponerende conditie is voor bacteriële meningitis, maar dat er betere preventie mogelijk
is door adequate vaccinaties. Ook de patiënt – en de behandelende artsen – moeten beter
op de hoogte zijn van het verhoogde risico op pneumokokkenmeningitis. Hierdoor kan de
mortaliteit en morbiditeit verder verlaagd worden.
120

Bacteriële meningitis tijdens de zwangerschap is zeldzaam en slechts enkele casus zijn eerder
Samenvatting
in de medische literatuur beschreven. In hoofdstuk 4 hebben wij de klinische kenmerken,
het beloop en de uitkomst van 6 zwangere patiënten met bacteriële meningitis beschreven,
geïncludeerd in onze cohortstudie tussen 2005 en 2010. Al deze patiënten waren multigravida
en bij alle patiënten was S. pneumoniae de verwekker van de bacteriële meningitis. Twee van
de 6 patiënten kwamen te overlijden, de foetale uitkomst was goed in 5 van de 6 episodes.
Daarnaast is de medische literatuur over bacteriële meningitis tijdens de zwangerschap
doorzocht en vonden we 42 beschreven casus. Bij het combineren van onze patiënten en de
patiënten beschreven in de literatuur, bleek L. monocytogenes de tweede meest voorkomende
verwekker. Otitis was de meest voorkomende predisponerende conditie voor bacteriële
meningitis tijdens zangerschap. Verder bleken de vrouwen in ons cohort relatief oud in
vergelijking met de casus in de literatuur, 4 van de 6 vrouwen waren ouder dan 35 jaar. We
concludeerden dat de empirische antibiotica gegeven bij bacteriële meningitis bij zwangeren
zowel S. pneumoniae als L. monocytogenes moet dekken. Ondanks optimale antibiotische
behandeling kan bacteriële meningitis tijdens de zwangerschap een snelle fatale uitkomst
hebben voor zowel moeder als kind.
Om te onderzoeken wat het effect is van genetische variatie in het complementsysteem ten
opzichte van de gevoeligheid voor bacteriële meningitis hebben wij een prospectieve ge-
netische associatiestudie verricht. We genotypeerden 17 SNPs in genen die coderen voor het
complementsysteem bij patiënten en controles, zoals beschreven in hoofdstuk 5. Daarnaast
hebben we ook de complementwaarden in de liquor van patiënten gemeten. We hebben
een associatie tussen een SNP in C3 gevonden en gevoeligheid voor meningitis, wat een
deel van de inter-individuele verschillen voor gevoeligheid voor bacteriële meningitis kan
verklaren.
Nadat in de literatuur werd beschreven dat de β2-adrenoceptor/β-arrestine pathway een

belangrijke rol speelt in het passeren van de bloedhersenbarrière door Neisseria meningitidis,
hebben we in hoofdstuk 6 onderzocht of SNPs in de β2-adrenoceptor/β-arrestine pathway
gevoeligheid voor bacteriële meningitis beïnvloeden. We identificeerden een functioneel
polymorfisme in ADRB2 dat is geassocieerd met een verhoogd risico voor bacteriële
meningitis. Niet-selectieve beta-blokkers binden aan de β2-adrenoceptor, dus we hebben
ook onderzocht of gebruik van dit medicijn het risico op bacteriële meningitis beïnvloedt.
We vonden dat patienten dit medicijn minder vaak gebruikten dan Nederlandse patiënten
van dezelfde leeftijd die geen meningitis hebben gekregen, echter dit verschil was statistisch
niet significant. Mogelijk hebben niet-selectieve beta-blokkers een beschermend effect
121

Samenvatting
tegen bacteriële meningitis, maar verder onderzoek is nodig om hier meer zekerheid over
te verkijgen.
Ten slotte geven we in hoofdstuk 7 een overzicht van risicofactoren en risicogroepen bij
volwassenen die meer kans hebben op bacteriële meningitis, met daarbij mogelijke preven-
tieve maatregelen en mogelijkheden voor behandeling.
122

Samenvatting
123

Dankwoord
Dankwoord_Kirsten.indd 125 19-8-2015 9:17:31

Dankwoord
Graag wil ik iedereen bedanken die een bijdrage heeft geleverd aan de tot stand koming van
dit proefschrift. Een aantal mensen wil ik graag in het bijzonder bedanken:
Ten eerste alle bacteriële meningitispatiënten, hun partners en familieleden. Zonder uw

medewerking was dit onderzoek niet mogelijk geweest.
Professor Diederik van de Beek, mijn promotor. Lang geleden ben ik als tweedejaars
geneeskundestudent bij Jan de Gans beland om “wat statussen te bekijken”. Tijdens mijn
wetenschappelijke stage was jij hard bezig aan je promotie en je gedrevenheid maakte diepe
indruk op mij. Na je promotie ben je keihard doorgestoomd en behoor je inmiddels tot
de top van medisch wetenschappelijk Nederland. In combinatie met Matthijs ben je een
gouden team en wat heb ik ongelooflijk veel aan je te danken. Binnenkort – als de rook
van de promotie is opgetrokken – weer een goed glas wijn bij jou en Judith in jullie tuin?
Matthijs Brouwer, mijn co-promotor. Als co-assistent heb ik al eens een nachtdienst met
je meegelopen, waarbij ik je weinig heb gesproken, er gebeurde immers niets, een typische
“Brouwer-dienst”. Je kwam als eerste AIOS naar het OLVG toen ik daar oudste co-assistent
was en hebt mij geholpen mijn eerste artikel af te schrijven onder het genot van zelfgebakken
pannenkoeken en citaten uit Gummbah. Door jouw enthousiasme, droge humor, maar ook
wetenschappelijke kennis en ervaring was promoveren leuk. Ik heb bewondering voor je
en mijn dank is groot. Wat hebben jij en Diederik een goede onderzoeksgroep opgezet. De
avondjes IJsbreker zijn sterk in frequentie afgenomen door onze jonge kinderen, maar ik
hoop in de toekomst toch de regelmaat erin te houden!
Jan de Gans, ooit heb ik als tweedejaars geneeskunde, als junior co-assistent het hokje
“Neurologie” zwart gemaakt op een keuzeformulier. Geen idee wat neurologen precies deden
en wat voor dokters dat waren, dat was de reden voor de keuze. En wat een prachtig vak bleek
het te zijn. In de week dat ik met jou meeliep ben ik verwonderd en gebiologeerd geraakt, iets
wat ik nog steeds elke dag heb. Dank je wel voor je enthousiasme en jouw gave om te laten
zien hoe mooi de Neurologie is en in het bijzonder de neurologische infectieziekten. Jij bent
ook degene die de basis voor dit proefschrift heeft gelegd, zonder jou was ik misschien geen
neuroloog geworden en bij jou mocht ik onderzoek gaan doen. Uit betrouwbare bronnen
weet ik ook dat vele andere neurologen tijdens de opleiding door jou zijn geraakt en zijn
geïnspireerd, je bent een heel bijzonder mens. Dank voor alles.
De leden van mijn promotiecommissie, dank u wel dat u bereid bent geweest mijn proef-
schrift te beoordelen en zitting heeft genomen in de promotiecommissie.
126

Mijn opleiders, professor Jan Stam en professor Yvo Roos.
Dankwoord
Jan, zoveel is al gezegd bij jouw afscheid, maar wat was je een inspirerende opleider voor
mij. Streng doch rechtvaardig en je hebt mij voor een groot deel “gevormd” als clinicus. Het
was een eer om door jou opgeleid te worden. In de eerste maanden als jonge klare neuroloog
heb jij veel over mijn schouder meegekeken; zonder dat jij het wist, klonk er vaak een “Jan
Stam-stem” in mijn gedachten als ik nadacht over een moeilijke casus.
Yvo, ik heb het je al eerder gezegd, maar je bent een waardig opvolger als opleider. Betrokken
en steunend, ook nog na afronding van de opleiding. Ik heb het gevoel dat je voor iedereen
klaarstaat, wanneer dan ook, en dat is iets bijzonders.
Het hoofd van de afdeling neurologie, aan het begin van mijn opleiding eerst professor Rien
Vermeulen, daarna professor Ivo van Schaik.
Beste Rien, dank voor je goede begeleiding tijdens mijn opleiding, de maandagochtend
besprekingen waren een belevenis met jou voor de zaal, de assistentendiners legendarisch.
Tijdens mijn opleidingstijd tot arts waren jouw colleges beroemd vanwege jouw gave
neurologische ziektebeelden zeer natuurgetrouw na te kunnen doen of een nystagmus uit
te beelden met een handgebaar. Ik wil je heel erg bedanken voor alles!
Ivo, ook jou ken ik al vanaf mijn eerste stappen binnen de Neurologie, samen met Peter
Portegies werkte je toen nog als neuroloog in het OLVG. Inmiddels hoofd van de afdeling
Neurologie in het AMC, bijzonder om al die jaren met jou te hebben samengewerkt. Dank!
Professor Peter Portegies. Peter, je bent heel belangrijk – nog steeds – in mijn vorming
als onderzoeker, mens en arts. Mijn meest indrukwekkende jaren heb ik beleefd in het
OLVG, als beginnend arts, mede onder jouw rustige begeleiding. Ik was al gegrepen door
de Neurologie en door de infectieziekten; jij wakkerde dit nog verder aan. Op een of andere
manier, heb jij mij altijd geholpen en aan de juiste mensen voorgesteld, bedankt dat je mij
het gevoel geeft dat ik te allen tijde bij je terecht kan. En om een uitspraak van jou om te
draaien “Nee, jij bedankt!”.
Paranimfen, Hannah Roelofs en Madelijn Geldhoff.
Hannah; wij gaan een “long way back”. Als basisschoolleerlingen hadden wij dezelfde beste
vriendin, en kenden wij elkaar via via vanaf ons 6e jaar. Op de middelbare school werden
wij goede vriendinnen en inmiddels zijn we dat al 24 jaar. Bijzonder om alle belangrijke
mijlpalen in het leven met jou te delen. Jij was getuige op mijn huwelijk, ik was aanwezig bij
127

Dankwoord
de geboorte van jouw tweede dochter, onze oudste dochters zijn dikke vriendinnen. Jij en
Allerd staan altijd voor ons klaar, jullie zijn geweldige vrienden. Je bent inmiddels zoveel
meer dan een vriendin, onze levens en gezinnen zijn verstrengeld. Lieverd, je bent een schat!
Madelijn; wij kennen elkaar van de “Meningitiskamer”. Je hebt mij in vogelvlucht het echte
laboratoriumwerk laten zien, iets waar ik weinig kaas van had gegeten. Je hebt hartelijk
gelachen om mijn “eitje”, wat een “Y-tje” moest zijn. Inmiddels ben jij ook in opleiding tot
neuroloog en 2 kinderen rijker. Op naar jouw proefschrift! You go girl!
Nathalie Spaans, lieve Nath, net als Hannah mijn lieve beste vriendin. Wij kennen elkaar uit
de kleuterklas en zijn alweer 31 jaar bevriend, hoe bizar! Met zijn drieën wonen we bij elkaar
om de hoek en houden we af en toe een avond “Langendijk” of “Olifant” om in no-time bij
te praten over werk, kinderen, hobby’s, familie en onze relaties. Ook jij bent er altijd voor
mij, dag en nacht bereikbaar, en wanneer het nodig is ook nog oppas of kinderentertainer.
Al jaren veel meer dan een vriendin… je bent familie!
Renée van Marissing, al lange tijd vriendinnen en elkaar ooit noodgedwongen leren kennen
door een opsluiting in een klaslokaal; saillant detail… door diezelfde Hannah Roelofs die
vond dat we een stuk voor de schoolkrant moesten schrijven. Sindsdien zien wij elkaar –
vaak onregelmatig – maar wat is het toch altijd fijn om even samen met jou te praten over
het leven, Ramses Shaffy te luisteren of naar de film te gaan. Dank je voor het laten zien van
een totaal andere wereld, die van roman- en scenarioschrijfster. Uiteindelijk zijn wij beiden
na de schoolkrant toch nog heel goed terechtgekomen qua schrijfkunst.
Al mijn andere vrienden, dank jullie voor jullie nooit aflatende interesse! Ook al zien we
elkaar een stuk minder vaak, toch zijn en blijven jullie belangrijk. Vaker tijd voor kopjes
koffie en feestjes, dat wens ik ons allen toe.
Alle meningitisgroep-onderzoekers van nu en vroeger: Barry Mook, Sebastiaan Heckenberg,

Ewout Schut in het bijzonder voor de eerste gezellige tijd op de meningitiskamer! (En
nogmaals sorry voor het wuppieplankje…). Inmiddels is de groep verder uitgedijd en de
gezelligheid alleen maar toegenomen.
De medewerkers van het Nederlands Referentie Laboratorium voor Bacteriële Meningitis

en de afdeling microbiologie van het AMC.
Alle medeauteurs, dank voor jullie inbreng en de samenwerking.
128

Alle arts-assistenten en neurologen van de afdeling Neurologie van het AMC. Dank
Dankwoord
jullie voor alle gezelligheid, assistentenuitjes, opleidingsdiners, begeleiding, nachtelijke
telefoongesprekken in de dienst, onderwijs en saamhorigheid. Velen van jullie zijn heel
speciaal voor mij. Een paar van jullie wil ik in het bijzonder noemen: Judith Citroen
tegelijk neuroloog en goede vriendin, Judith Schouten “what happens at the Biemond,
stays at the Biemond”, Niels Schoenmaker met gitaar voor bij een kampvuur, Filip Eftimov,
wijnkenner, vriend sinds jaren en virtuoos op de piano, Antje Seeber de liefste neuroloog
die ik ken, de dames van het KNF-jaar: Bregje Jaeger en Cathelijne Gorter de Vries, wat
was dat een fijn jaar!
Mijn nieuwe collega’s in Tergooiziekenhuizen: Jean-Michèl Krul, Martijn Stevens, Jelle

de Kruijk, Ron Witjes, Salka Staekenborg, Hans Carpay, Paul Bouma, Pieter Laboyrie,
Jules Claus, Dirk Herderscheê, Dennis Buis en Ronald Willemse. Dank voor de soepele
overgang van neuroloog-in-opleiding naar neuroloog.
De onderzoeksgroep tropische infectieziekten van het ErasmusMC. Allereerst professor Eric

van Gorp; Eric, dank dat jij mij de mogelijkheid hebt geboden om infectieziektenonderzoek
bij jou te kunnen voortzetten. Ik moet mij af en toe nog in de arm knijpen, zo leuk is
het allemaal bij jullie in Rotterdam. Lennert, Marco, Wesley en alle anderen van de
onderzoeksgroep: dank voor het warme welkom en de fijne samenwerking! Marco, dankzij
jou ben ik voor het eerst in mijn leven door een papegaai gefeliciteerd…waarschijnlijk iets
wat er gewoon bij hoort bij de tropische infectieziekten…
Vriendinnengroep “3”, samen delen we alles, vooral via de whatsapp; alles is herkenbaar en
ik leer zo veel van jullie. Dank voor al jullie steun, dag en nacht.
Lieve Annette en Leo Cahn, mijn schoonouders. Ik heb best vaak daar in Drenthe in het
kleine slaap- annex studeerkamertje zitten werken en typen, voorzien van koffie van Leo
of een kopje thee van Annette. Altijd oprecht geïnteresseerd in mijn werk en onderzoek en
nu kan ik eindelijk eens opschrijven wat voor een bijzondere en lieve mensen jullie zijn.
Daarnaast komt Annette regelmatig helemaal vanuit Drenthe naar Amsterdam om een dag
op de kleinkinderen te passen, als “oma Netje”. Zonder jullie zou werk en privé een stuk
moeilijker te combineren zijn. Dank jullie wel!
Caspar Adriani, mijn broer. Als kinderen hadden we vaak lol samen en nu – ook als we
elkaar een tijd niet zien – is het altijd gezellig. Inmiddels allebei een druk gezin rijker, met
kinderen die elkaars dikke vrienden, neven en nichten zijn. Allebei een drukke baan, jij als
129

Dankwoord
eigen ondernemer, ik als arts, jij af en toe op bezoek bij schoonouders in China, dus tijd
vinden voor elkaar is soms lastig. Lieve broer, en ook je vrouw Linda, ook jullie bedankt
voor jullie interesse en steun!
Henk en Inge Adriani. Lieve Henk, mijn vader en Inge, mijn moeder. Zonder jullie goede
opvoeding en nooit aflatende steun voor alles wat ik doe in mijn leven was dit proefschrift
er natuurlijk nooit geweest. Altijd staan jullie voor mij en mijn broer klaar en ook voor jullie
kleinkinderen. En dat is zowel met mentale steun, als heel praktisch met kinderen van school
halen. Jullie hebben mij geleerd dat je je hart moet volgen en dat uiteindelijk alles mogelijk
is in het leven. Jullie zijn geweldig en ik hou van jullie.
Arjé Cahn, mijn man. Lieve Ar… waar moet ik beginnen met omschrijven wat jij voor mij
betekent… Met jou ben ik alles, samen kunnen wij alles en maken we mooie dingen mee.
Jij steunt me te allen tijde in mijn werk, en kwam met een prachtige laptop aanzetten toen
ik vertelde te willen promoveren. Altijd lieve en praktische kado’s. Allebei kunnen we nooit
stil zitten en hebben we steeds behoefte aan nieuwe uitdagingen, dus na dit feest weer verder
samen op avontuur en op naar het volgende feest. Ik hou ontzettend veel van je!
Lieve Nora, Linde en Fenna. Dit proefschrift is opgedragen aan jullie, omdat jullie het
allerbelangrijkste zijn in mijn leven. Jullie zijn drie prachtige en geweldige dochters, ik
kan me geen lievere en leukere kinderen wensen. Soms kan werk en zorgen voor jullie een
spagaat zijn, maar ik ben ook apetrots als jullie vertellen “dat alle mama’s dokters zijn”. Ik
hoop dat jullie opgroeien tot drie fantastische, gelukkige vrouwen.
130

Dankwoord
131

About the author
About_Kirsten.indd 133 19-8-2015 9:17:43

About the author
Curriculum vitae
Kirsten Adriani was born on July 2, 1979 in Amsterdam, the Netherlands. She graduated
from Secondary School (Fons Vitae Lyceum, Amsterdam) in 1997. In 1998 she started her
medical education at the University of Amsterdam. During her studies she was student-
member of the KNMG district Amsterdam. In 2002 she was student-editor for the book
“Student Grand Rounds – de co-assistent aan het ziekbed” (Prof.dr. J.B.L. Hoekstra). Her
first scientific research was done at the Department of Neurology of the Academic Medical
Centre under supervision of dr. J. de Gans and Prof.dr. D. van de Beek on recurrent bacterial
meningitis. After her graduation in 2005 she worked in 2006 as ANIOS in the Onze Lieve
Vrouwe Gasthuis. She started her Neurology training at the Academic Medical Centre in
2007 (Prof.dr. J. Stam, Prof.dr. M. Vermeulen, Dr. J.H.T.M. Koelman, Prof.dr. Y.B.W.E.M.
Roos, Prof.dr. I.N. van Schaik). One year of the residency was spent in the Onze Lieve Vrouwe
Gasthuis (Prof.dr. P. Portegies). From 2007 on she combined her Neurology training with a
PhD project on risk factors for community-acquired bacterial meningitis at the Department
of Neurology of the Academic Medical Centre (Prof.dr. D. van de Beek, Dr. M.C. Brouwer),
resulting in this thesis. In July 2014 she finished her neurology training and started working
as neurologist in Tergooiziekenhuizen in Blaricum and Hilversum. She participates in
research on viral encefalitis at the Department of Viroscience, Erasmus Medical Centre in
Rotterdam (Prof.dr. E.C.M. van Gorp). She is married to Arjé Cahn and they have three
daughters, Nora, Linde and Fenna.
134

Publications
About the author

In this thesis
1. Adriani KS, Brouwer MC, van de Beek D. Risk factors for community-acquired
bacterial meningitis in adults. Review. NethJM, 2015; 73(2): 53-60.
Authors’ contributions: KSA wrote the first draft of the manuscript, contributed to the
data interpretation and review of the literature. MCB and DvdB contributed to the data
interpretation, review and critical revision of the manuscript. All authors contributed to
and have approved the final manuscript. No conflicts of interests were declared.
2. Adriani KS, Brouwer MC, van der Ende A, van de Beek D. Bacterial meningitis in
adults after splenectomy and hyposplenic states. Mayo Clin Proc. 2013; 88(6): 571-578.
Authors’ contributions: KSA undertook the analyses and wrote the first draft of
the manuscript. KSA, MCB, AvdE and DvdB contributed to the study design, data
interpretation and critical revision of the manuscript. AvdE contributed to the
organisation/materials and analysis tools. All authors contributed to and have approved
the final manuscript. No conflicts of interests were declared.
3. Adriani KS, Brouwer MC, Geldhoff M, Baas F, Zwinderman AH, Paul Morgan B, Harris
CL, van der Ende A, van de Beek D. Common polymorphisms in the complement
system and susceptibility for bacterial meningitis. J Infect. 2013; 66(3): 255-262.
Authors’ contributions: Experimental procedures were carried out by KSA, MG and
MCB. AvdE, FB en AHZ contributed to the organisation/materials and analysis tools.
The manuscript was drafted by KSA and MCB and discussed and edited by DvB, BPM,
FB, AHZ, CLH and AvdE. All authors contributed to and have approved the final
manuscript. No conflicts of interests were declared.
4. Adriani KS, Brouwer MC, Baas F, Zwinderman AH, van der Ende A, van de Beek
D. Genetic variation in the β2-adrenocepter gene is associated with susceptibility to
bacterial meningitis in adults. PLoS One 2012; 7(5): e37618.
Authors’ contributions: KSA undertook the analyses for the manuscript and wrote the first
draft. Experimental procedures were carried out by KSA and MCB. It was discussed and
edited by MCB and DvB. AvdE, FB en AHZ contributed to the organisation/materials
and analysis tools. All authors contributed to the conception, design and interpretation
of analyses for the manuscript as well as its critical revision. All authors contributed to
135

About the author
5. Adriani KS, Brouwer MC, van der Ende A, van de Beek D. Bacterial meningitis in pregnancy:
report of six cases and review of the literature. Clin Microbiol Infect 2012; 18(4): 345-351.
Authors’ contributions: KSA wrote the first draft of the manuscript and undertook the
analyses for the manuscript, and it was discussed and edited by MCB and DvB. AvdE
contributed to the organisation/materials and analysis tools. All authors contributed to
6. Adriani KS, van de Beek D, Brouwer MC, Spanjaard L, de Gans J. Community-acquired

recurrent bacterial meningitis in adults. Clin Infect Dis. 2007; 45(5): e46-51.
Authors’ contributions: KSA wrote the first draft of the manuscript and undertook the
analyses for the manuscript, and it was discussed and edited by MCB, DvB and JdG. LS
contributed to organisation/materials and analysis tools. All authors contributed to and
have approved the final manuscript. No conflicts of interests were declared.
Other publications
1. Staekenborg SS, Adriani KS, van Oosten BW, Wattjes MP, Vandertop WP. Anterieure
thoracale transdurale myleumherniatie. Tijdschrift voor Neurologie en Neurochirurgie,
accepted.
2. Adriani KS, van de Beek D, Troost D, Brouwer MC. The diagnostic pitfall of
infratentorial subdural empyema. Arch Neurol. 2012; 69(8): 1076-1077.
3. Adriani KS, Stenvers DJ, Imanse JG. Pearls & oy-sters: Lumbar paraganglioma: can
you see it in the eyes? Neurology 2012; 78(4): e27-e28.
4. Vergouwen MD, Adriani KS, Roos YB, Groothoff JW, Majoie CB. Proximal cerebral artery
stenosis in a patient with hemolytic uremic syndrome. AJNR Am J Neurorad 2008; 29(5): e34.
136

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Risk factors for community-acquired bacterial meningitis in adults

Citation for published version (APA):

UvA-DARE is a service provided by the library of the University of Amsterdam (http://dare.uva.nl)

Download date: 23 Dec 2020

Risk factors for community-acquired bacterial meningitis in adults Kirsten S. Adriani

Officieel_Kirsten.indd 1 19-8-2015 9:15:27

Cover Esther Ris, Proefschriftomslag.nl

© Kirsten S. Adriani, 2015

Officieel_Kirsten.indd 2 19-8-2015 9:15:27

ter verkrijging van de graad van doctor

Kirsten Saskia Adriani

Officieel_Kirsten.indd 3 19-8-2015 9:15:27

Promotor: Prof. dr. D. van de Beek, Universiteit van Amsterdam

Co-promotor: Dr. M.C. Brouwer, Universiteit van Amsterdam

Overige leden: Prof. dr. P. Portegies, Universiteit van Amsterdam

Faculteit der Geneeskunde

Officieel_Kirsten.indd 4 19-8-2015 9:15:27

Officieel_Kirsten.indd 5 19-8-2015 9:15:27

Chapter 2 Community-acquired recurrent bacterial meningitis in adults 15

Chapter 3 Bacterial meningitis in adults after splenectomy and in 29

Chapter 4 Bacterial meningitis in pregnancy: report of six cases and review 45

Chapter 5 Common polymorphisms in the complement system and 61

Chapter 6 Genetic variation in the β2-adrenoceptor gene and association 81

Chapter 7 General discussion: risk factors for community-acquired bacterial 95

TableOfContents_kirsten.indd 7 20-8-2015 8:50:20

Chapter_1_Kirsten.indd 9 19-8-2015 9:15:55

Bacterial meningitis is a life-treatening disease because the proximity of the infection to

Susceptibility and risk factors – outline of this thesis

Chapter_1_Kirsten.indd 10 19-8-2015 9:15:55

In chapter 2 a nation-wide prospective cohort study in adults with recurrent bacterial

Chapter 5 describes a prospective nationwide genetic association study in adults with

3. de Gans J, van de Beek D. European Dexamethasone in Adulthood Bacterial Meningitis Study

Chapter_1_Kirsten.indd 11 19-8-2015 9:15:55

Chapter_1_Kirsten.indd 12 19-8-2015 9:15:55

Chapter_1_Kirsten.indd 13 19-8-2015 9:15:55

Clinical Infectious Diseases 2007; 45(5): e46-51.

Chapter_2_Kirsten.indd 15 19-8-2015 9:16:06

Chapter_2_Kirsten.indd 16 19-8-2015 9:16:06

Recurrent bacterial meningitis

Chapter_2_Kirsten.indd 17 19-8-2015 9:16:06

remote neurosurgerical procedure, and remote head trauma. Neurosurgerical procedures

Mean age, years (range) 43 (17–83)

Table 2.1 continues on next page

Chapter_2_Kirsten.indd 18 19-8-2015 9:16:06

Recurrent bacterial meningitis

Focal neurological deficits 10/34 (30)

Chapter_2_Kirsten.indd 19 19-8-2015 9:16:06

Chapter_2_Kirsten.indd 20 19-8-2015 9:16:06

Recurrent bacterial meningitis

The causative microorganisms, as identified by CSF culture, were S. pneumoniae in 28

The distribution of serotypes of S. pneumoniae was type 14 in 5 (18%) episodes; types 6B 2

Initial antimicrobial treatment consisted of penicillin or amoxicillin for 17 (50%) of 34

During the clinical course, neurologic complications occurred during 23 (67%) of 34

Chapter_2_Kirsten.indd 21 19-8-2015 9:16:07

Complication or outcome No. (%) of episodes

Seizures 7/34 (21)

Chapter_2_Kirsten.indd 22 19-8-2015 9:16:07

Recurrent bacterial meningitis

The predominant causative organism was S. pneumoniae. This bacterium is a frequent

Chapter_2_Kirsten.indd 23 19-8-2015 9:16:07

In patients with no apparent cause of recurrent meningitis or known history of head

Chapter_2_Kirsten.indd 24 19-8-2015 9:16:07