“A RETROSPECTIVE STUDY OF CSF CELL COUNT

AND CHEMISTRIES IN BACTERIAL MENINGITIS”

DISSERTATION SUBMITTED TO
(SCHOOL OF SCIENCES)
MAULANA AZAD NATIONAL URDU UNIVERSITY
(A Central University established by an act of parliament in 1998)

A PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE

REQUIREMENTS FOR THE AWARD OF DEGREE OF

B.Voc.Medical Laboratory Technology

Submitted By

MD Khushdil (A200177) Shaban Ahmad(A201807)

MD Fahad Gufran(A200173) Musarrat Fauzi(A200169)
Mohammad Arif Khan(A200162) Afifa Khatoon(A200172)
Shahadat Hussain(A201201) Shagufta Afrin(A181063)

Under the supervision of

Research Supervisior Faculty Supervisior

Dr. Swathi Sreesailam
MD Pathology(Lab Director Medicover
Hospital)
Dr.Khan Mohammed Taha Ali
MD(Pathology), PDF(Hematopathology)
Dr.Wajihus Shams
P.hD(Assistant professor B.Voc
Programme,Maulana Azad National
Urdu University)

Gachibowli, Hyderabad-500032
December-2023
 DECLARATION BY CANDIDATE’S
We hereby declare that this dissertation entitled “CSF CELL COUNT AND
CHEMISTRIES IN BACTERIAL MENINGITIS,,Is a Bonafide and Genuine
research work carried out by us under the supervision of Dr.Swathi sreesailam
(MD Pathology) LAB DIRECTOR MEDICOVER HOSPITAL, Dr.Khan Mohammed
Taha Ali (MD PATHOLOGY), PDF (Hematopathology),& Dr.Wajihus Shams,P.hD
(ASSISTANT PROFESSOR B.VOC.PROGRAM,Maulana Azad National Urdu
University).

Date:
Place:Hyderabad

MD KHUSHDIL(A200177) ___________________

MD FAHAD GUFRAN(A200173) ___________________

MOHAMMAD ARIF KHAN(A200162) ___________________
SHAHADAT HUSSAIN(A201201) ___________________
SHABAN AHMAD(A201807) ___________________
MUSARRAT FAUZI(A200169) ___________________
AFIFA KHATOON(A200172) ___________________
SHAGUFTA AFRIN(A181063) ___________________
 Certificate
This is to certify that project report entitled “CSF CELL COUNT AND CHEMISTRIES
IN BACTERIAL MENINGITIS” Submitted by Mr.MD Khushdil, Mr.MD Fahad
Gufran, Mr.Mohammad Arif Khan , Mr.Shahadat Hussain, Mr.Shaban Ahmad ,
Ms.Musarrat Fauzi , Ms.Afifa khatoon , Ms.Shagufta Afrin in partial fulfillment of the
requirements for the award of Bachelor of Vocational Medical Laboratory Technology (B
Voc.MLT) is an authentic work carried out by them under our guidance and supervision.
The results presented in this report have been verified and are found to be satisfactory. The
results embedded in this dissertation have not been submitted to any other University for the
award of any other degree.

Date:
Place:Hyderabad

Signature of the Research supervisor Signature of the Faculty Supervisior

Dr.Swathi Sreesailam Dr.Wajihus Shams

MD(Pathology,Lab Director
Medicover Hospital) P.hD(Assistantprof.B.Voc.program,
Maulana Azad National Urdu
University)

Dr.Khan Mohammed Taha Ali

MD(Pathology),PDF(Hematopatholog
y)Consultant Hematopathologist
Medicover Hospital
 ENDORSEMENT BY THE DEAN / NODAL OFFICER OF
THE InSTITUTION
This is to certify that the project entitled “CSF Cell Count Chemistries in Bacterial
Meningitis’’ is the bonafide work done by Mr.MD Khushdil, Mr.MD Fahad
Gufran, Mr.Mohammad Arif Khan , Mr.Shahadat Hussain, Mr.Shaban
Ahmad , Ms.Musarrat Fauzi , Ms.Afifa khatoon , Ms.Shagufta Afrin the
undergraduate students of B.Voc. MLT under the supervision of Dr.Swathi Sreesailam
MD(Pathology,Lab Director Medicover Hospital),Dr.Khan Mohammed Taha Ali
MD(Pathology)PDF(Hematology),consultant Hematopathologist Medicover Hospital and
Dr.Wajihus Shams P.hD(Assitant prof.B.Voc. Program)is submitted to the Maulana
Azad National Urdu University

Date :
Place : Hyderabad

DEAN NODAL OFFICER

School of Science B.Voc. program:
Dr.Salman Ahmad Khan Prof. S. Maqbool Ahmed
 ACKNOWLEDGEMENT

It is most appropriate that we begin by expressing our undying gratitude to the ALMIGHTY
ALLAH for giving us the strength both mentally and physically to complete this task. We
feel privileged to express our gratitude and respect to our teachers , guides , and
mentors.“First and fore most, we would like to express our deep gratitude and sincere thanks
to our guide, Dr.Swathi Sreesailam MD(Pathology) Lab Director Medicover

Hospitals, Hyderabad, Dr.Khan Mohammed Taha Ali, MD(Pathology),

PDF(Hematopathology) Consultant Hematopathologist Medicover Hospital Hyderabad,&
Co-Guide Dr.Wajihus Shams P.hD(Assistant prof. B.Voc.Programme,Maulana Azad
National Urdu University Hyderabad). for preparing us for this task guiding us with their
superb talent and professional expertise, showing great care and attention to details and
without their supervision and guidance this dissertation would have been impossible”
Our Special thanks and gratitude to Prof. Salman Ahmad khan ,(Dean School Of
Sciences,)Prof. S.MAQBOOL AHMAD (Nodal Officer B.voc Program ),MAULANA AZAD
NATIONAL URDU UNIVERSITY for the constant help and inspiration.
We must give our sincere thanks to our PARENTS for their abundant
love,endurance,support,in numerable sacrifices and unceasing encouragement that has
moulded us into the person we are today.
We sincerely thanks to whole Faculty Members and Non teaching staff of B.Voc. Program.
and all our classmates who had helped us in preparing this dissertation. Finally we express
our appreciation to all patients for their willingness and
co-operation during the study.
 TABLE OF CONTENTS
SR.NO TOPIC NAME PAGE NO.
.

01 ABSTRACT 01
02 AIMS & OBJECTIVES 02
03 ABBREVIATIONS 03
04 INTRODUCTION 4-28
05 CLINICAL FEATURES & DIAGNOSIS 29-49
MATERIALS & METHODS 50-61
06 CSF CHEMISTRIES 62-65
07 RESULTS 66-70
08 REVIEW OF LITERATURE & 71-72
DISCUSSION
09 REFRENCE 73-77
 LIST OF FIGURES
Figure no. Name of the Figure Page no.

01 Bactrerial meningitis 06
02 The extraction of stone of madness 07

03 Heinrich irenaeus Quincke 08

04 Dommenico cotungno 10

05 Lumbar puncture at the beginning of 20th century 10

06 Vladimir erning 10
07 Meningitis rash 32
08 Cranial CSF spaces 47
09 Ventricular volume of CSF 47
10 Thermo scientific cytospin cytocentrifuge 54
11 Prepration of slide in cytospin 54

12 Cytospin prepration stained with H&E 54

13 Cells stained with anti ALK antibody 54
14 Neutrophil 56
15 Neubauer chamber 56
16 Areas of grid where RBC,s counted 58
17 Microscope focusing and cell counting 60
18 CSF Glucose Tube 63

19 CSF Protein Tube 65

 List of Tables

Table no. Name of the Table Page no.

01 The changing epidemiology of B.M 16

02 Potential vaccine candidates considered for 21

meningococcal group B vaccination
03 Changing trends in Hib,S.pneumoniae and N.M after 23-24
vaccination
04 Dosage & frequency of the common antibiotics used in 42
B.M
05 Composition of CSF 43

06 Normal refrence of cerebro spinal fluid according 45

different age groups
07 CSF finding in defferent type of meningitis 48

08 Change in CSF in B.M 49

09 Refrence range of CSF Protein 65

10 The table shows no. of patient Data 67

11 Distribution of data age wise 68

12 The table shows Gender wise distribution & incidence 69

13 The table shows Neutrophil count in our 70

14 Data for study of CSF chemistry in B.M 70

15 Comparison between our study and other previous 71

studies
 ABSTRACT

This dissertation is about studying the fluid around the brain and spinal cord (called
cerebrospinal fluid or CSF) to understand how it can help detect and manage a serious brain
infection called bacterial meningitis. We looked at lots of previous studies to see what they
found out about the cells and chemicals in this fluid and how they relate to bacterial
meningitis.
We collected data of patient from The Pathology & Biochemistry department of
MEDICOVER HOSPITAL who were suspected meningitis and studied them closely. Our
goal was to figure out if certain cell counts and chemicals in the fluid could tell us if someone
has bacterial meningitis or another type of infection that affects the brain and spinal cord.
Our research showed that specific counts of cells and certain chemicals in the fluid can help
doctors diagnose and predict how serious bacterial meningitis is. This study suggests that
examining this fluid can be very important in telling apart bacterial meningitis from other
similar infections in the brain and spine.
Overall, our findings can help doctors better understand and treat bacterial meningitis by
using information from the fluid around the brain and spinal cord.

1 | Page
 AIMS & OBJECTIVE

Aims:
1.Testing the fluid around the brain and spine (CSF) To Diagnose bacterial meningitis.
2. Identification of CSF markers to detect the severity of bacterial meningitis.
3. Clinical advantage of CSF Test in B.M Treatment.

Objectives:
1. correlation with studies on CSF in B.M.
2. Retrospesctive analysis of data of CSF CELL Count and Chemistries from patient with
Suspected B.M.
3.Comparative analysis of CSF Study with other similar illness.
5. Recent Advances in CSF Analysis To Diagnose B.M

2 | Page
 ABBREVIATIONS USED

BBB Blood Brain Barrier

BM Bacterial Meningitis
CNS Central Nervous System
Hib Haemophilus influenza type B
LP Lumbar puncture
LPS Lipopolysaccharide
NS Niesseria Meningitis
PCR Polymerase chain Reaction
WHO World Health Organization

3 | Page
 CHAPTER 1
INTRODUCTION

4 | Page
INTRODUCTION
Bacterial meningitis:
Bacterial meningitis is the most prevalent type of meningitis. The most common
agents of bacterial meningitis are Haemophilus influenzae type b, Neisseria meningitidis,
serogroups A, B, C, W135 and Y, and Streptococcus pneumoniae. Globally, bacterial
meningitis affects approximately 1.2 million people each year and causes almost 170,000
deaths. In the absence of proper treatment, the mortality rate associated with bacterial
meningitis can be as high as 50%. For this reason bacterial meningitis is among the 10 leading
causes of mortality due to infections worldwide. Survivors of bacterial meningitis can suffer
from serious neurological complications such as deafness, blindness, cognitive and
intellectual impairment etc which often persist throughout the life. Although no age group is
exempt from acquiring the infection, bacterial or pyogenic meningitis has the highest
incidence in the first year after birth. Adolescence also shows a higher incidence between 15-
24 years of age which accounts for almost 30% of all the cases of bacterial meningitis. 1.2.
Other causes of meningitis: Apart from bacterial meningitis many other causes of meningitis
exist; these are viral meningitis, tuberculous meningitis (TBM) and other non-infectious
causes of aseptic meningitis. Viral meningitis, which is usually less severe than bacterial
meningitis, is a result of meningeal infection by various viruses. A virus may only be
identified in 50% of the cases; the most common of those identified are some enteroviruses.
Common childhood infections such as chicken pox and measles have often been implicated in
viral meningitis. TBM is caused by Mycobacterium tuberculosis and is a very severe form of
disseminated tuberculosis. Like acute bacterial meningitis, TBM also results in high rates of
neurological complications and often lifelong sequelae. Without proper treatment the
mortality rate with TBM can be very high. Tuberculosis is a disease linked to low socio-
economic status; therefore TBM is rare in developed countries. The individuals most at risk of
acquiring TBM are the young children already exposed to primary tuberculosis,
immunocompromised such as very old age, malnourished or patients with concurrent HIV
infection. Aseptic meningitis is a term reserved for the meningitis for which initial clinical
examination and routine laboratory tests (including Gram staining and CSF culture) fail to
reveal a definite cause. The etiology of aseptic meningitis often includes viral, fungal or
TBM. Non-infectious causes of aseptic meningitis such as malignancies with brain metastasis

5 | Page
or some medications notably sulphamethoxazole and nonsteroidal anti-inflammatory drugs
have also been identified .

Definition:
“Bacterial meningitis is an inflammatory response to bacterial infection of the membranes
covering the brain and spinal cord”. In literature various practical definitions have been used
to set up an inclusion criterion for cases of bacterial meningitis. A study conducted in Mali in
2009 on the persistence and spread of meningococcal meningitis defined a “suspected case”
as the one which is only clinically diagnosed. A “probable case” was defined as a suspected
case with a cloudy CSF sample. A “case” was confirmed only after the etiology was
established biologically. Some studies defined cases based on clinical signs and symptoms
specific to bacterial meningitis such as neck stiffness, altered consciousness, high grade fever,
seizures etc. But clinical symptoms are often non-specific and vary from patient to patient.
Other studies in literature have defined a “case” based on WHO recommendations which
defines a case as a patient with purulent CSF and with a cell count of >100 cells/mm3. But
this definition requires readily available laboratory assistance which may not be possible in
many hospitals in the developing countries of the world. Due to this reason a more clinical
definition of meningitis is used in many studies to formulate an inclusion or exclusion criteria.

Figure.1

6 | Page
 .

Bacterial meningitis is a serious illness that causes more than 300 000 deaths worldwide each
year.Meningitis is inflammation of the tissues surrounding the brain and spinal cord (the
meninges) and is often caused by an infection. Symptoms may include fever, headache, stiff
neck, eye discomfort in bright light, confusion, drowsiness, seizures, nausea, and vomiting.
Meningitis is most commonly caused by viral infections. About 8% of meningitis cases are
caused by bacterial infections.

History of Bacterial Meningitis-

Infections of the central nervous system, which can be of infectious and non-infectious
genesis, are inflammatory process of the brain and the brain membranes. These, otherwise
serious infections that can endanger human life, take on even greater weight when, not so
rare, complicate with neurological manifestations. Bacterial meningitis means inflammation
of the meninges, that different types of bacterial cause. Viral meningitis presents a serous
inflammation of leptomeninges First data connected with inflammatory diseases of nervous
system were noted by Thomas Willis (1621–1675), English physician, who described patients
suffering from "inflammation of the meninges and present fever," and it can be said that he
spoke of meningitis, even in 1661. The first time the epidemic meningitis was noted in 1805
in Geneva,then 1814 in Grenoble and Genova. After that epidemic appeared in France in 1822
then in 1823 in Germany, and after 7 years at Sunderland 3. An epidemic of meningococcal
meningitis had been described by Swiss physicians, Gaspard Vieusseux (1746–1814), and
Andre Matthey (1778–1842) in Geneva. First epidemic in Africa was described in 1840.They
had become more common in the 20th century, so the first bigger epidemic was noted in
Nigeria and Ghana (1905– 1908), when a large number of people had suffered . The origin of
the disease, and even the name of it, stayed unknown. This disease was identified by doctors
as "sinking typhoid", or "spotted fever" 5. Although still Herophilos (335–280 BC), an ancient
Greek physician, first explained the anatomical structure of the brain and brain
membrane,describing fourth ventricle, representing it as a place of the soul, it was not known
for the occurrence of inflammation of the meninges. Herodotus (c.484–425 BC), an ancient
Greek physician, spoke of "doctors for the head"
in Egypt, who dealt with both physical and mental
causes of the disease. Certainly based on historical
medical data, as well as other diseases in
prehistoric times, supernatural causes were

7 | Page
attributed to the occurrence of inflammatory processes in the brain tissue, also. One
particularly popular method of diagnosis, and treatment, linked to brain disease, known in
time of prehistory, was a trepanation of the skull or "šaronjanje",name used in some parts of
our country as intervention on bone parts of the skull. It was used in the occasion of the

existence of neurological diseases, and psychiatric disorders,but most commonly in post-

traumatic headaches. While the prehistoric "surgeons", thought that opening the skull can rid
the patient of evil thoughts and demons, the latter in some parts of our country, during the
19th century, the whole process had an element of vendetta. Particularly interesting is the fact
that a high percentage of these patients, underwent surgery, and survived without the
inflammatory process of the brain and meninges. A staggering figure when one considers that
the intervention was performed by opening the skull, with unsterilized instruments, on which
occasion would perpetrator watch brain membrane and thus establish "if it is dropped blood to
the brain".Nature cause of a disease was first described by Galen (c.130 AD–c.210/c.216AD),
a Roman physician and philosopher of Greek origin, who was stating that the challengers
were in the water, air and rotting substances, calling them "miasmas". Since the natural cause
of the disease was first mentioned in paper "De contagione et contagiosis morbis" by an
Italian physician, Girolamo Fracastoro

(1478–1553), having started involvement in determining

the etiology of the disease and finding cause of the infectious
diseases including inflammatory diseases of the nervous
system . for the occurence of meningitis various agents have
been blamed through the history. Meningitis was commonly
called "brain fever" or "brain inflammation" in the past, and
it was believed that potential triggers for its appearance
were: the sun, the temperature change, mental
disorders,stress, and numerous other factors. In the early 20th century,these beliefs were
discarded in the United States, as in the most Western European countries. Nerve disturbances
and mental disorders, were also blamed, as shown Fig-3-Heinrich Irenaeus Quincke (1842–1922 in the
literature of Russian writers.As a very common complication of inflammatory diseases of the
nervous system was hydrocephalus, which was represented as an enlargement of brain
ventricles due to increased amounts of cerebrospinal fluid in the brain
chambers.Hydrocephalus was described by Hippocrates (c. 460–c.370 BC),Galen and Arabian
doctors, who believed it was a disease caused by extracerebral accumulation of water.
Concept of cerebrospinal fluid (CSF) is closely linked to historical and medical development

8 | Page
of meningitis. It is now known that the CSF is fluid that fills the subarachnoid space of the
brain and spinal cord, and brain ventricles. It is believed that Imhotep,an Egyptian doctor, and
the notary, was the author of papyrus from 3000 BC, and the first one who discovered
intracranial CSF. Name of cerebrospinal fluid was introduced by Francois Magendie (1783–
1855), French physiologist, in the first half of the 19th century. Nicolo Massa (1485– 1569),
an Italian anatomist, in his book“ Liber Introductorius Anatómiae“ in 1536 was the first who
described the CSF with cerebral
chambers, based on autopsies. Previously, it was thought, by the beliefs of Hippocrates and
Galen, that the brain ventricles contained "spirit of animals". It is generally accepted in
medical history that the CSF was discovered by Domenico Felice Cotugno an Italian
physician (1736–1822). This famous doctor who lived in Naples in the 18th century published
a paper, when he was 25, about the anatomical structures of the ear. He stated that not only
were brain ventricle but the subarachnoid spaces filled by CSF, which was called "liquor
cotunii" . Domenico Cotugno (1736–1822)(figure-6). A very important moment in the history
of development of meningitis, was the introduction of lumbar puncture. Lumbar puncture
includes diagnostic procedure used to obtain cerebrospinal fluid, but in rare cases, therapeutic
method for reducing increased intracranial pressure . In the beginning, the purpose was purely
therapeutic. But soon, lumbar puncture was introduced as a diagnostic procedure . In 1881
Wernicke performed sterile ventricular puncture and external drainage of cerebrospinal fluid.
These were followed-up in 1891 with serial lumbar punctures by Quincke (figure-7) . The
first technique was described by an English physician Walter Essex Wynter, in 1889 in
patients with tuberculous meningitis, when he used cannulation, which then had more
therapeutic than diagnostic significance . Definitive lumbar puncture technique was
introduced by a German physician Heinrich Irenaeus Quincke (1842–1922)(fig.-5) who
presented his experience at the Conference of Internal Medicine in Wiesbaden, Germany. In
the United States, the procedure was implemented in 1891 by Arthur H.Wentworth in the
children's hospital .Winter's technique was involved in making incisions in 2nd lumbar region,
such as major cut and placing a tube with a rubber drainage and so knocked infected content
and reduced the pressure.
Also, he measured the level of sugar and protein in the cerebrospinal fluid, describing low
sugar in purulent meningitis. He found of the tuberculosis Mycobacterium tuberculosis in the
CSF and thus diagnosed

tuberculous meningitis.Neurotuberculosis is a chronic inflammation of the nervous system,

which is primarily caused by Mycobacterium tuberculosis, accounting for about 5–10% of all
forms of extra pulmonary tuberculosis.Tuberculous meningitis was first described by an

9 | Page
Edinburgh physician Sir Robert Whytt (1714–1766), but his work was published
posthumously in 1768. However, the link between tuberculous bacillus and meningitis was
discovered even after 100 years.

In the years after the World War 2nd, at the Clinic

of Infectious Disease in Belgrade, a large number
of patients with tuberculous meningitis, mostly
children, a population that had been the most
frequent and the most vunerable were hospitalized
and treated. Great merit in the fight against this disease, which mortality rate was 88.7%
during the period from 1947 to 1949 belonged to Professor Dr. Kosta Todorović, a famous
infectologist and scientist, who invested great efforts in his work. According to the data from
the Clinic of Infectious Diseases, ten years later children were the most numerous patients
still, but the mortality rate was 9.5%. The statistics speak in favor of a successful fight of
infectology team and associates in post-war year against the serious and deadly disease, and
certanly immeasurable satisfaction in recovering patients. In the historical development of
meningitis special place had meningeal signs, and the credit for that had scientists Kernig and
Brudziński. Meningeal signs are in fact reflections that occur in response to the increase of

elevated intracranial pressure, which can occur when performing certain

movements at the examination of patients.Disclosed are: stiff neck; sign
of Brudzinski that is positive when in passive flexion of the head and
neck, the response is flexion of the ankle of hip and knee; the character
of the lower Brudzinski is positive, when during flexion of legs in the
ankle of hip and knee, due to the stretching of the nerve ischiadic and
distal spinal cord, the response is
flexion of the other leg in the same
joint; a positive sign of Kernig means that in the course of
moving the patient from a lying to an upright position, the
patient is unable to take a right angle etween torso and legs
and also when lifting the leg, they can not take the right
angle in relation to the body. Vladimir M. Kernig (1840–
1917)(figure-8), was a neurologist of Russian-Baltic
origin. Kernig’s sign was described in 1882 in the article of the Weekly Medical Journal,
where was stated that during the years of test cases of meningitis he noticed a sign that had
practical value. He stated that "if one attempts to extend the patients knees they will succed

10 | Page
only to an angle of approximately 135°.In cases which the phenomenon is very pronounced
the angle may even remain 90°. was a Polish Jozéf doctor, a pediatrician.

After World War I, he renewed the Polish University in Warsaw, and was appointed as a
director of the same. In that time, Brudziński released four maneuvers in detection of
meningitis. First it was cheek positive sign and that means when putting pressure on both
cheeks under zygomatic arch can cause flexion of the forearm and arm. Also, symphyseal
positive sign shows that pressure on the pubic symphysis causes flexion of the hip and knee,
abduction of the leg. When passive flexion of the knee causes flexion of oposite knee, than it
is named Brudziński’s reflex. And Brudziński’s sign is described as positive, when the
passive flexion of the neck causes flexion of the hips and knees . The majority of the patients
were children, the population most affected by tuberculosus meningitis. Brudziński recorded
21 cases of tuberculous meningitis out of 42 investigated cases of meningitis. Contemporary
literature registers that bacterial meningitis is caused in 80% of cases mostly by
Hemophylus influenzae, Neisseria meningitidis, and Streptococcus pneumonia . These
organisms that caused meningitis were discovered in the late 19th century.Serum therapy
against meningococcal meningitis was introduced by a physician George Joachmann (1874–
1915) in Germany and Simon Flexner (1863–1946) in America. Antibiotic therapy began in
the 20th century with the use of sulfonamides by Francois Schwentker (1904–1954) and
penicillin by Chester Keefer (1897–1972), an American physician. The vaccination began in
early 20th century 18. In 1881, two microbiologists, George M.Stenberg (1898– 1915) in the
United States, and Louis Pasteur (1822–1895) in France, independently described a couple of
bacteria in human saliva. Both of them found diplococcus in the blood of rabits. Paster called
it „Microbe septicemique du saliva“, and Sternberg „Micrococcus pasteuri“. In 1886 it was
named Pnemococcus by Frenkel, due to the possibility to cause pneumonia 19. However, the
full name of Streptococcus pneumoniae was obtained in 1974 according to the growth of
bacteria in chains. The role of germs in lobar pneumonia was proven in 80's of the 19th
century and later in the same decade, pneumococcus was presented as the cause of meningitis
and middle ear infections 19. An Austrian pathologist and bacteriologist Anton
Weichselbaum (1845–1920) in 1887 was the first who showed that there was a connection
between N. meningitidis (then known as Diplococcus intracellularis meningitidis) and
epidemic cerebrospinal meningitis. An Italian scientist, Vieusseux (1779–1863), was the first
who described meningococcal disease, in Geneva 1805 and he was stating that the infection
was being spread through "bad air". Simon Flexner succeeded in producing meningococcal
serum in 1906 of equine origin, which reduced mortality of meningococcal disease from
75%–80% to 30%.

11 | Page
The disease was fatal to the military forces during World War II, but thanks to the antiserum
and antimicrobial treatment has become a curable disease. One of the biggest epidemic of
meningococcal meningitis in the history of medicine, was in Brazil in 1974 before a vaccine
was used. The World Health Organization annually records at least 500000 new cases of
meningococcal disease, resulting in more than 50000 deaths annually. Haemophilus
influenzae was described in 1892 by Richard Pfeiffer, during an influenza pandemic, and for a
long time, until 1933 was considered as a challenger of influenza, so the infection by this
bacteria was often referred as "bacterial flu". Later was discovered that it caused bacteremia,
pneumonia and acute bacterial meningitis in infants and children. From 1990 a conjugated
Hib vaccine that reduces the incidence of meningitis has been used in the United States . In
the prevention of bacterial meningitis at the present time, in addition to maintaining a healthy
life style and sanitary habits, avoiding close contact with carriers of a disease,
chemoprophilaxis and immunoprophilaxis are used. Rifampicin, ceftriaxone and ciprofloxacin
are suggested in case of meningococcal disease. Immunoprophilaxis covers a monovalent
vaccine antigen of specific meningococcal serogroup and quadrivalent, and does not offer
protection against the B serogroup. Chemoprophilaxis of pneumococcal infections is being
implemented in the form of rifampicin, and immunoprofilaxis includes 23-valent
pneumococcal vaccine. Haemophilus influenzae B meningitis includes rifampicin
chemoprophilaxis and immunoprophilaxis implementation of conjugated vaccines with
polyribose-ribitol phosphate Haemophilus influenza B with the carrier protein. Also
hyperimmune globulin can be used according to indications . Before using specific
antiserums, the odds of one who suffered from bacterial meningitis were bad. In 1920 a total
of 77 of the 78 children at Boston Children's Hospital with Haemophilus influenzae
meningitis died. A similar was the prognosis for untreated pneumococcal meningitis when
from 300 observed patients all died. Meningococcal meningitis in the beginning of the 20th
century had a mortality rate of 75–80%. Simon Flexner succeeded in use of intrathecal equine
meningococcal antiserum in 1,300 patients in 1913, when he reduced mortality to 31%.
Unfortunately, forecasts with pneumococcal meningitis stayed bad and after using specific
antiserum. In the thirties of the last century, mortality rate in meningococcal meningits
decreased introducing sulfonamides. In the early 50's of the last century, the use of
chloramphenicol and sulfadiazine reduced the number of fatal cases, and thus ruled out the
use of antiserum. Penicillin therapy of pneumococcal meningitis began in the mid-40’s of the
last century. In the second half of the 20th century, in the treatment of bacterial meningitis
were used: intravenous penicillin, ampicillin and cephalosporins of 3rd generation 18. It is
important to begin empirical treatment, and than to identify the causative agent and use the

12 | Page
target – specific therapy. Penicillin, chloramphenicol and ampicillin, ceftriaxone, amikacin,
meropenem, ciprofloxacin, cephalosporins of the 4th generation parenterally are used . In
patients with Haemophilus meningitis dexamethasone was introduced in 1990 too, which has
not changed mortality, but reduced the existence of neurological sequelae, especially hearing
loss. A particular problem in the antibiotics era makes the emergence of antimicrobial
resistance. In future, more emphasis will be placed on preventive, rather than therapeutic
measures . Complications of bacterial meningitis may be systemic, related to distant organs or
neurological nature. Although much less common, neurological complications can be very
serious. The most common neurological complications include: hearing loss, motor deficits,
cognitive defects and problems with speech, sensory deafness, followed by seizures and
motor deficit, which is more common in children. Patients with bacterial meningitis are
admitted to the intensive care unit if they are in a coma or with complications of the disease.
Very common, serious and complex complications are reported during viral encephalitis, due
to the possibility of being threatened as emergencies. Neurological sequelae are related to
nerve damage, seizures, hemiparesis, as well as damage of intelligence.

Epidemology-
In this review, we describe the changing epidemiology of bacterial meningitis by reviewing
the global changes in etiological agents followed by specific microorganism data on the
impact of the development and widespread use of conjugate vaccines. During the past 15
years we have witnessed enormous changes in the epidemiology of bacterial meningitis. This
review concentrates on our new knowledge, because most textbooks of pediatrics, internal
medicine, microbiology, and infectious disease include excellent discussions of the basic
epidemiology of meningitis.
The most dramatic change has been the virtual disappearance of meningitis and other forms of
invasive disease caused by Haemophilus influenzae type b (Hib) in those countries that have
introduced programs for immunization of infants with conjugate Hib vaccines, such as
Finland, Iceland, the United States, Canada, Sweden, Denmark, Norway, the Netherlands, the
United Kingdom, France, Germany, Uruguay, Chile, and Gambia. The total incidence of
bacterial meningitis has been cut in half following successful implementation of Hib vaccine
programs. Mass vaccination has also caused a marked change in the age distribution of
bacterial meningitis, such that the majority of cases of meningitis now occur in adults.
The rapid demonstration of the efficacy of Hib vaccines led to many new studies of the
incidence of Hib disease as researchers around the world sought to document the need for the
vaccine in order to obtain government funding for Hib immunization programs.The success of

13 | Page
Hib vaccination also stimulated many epidemiology studies of pneumococcal
and meningococcal meningitis in order to obtain baseline data prior to introduction of
new conjugate vaccines against these pathogens.
Another new feature of the epidemiology of bacterial meningitis has been the occurrence of
clusters of cases of meningococcal meningitis among adolescents as a result of contact in
school, university, bars, dances, sports clubs, or other places or events where adolescents and
young adults gather.Almost all of these outbreaks have been associated with the appearance
of a new serotype of serogroup C meningococci, most often serotype 2a. Similarly, the
recurrent epidemics of serogroup A meningococcal disease in sub-Sarahan Africa, the Middle
East, the Indian subcontinent, and China have also been recognized to be associated with the
appearance and spread of a new clone of serogroup A.
Finally, the recent demonstration that exposure to cigarette smoke, either actively or
passively, is a risk factor for bacterial meningitis in general, and meningococcal carriage and
disease in particular, adds additional urgency to control of cigarette smoking.

Incidence of the bacterial meningitis-

Surveillance data obtained by passive reporting systems is variable in terms of of
underreporting, making data from many studies unhelpful for geographic and temporal
comparisons. Recent analyses of the extent of underreporting by passive surveillance systems
found rates of 50% in Nottingham, England,50% in Tennessee, United States, and 65% in
England and Wales. Data on the incidence of bacterial meningitis from population-based
studies in which active surveillance systems were used. Studies of the incidence of bacterial
meningitis performed in the United States during the 1950s, 1960s, and 1970s found
significant attack rates for the common meningeal pathogens at that time (Haemophilus
influenzae, Neisseria meningitidis, and Streptococcus pneumoniae), although these case-
finding efforts were performed with relatively small populations. Despite the retrospective
design and relatively small populations in these studies, therapeutic and preventive strategies
were targeted toward these microorganisms, given the high frequency of isolation of these
specific pathogens (>70% of cases).

In 1977, the Centers for Disease Control and Prevention (CDC) established a nationwide
surveillance system to gather prospective epidemiological data that would supplant the
retrospective and community-based studies of cases of bacterial meningitis in previous
reports. In the first published study, 13,974 cases of bacterial meningitis reported to the CDC
from 27 states in the United States from 1978 through 1981 were analyzed. The overall attack

14 | Page
rate was 3.0 cases per 100,000 population with variability based on age (76.7 cases per
100,000 for children under 1 year of age), race, and sex (males versus females of 3.3 versus
2.6 cases per 100,000, respectively). The three most common pathogens were H.
influenzae, N. meningitidis, and S. pneumoniae, accounting for more than 80% of cases.
However, there was a significant underreporting in that study because no active effort was
taken to detect cases.In a subsequent study performed in 1986 that was an active, laboratory-
based surveillance study for all cases of bacterial meningitis in five states (Missouri, New
Jersey, Oklahoma, Tennessee, and Washington) and Los Angeles County, which included a
population of almost 34 million, analysis was performed for the five most common etiological
agents of bacterial meningitis (H. influenzae, N. meningitidis, S. pneumoniae, Listeria
monocytogenes, and Streptococcus agalactiae). Given the better system of searching for
active cases, the overall incidence of bacterial meningitis was two to three times that of the
previous report , although H. influenzae, N. meningitidis, and S. pneumoniae continued to
account for the majority of cases (77%). These data confirmed the importance of identifying
strategies for the development of effective vaccines against these pathogens.With the
introduction of H. influenzae type b conjugate vaccines in the United States and several
countries throughout the world, the epidemiology of bacterial meningitis dramatically
changed. In a subsequent study conducted by the CDC in 1995 in laboratories serving all of
the acute-care hospitals in 22 counties of four states (Georgia, Tennessee, Maryland, and
California) that served more than 10 million people, the incidence of bacterial meningitis
dramatically declined as a direct result of the vaccine-related decline in cases caused by H.
influenzae type b; the incidence of the other etiological agents had little or no change
compared with the 1986 data. This was accompanied by a change in the mean age of cases of
bacterial meningitis, from 15 months of age in 1986 to 25 years of age in 1995, because most
cases of H. influenzae meningitis reported prior to vaccination occurred in infants and
children aged 6 to 12 months. These data highlighted the importance of vaccination and
indicated the need for the development of effective conjugate vaccines against the other
common meningeal pathogens.In 2000, a heptavalent pneumococcal conjugate vaccine was
introduced and has been associated with a significant decline in the incidence of
pneumococcal meningitis. In a CDC surveillance study performed from 1998 to 2003, there
was a significant reduction in the incidence of cases of pneumococcal meningitis in patients
less than 2 years of age. A tetravalent meningococcal conjugate vaccine was licensed for use
in the United States in 2005, although there is currently no epidemiological data for the
United States that has examined the impact of this vaccine. More detail on the efficacy of
these vaccines is discussed below.Bacterial meningitis is an even more significant problem in

15 | Page
 many other areas of the world, especially in developing countries. In Dakar, Senegal, from
1970 through 1979, the average incidence was 50 cases per 100,000 population, with
approximately 1 in 250 children developing bacterial meningitis during the first year of life .
In African countries with high rates of human immunodeficiency virus (HIV) infection, the
majority of meningitis cases are caused by S. pneumoniae, and this has been associated with
high mortality rates . Sub-Saharan Africa, also referred to as the meningitis belt, is known for
epidemics of meningococcal meningitis, with incidence rates of 101 cases per 100,000
population in the period of 1981 to 1996 in Niger and up to 40 cases per 100,000 during an
outbreak in Burkina Faso.Studies from Northwest and Southern Europe, Brazil, Israel, and
Canada showed epidemiological trends similar to those observed for the United States. The
most common agents in adults and children are S. pneumoniae and N. meningitidis, because
vaccination has virtually eliminated H. influenzae type b meningitis in children.In the largest
review of 4,100 cases of bacterial meningitis at the Hospital Couta Maia in Salvador, Brazil,
from 1973 through 1982, the attack rate was 45.8 cases per 100,000 population ; H.
influenzae, N. meningitidis, and S. pneumoniae accounted for 62% of cases. Other confirmed
etiologiewere Enterobacteriaceae (3.5%), Staphylococcus species
(1.0%), Streptococcus species other than S. pneumoniae (0.6%), and Pseudomonas species
(0.3%). For 33% of cases, no bacteria could be cultured. Children younger than 15 years of
age accounted for 79% of cases, and 45% of the cases were children younger than 2 years of
age.

The changing epidemiology of bacterial meningitis in the united state, 1986-2003

1986 1995 1998-

2003
Menigeal pathogens
Haemophilius influenza 45% 7% 7%
Streptococcus pneumonia 18% 47% 61%
Neisseria meningitides 14% 25% 16%
Group B streptococcus 5.7% 12% 14%
Listeria monocytogenes 3.2% 8% 2%
Median age 15 25years 39years
months
Estimated number of cases per year in the 12,920 5755 4450
Table-1 united states

16 | Page
AGE
Prior to the introduction of effective vaccines against Hib, over two thirds of cases of bacterial
meningitis after the neonatal period occurred in children less than 5 years of age. The peak
age-specific incidence occurs at 6 to 8 months of age for meningitis caused by
Hib, Streptococcus pneumoniae, and Neisseria meningitidis, the age at which the immunity
afforded by passively acquired maternal IgG antibodies disappears.As noted above, mass
immunization with Hib conjugate.

RACE
The incidence of pneumococcal and Hib meningitis is much higher among Africans and
African-Americans, native American populations (Inuit, Navajo, Apache), and Australian
Aboriginals. The results of a large number of small-scale studies suggest that the incidence of
Hib meningitis is much lower among Chinese and other East Asian populations than in
Caucasian children. Whereas the occurrence of sickle cell disease has been shown to
increase..

SOCIOECONOMIC RISK FACTORS

Socioeconomic conditions have a major impact on the incidence and distribution of
meningitis.
Poverty, overcrowding, limited access to health care, and low educational level of parents all
interact to increase the incidence of meningitis. Socioeconomic risk factors are such important
determinants that differences in meningitis rates between African-Americans and whites
disappear when corrected for differences in socioeconomic status.
CLUSTERS OF MENINGOCOCCAL DISEASE
Clusters of meningococcal disease among adolescents and young adults in the general
population have been reported with greatly increased frequency during the past 15 years. A
cluster has been defined as “two or more cases of the same serogroup that are closer in time
and space than expected for the population or group under observation (e.g., several cases of
the same serogroup in a school).”An outbreak or epidemic, on the other hand, exists when
there is “an increase in the number of caseses.

CIGARETTE SMOKING AND BACTERIAL MENINGITIS

Exposure to cigarette smoke has recently been demonstrated to increase the risk of bacterial
meningitis. Case-control studies have found that meningitis cases have a twofold to fourfold
higher risk of exposure to cigarette smoke than controls. Carriage of Hib, pneumococcus, and

17 | Page
meningococcus has been found to be more common among smokers, both active and passive,
than nonsmokers, increasing the risk of transmission to household and other close contacts.

Vaccination Bacterial meningitis remains an important cause of morbidity and mortality in

childhood despite the implementation of childhood vaccination programmes, antibiotic use
and intensive care support. The fatality rates in industrialized countries are between 5% and
10%, and are considerably higher in the developing world.1–6 Survivors often have resulting
neurological sequelae, including developmental delay, hydrocephalus, sensorineural deafness
and seizures.5–8 The clinical severity of meningitis depends on both the nature of the
infecting organism and a number of host factors. Many viruses are also known to cause
meningitis.

type b (Hib), once an important cause of meningitis in children under 5, has become
uncommon in industrialized countries since the introduction of the Hib vaccine from the late
1980s. Group B streptococcus is the leading cause of neonatal meningitis in the UK; other
causes are Gram negative enteric pathogens and Listeria which account for small numbers of
cases overall.

introduced Hib vaccine into routine vaccination schedules have done so with the addition of a
booster dose in the second year of life. The main reason for this is the observation that
vaccine-induced antibody wanes over time, leading to the concern that this may be
accompanied by an increase in susceptibility to disease.In most developing countries with
high infant mortality rates from Hib meningitis and pneumonia, Hib vaccination is not
included in immunization schedules. However, increased uptake of vaccine is being made
possible in a number of countries through the Global Alliance for Vaccines and
Immunizations (GAVI), and wider use of affordable Hib may be possible through technology
transfer to manufacturers in developing countries.Vaccine delivery infrastructure is essential
for sustainable vaccination programmes, and the evaluation of local disease burden is vital to
allow cost–benefit calculations and to make the case for use of Hib vaccine in the populations
with the greatest need.

Neisseria meningitides
Neisseria meningitidis, a Gram-negative encapsulated diplococcus with inner and outer cell
membranes, is classified into 12 serogroups based on the polysaccharide capsule. Five
serogroups (A, B, C, W135 and Y) account for virtually all meningococcal disease.In
industrialized countries the incidence of invasive disease is ~1–5 per 100 000, but incidences
are much higher in the developing world and during epidemics in affected
populations.Serogroup A causes the majority of epidemic meningococcal infection in the
African meningitis belt, amongst Hajj pilgrims and in China. Serogroup B and C

18 | Page
meningococci were responsible for the majority of endemic meningococcal disease in
European countries prior to the recent introduction of serogroup C protein–polysaccharide
conjugate vaccines. Recently, serogroup W135 has been associated with an outbreak amongst
Hajj pilgrims as well as a large epidemic in Burkina Faso during 2002 and 2003.26–28
Neisseria meningitidis is carried in the nasopharynx of adolescents and adults, with low
carriage rates in children <10 0 years of age. Carriage is usually self-limiting and of variable
duration. The peak incidence of invasive disease is between the ages of 6 months and 2 years,
and ranges from mild disease to fulminant septicaemia leading to death within a few hours of
onset. Immunosuppressed individuals, those with complement deficiency or hyposplenism
and those in crowded situations are at increased risk of developing meningococcal disease. In
several European countries and some parts of Canada, the group C glycocongugate vaccines
have been adopted in the infant immunization schedule either as a three-dose course or as a
single dose in the second year of life. In the UK a catch-up target campaign was also
performed on children aged 4–24 months. This resulted in a dramatic decline in the incidence
of group C meningococcal infection, with 97% effectiveness for ages 15–19 and 92%
effectiveness for ages 2–3. In addition to the reduction in serogroup C disease, the vaccine has
reduced the carriage of serogroup C meningococci inteenagers from 0.45% to 0.15%, and thus
induced herd immunity. As with Hib vaccine, the protection given by MCC vaccination is age
dependent, and cohorts vaccinated at older ages seem to have longer-lasting protection than
those routinely vaccinated in infancy.32 The possibility of waning immunity in those
vaccinated in early infancy may need to be considered in vaccination schedule design. A
number of trials have shown the safety and immunogenicity of both bivalent serogroups A
and C and monovalent serogroup C conjugate meningococcal vaccines in adults and children.
A quadrivalent ACYW conjugate vaccine is under development by a number of
manufacturers and will have a major impact on non-B meningococcal disease. This vaccine
has better coverage for meningococcal disease in North America, where there are high rates of
group Y disease, and for travellers to regions of the world where there is an increased risk of
serogroup A and W disease. This is the ideal vaccine for the meningitis belt of Africa, where
outbreaks or epidemics of disease caused by A, C and W135 have been described, and for
travellers and aid workers in high-risk areas. A majority of endemic disease in industrialized
countries is caused by serogroup B meningococci, and vaccines against this organism are
much more difficult to develop. The B polysaccharide is not immunogenic because of its
chemical identity to human neural surface antigens, and attempts to improve immunogenicity
could lead to the induction of autoantibodies that cross-react with glycosylated host antigens,

19 | Page
most notably foetal brain tissue.37 A number of different approaches to vaccine development
have been tried, but no vaccine has yet proved to be highly effective.

Current strategies

Live vaccines

Development of immunity is thought to occur through cross-protection from commensal

meningococcal species. Live-attenuated group B vaccines have been studied in animal
models. Neisseria lactamica whole cells, outer membrane vesicles and outer membrane
protein protected against challenge by meningococcal isolates representing different clonal
lineages belonging to serogroups B and C. Safety issues would need to be evaluated prior to
live vaccine implementation.

Subunit vaccines

Polysacharide-based group B meningococcal vaccines. In these vaccines, the native N-acetyl

groups on the B polysaccharide have been substituted by N-propionyl and conjugated to a
carrier protein (recombinant PorB outer-membrane protein) in an attempt to overcome
immunological tolerance. This vaccine has been shown to be immunogenic in animals and the
conjugate vaccine has reached phase 1 clinical trials. So far the vaccine has been shown to be
well tolerated in adults; however, vaccine antibodies were shown to be poorly functional in
vitro. Safety concerns over autoantibody have been raised. There has been no short-term
evidence of autoantibody production, but further preclinical studies are warranted.Conjugate
vaccination also has a number of cost implications.

Outer-membrane protein vesicle (OMV) vaccines. Outer-membrane vesicles contain a

number of proteins which could potentially serve as vaccine candidates, with PorA being the
most highly expressed and immunodominant antigen. Several efficacy trials using OMV
vaccines were undertaken in the 1980s in Cuba, Norway, Iceland, Brazil and Chile, and
showed efficacies of up to 80% in adults. However, these vaccines elicited limited protection
in infants and young children, and there was limited cross-protection to non-vaccine
meningococcal group B strains. The OMV vaccines may have an advantage over recombinant
protein vaccines as they present the conformational antigenic structures to the immune system
and have demonstrated efficacy, at least in older children and adults. Further development of
OMV vaccines, originally developed in Cuba, The Netherlands and Norway, is being
undertaken. An OMV vaccine for children in New Zealand was introduced during 2004 for a
clonal epidemic of serogroup B meningococcal disease. The New Zealand vaccine is expected

20 | Page
to offer little cross-protection, and currently there is no evidence to support its implementation
more widely. Following the observation of antigenic structuring amongst hyperinvasive
lineages of bacteria, a novel approach using a combination of OMVs has been suggested
which may potentially offer broad cross-protection.

A number of other potential outer-membrane protein vaccine candidates have been identified
including NspA, a conserved protein in serotypes A, B and C. Anti-NspA monoclonal
antibodies have been shown to be bactericidal but are variably expressed in pathogenic group
B meningococci, resulting in inconsistent protection.50 A number of other potential vaccine
candidates are listed in Table 4. The variability in the surface proteins of N.meningitidis
resulting from high spontaneous recombination and mutation rates as well as immunological
pressure on surface-exposed epitopes means that single purified proteins are unlikely to
provide a cross-protective vaccine.

Potential vaccine candidates considered for meningococcal group B vaccination

Protein Function

Adhesion penetration protein (app) Auototransporter,induces antibodies after

infection

Ferric binding protein (FbpA) Iron binding

Lactoferrin binding protein(LbpA) Lactoferrin binding

Neisserrial surface protein A (NspA) Immunogenic surface protein

Opacity associated protein (OpA;class Adhesion,invasion

5)

OpcA (Opc class 5c) Invasion,adhesion

Pilin Adhesion

PorA(class 1 protein) Cation porin

PorB (class 2/3 protein) Anion porin,induces immunity

Transferrin binding protein B (TbpA) Iron acquisition from transferrin

immunogenic in animals,not proven in
humans

Transferrin binding protein A (TbpA) Iron acquisition from transferrin

immunogenic in animals.

Table.2

21 | Page
Group B streptococcus
Group B streptococcus (GBS) is a predominant cause of neonatal meningitis. It has nine
serotypes, each of which has a different polysaccharide capsule. Purified polysaccharide
vaccines were assessed in women in the late 1980s, but were shown to be poorly
immunogenic. Whole-genome sequencing of serotypes Ia, III and V has offered new insights
into GBS virulence, with potential vaccine candidates including capsular polysaccharide, β-
haemolysin, C5a peptidase, adhesins and immunogenic surface proteins. Currently,
prophylactic antenatal antibiotic therapy is the main preventive strategy. The development of
multivalent protein polysaccharide or conjugate vaccines would extend protection against
invasive disease in the neonatal period. Conjugate vaccines have been prepared against the
most prevalent GBS serotypes in the USA (types Ia, Ib,II, III and V) and Japan (types VI and
VIII). Animal studies have established their efficacy, and phase 1 and 2 clinical trials
undertaken in adults have shown that their administration is safe. More recently conjugate
vaccines against types IV and VII have been assessed for efficacy in a neonatal mouse model
of GBS disease. The safety of maternal vaccination remains unknown and it is not clear if this
strategy would have any impact on late-onset GBS disease. However, these vaccines do offer
the potential to decrease perinatal GBS disease and phase 3 trials are awaited.

Tuberculosis

Currently, one-third of the world’s population is infected with Mycobacterium tuberculosis,

Bacillus Calmette–Guerin (BCG), the only vaccine currently licensed for prevention of
tuberculosis, is up to 77% effective against disseminated tuberculosis (TB) and ~50%
effective against infectious pulmonary TB.Its effectiveness in reducing morbidity and
mortality from disseminated meningeal and miliary TB has justified its use as a neonatal
vaccine. Neonatal vaccination provides protection against childhood disease, but this
protection wanes over time.BCG is safe and well tolerated, with adverse reactions being rare.
An improved TB vaccine could be employed either for naive individuals (and would need to
be at least as immunogenic and safe as BCG) or as a booster vaccine that would supplement
BCG and lead to lasting immunity in adults. Leading candidates for priming vaccines include
recombinant BCG, M.tuberculosis, M.vaccae or M.microti. In an augmented BCG vaccine
deleted genes lost from the parental strain could be added or increased expression of genes
already known to induce an effective immune response might be explored. Recombinant BCG
is due to enter clinical trials following studies showing better protective immunity than was

22 | Page
found with the parent strains. Modified M.tuberculosis generates good protection in mouse
models and is safe in SCID mice. This animal model of T-cell immunodeficiency has become
increasingly relevant because of the rising incidence of HIV and TB co-infection. The
advantages of a booster vaccine are that the well-established infant BCG programme could be
maintained whilst the booster vaccine would be added to maintain effective T-cell memory.
Approaches include the use of a subunit vaccine which may include either a recombinant
protein (ESAT-6, Ag85B) or DNA vaccination. DNA vaccination involves the vector delivery
of a plasmid encoding a gene product which leads to both CD4 and CD8 responses to the
target protein. Immunization with more than one gene product may be required in order to
ensure broad protection,and evidence suggests that efficacy is greater using the adjuvant
effects of cytokines or a prime/boost vector approach. Assessing both the safety and the
efficacy of these approaches will need to be undertaken in trials that are currently being
designed. A major challenge in the development of a TB vaccine is the evaluation of efficacy
against latent infection. There are potential risks of disease reactivation, and preclinical
animal data may be difficult to interpret since the human major histocompatibility complexes
are quite different. Better immunological correlates of protective immunity are also needed.
However, the greatest challenge remains safe and affordable delivery to the world’s poorest
individuals and the impact that HIV has on the rising incidence of TB infection.

Changing trends in Hib, S.pneumoniae, and Neisseria meningitides after vaccination

Study Countr Age Prior to After vaccine Decrease in

y vaccine (year) insidence,%
(year)
Haemophilus influenza
CDC {7} USA <5 23 (1990) 0.3 (1998- 99
2000)
Broadhurst et al [20] USA <5 91.7 (1984- 45.6 (After 50
1987) 1987)
Peltola et al.[21] Sweden <5 31 (1986) 1(1987-1990) 97
Kyaw et al. [16] Scotlan All age 1.2 (1983- 0.1 (1992- 92
d 1991) 1999)
Cowgil et al.[16] kenya <5 66 (2000- 7.6(2004-2005) 89
2001)
Daza et al.[22] Malawi <5 20-40 (1997- 0 (2003-2004) 100
2002)
Dickinson and perez Cuba <18 3 (1998) 0.1 (2003) 97
[18]
Wenger et al.[17] Qatar NS 14 (1992) 1 (1995) 93
Peltola [23] Urugay <5 22 (1992- 1 (1995-1996) 96
1993)
Streptococcus pneumonia

Poehling et al.[33] USA <3 11.8(1997- 7.2(2001-2004) 58

Months 2000)
Whitney et al.[30] USA <5 96.4(1998- 39.7(2001) 59
1999)
20-39* 11.2(1998- 7.6(2001) 32

23 | Page
 1999)
40-64* 21.5(1998- 19.7(2001) 8
1999)
>65* 60.1(1998- 49.5(2001) 18
1999)
Kyaw et al [36*] USA All ages 6.3(1999) 2.7(2004) 57
Abuelreish et al.[34] USA ≤18 15.5(1999) 6.5(2002) 58*
≤18 2.2(1999) 0.4(2002) 82*
O’Brien and USA <2 113.8 38.2 66
santosham[25]
CDC[32] USA <5 80(1998- 4.6(2003) 94
1999)
>65* 60.1(1998- 41.7(2003) 31
1999)
Neisseria Meningitides
Balmer et al.[37] UK 15-17 9.28(1999) 3.62(2001) 61
Ramsay et al.[42] UK <18 4.08(1998- 1.36(2001- 67
1999) 2002)
Miller et al.[43] UK <18 537(1998- 102(2000- 81
1999) 2001)
Brundage et al.[38] USA NS 23.6(1964- 1.3(1983-1998) 94
1971)
Wahdan et al.[45] Egypt 6-15 10.2(1973) 1.1(1973) 89
*Decrease incidence in S.pneumoniae in unvaccinated adult could represent herd immunity
*Incidence in 10,000 decrease in invasive pneumoniae disease
CDC-US Centers for disease control and prevention;Hib- haemophilus influenzae type b NS-not
stated.
Table-3

Etiology of bacterial meningitis-

Acute bacterial meningitis (ABM) is defined as an acute inflammation of leptomeninges
caused by bacteria . Acute bacterial meningitis is one of the most severe infectious diseases,
causing neurologic sequel and accounting for an estimated 171,000 deaths worldwide for each
year . Today, despite increased availability of strong antibiotics and sophisticated intensive
care units, bacterial meningitis continues to be a significant cause of morbidity and mortality,
and ABM has a case fatality rate of 20-30% . Unfortunately, mortality and morbidity of
meningitis and total cost of meningitis management annually did not clarify in Iran. In the
United States, meningitis accounts for about 72,000 hospitalizations and up to $1.2 billion in
hospital costs annually . The four most common etiologic agents of ABM are Haemophilus
influenzae type b (Hib), Streptococcus pneumoniae, Neisseria meningitidis, and
Streptococcus agalactiae which account for 90% of reported cases of ABM in the world ..
Additionally, accurate determination of the etiology of bacterial meningitis and estimating
cost of the disease may be essential in guiding vaccination policies.An Indian study suggests
that in approximately 85% of children suffering from bacterial meningitis, a causative
organism is not identified. Despite these challenges in diagnosing meningococcal meningitis
(MM), baseline cases have been regularly reported at Government hospitals and private setups
in the Country.

24 | Page
Role of Streptococcus pneumoniae:
S. pneumoniae is one of the most common causes of bacterial meningitis worldwide. It is a
capsulated bacterium which has 93 serotypes based on the different polysaccharide
characteristics of the capsule. Most of the serotypes are capable of causing disease but
majority of the infections in the developing countries are caused predominantly by serotypes 1
and 5. Although no age group is exempt from pneumococcal meningitis, it usually affects
small children under the age of 2 years. The other age group with high susceptibility to
pneumococcal infection is the old age. Immunocompromised people are also at a higher risk
of acquiring pneumococcal meningitis. Like N. meningitidis and H. influenzae, S.
pneumoniae spreads as respiratory droplets. The high rates of pneumococcal infections may
partly be due to the high carriage rates among the general population. Children under 6 years
of age have the highest rates of nasopharyngeal carriage.Due to this reason pneumococcal
disease has become the leading cause of vaccine preventable deaths in that age group.The
incidence in children under 5 years of age is estimated to be 17 cases per 100,000 population,
which is also associated with a high mortality rate often reaching up to 73% in some parts of
the developing world. Pneumococcal meningitis incidence may exhibit mild seasonal
variations. Although some strains of S. pneumoniae have been implicated in large outbreaks,
causing widespread epidemics is not considered typical of pneumococcal disease

Role of Neisseria meningitidis:

N. meningitidis is an obligate commensal residing in the human nasopharynx. The highest
incidence of nasopharyngeal carriage of N. meningitidis is in adolescents especially those
residing in overcrowded spaces. Particularly prone are school-going children and college
students, household contacts of meningococcal patients and also military recruits.Other
factors that may predispose to meningococcal carriage include lower socio-economic status
and concurrent viral or bacterial respiratory tract infection. In such individuals the carriage
rates can be as high as 34%. Recent estimates show that the global incidence of
meningococcal disease is 500,000 per annum with a worldwide mortality rate of 10%. N.
meningitidis can exist with or without a polysaccharide capsule. However, nearly all of the
meningococcal meningitis infections are caused by the capsulated form. Based on the
polysaccharide characteristics N. meningitidis can be divided into at least 12 different
serogroups. Serogroups A, B, C, W135, X and Y are isolated in almost 90% of the infections.
The serogroup distribution is often related to the age of the patient and more importantly to
the geographical location .Serogroup A is frequently isolated from CSF samples of meningitis
patients in sub-Saharan.

25 | Page
Africa where it causes epidemics. In these epidemics the incidence is very high, often
reaching up to 1 case per 100 population. The fatality rates even with treatment can be more
than 10%. Serogroups B and C are more common as a cause of meningitis in Europe,
America and Australia. Serogroup C has occasionally been the cause of epidemics and
outbreaks in these countries. The incidence of serogroup C has been reduced considerably in
the recent years due to the development of effective conjugate vaccines. Other serogroups
such as serogroups W135, X and Y are prevalent in some parts of Africa and US respectively.
Meningococcal disease may develop into a widespread blood infection known as
meningococcemia, which is a serious and often fatal form of meningococcal infection.

Role of Haemophilus influenzae type b: in bacterial meningitis

H. influenzae is a common respiratory pathogen which can occur either as capsulated or

uncapsulated form. The difference in structure of the polysaccharide capsule is the basis for
the division of H. influenzae into 6 serotypes; a, b, c, d, e and f. Out of these 6 serotypes,
serotype b is associated with most of the meningitis infections. Once known as the most
common cause of acute bacterial meningitis, the incidence of Hib has been reduced
substantially, principally due to the introduction of vaccine. A conjugate protein
polysaccharide vaccine that was introduced in early 1990s has been very effective in
controlling Hib infections. The infection occurs usually in children less than 5 years of age
and is rare in adults. The incidence varies in different parts of the world but it is generally
estimated to be higher in Africa where the incidence is around 46 per 100,000 population. In
Europe this incidence is much lower and is around 16 cases per 100,000 population. In
unimmunized patients, the mortality rate is estimated to be almost 43%.

Neonatal meningitis:
Neonates are particularly prone to acquiring bacterial meningitis possibly due to the
immaturity of their immune system. Even in the industrialized countries the incidence of
neonatal meningitis is about 0.3 cases per 1000 live births. In some parts of Africa and South
Asia the incidence in much higher and is estimated to be around 6.1 per 1000 live birth.
Although the mortality rates are less than 10% , the high incidence of long term neurological
complications is the matter of most concern. The organisms causing neonatal meningitis
include group B streptococci which accounts to about half of all the cases of neonatal
bacterial meningitis. This is followed by Gram negative enteric rods particularly E. coli which
is isolated in 20% of the cases. Another 5-10% of the cases are caused by L. monocytogenes.

26 | Page
In developing countries the incidence of gram negative rods such as E. coli and K.
pneumoniae may be much higher. A recent decrease in the incidence of group B streptococci
is attributed to the antibiotic prophylaxis given pre-partum to the neonates at risk.

Other organisms of bacterial meningitis:

Other uncommon causes of bacterial meningitis include Staphylococcus aureus, Pseudomonas
aeruginosa and some other enterococci. They are usually associated with nosocomial
infections and may be acquired after trauma or some surgical interventions. However, with
advancement of antibiotic therapy, immunization and aseptic techniques during interventions,
their incidence is on a rapid decline.

Pathogenesis of bacterial meningitis

While not the focus of this review, recent studies have enhanced our understanding of the
pathogenesis of bacterial meningitis among the major pathogens. To cause disease, the
pathogen must, in the absence of a neurosurgical procedure or CSF leak, colonize the
nasopharynx, traverse the nasopharynx into the bloodstream, survive host defense
mechanisms in the intravascular space, invade the blood-brain barrier (BBB), and survive and
replicate in the subarachnoid space, producing disease. Multiple interactions between the host
and the organism have been described in recent years and it is of interest that the major
meningeal pathogens have several similarities in common (e.g., asymptomatic carriage in the
nasopharynx, the ability to cause devastating disease, phosphoryl choline moieties,
polysaccharide capsules, IgA proteases, and certain physiologic features such as phase
variations, DNA transformation, and autolysis) . Our laboratories have concentrated on S.
pneumoniae; elsewhere in this issue the elegant work of Kim on the traversal of Escherichia
coli across the BBB is reported. A few highlights of recent studies follow (for a more detailed
discussion of pathogenesis.

Pathophysiology of bacterial meningitis

High grade bacteremia or the invasion of the blood by bacteria having the potential to cause
meningitis is the foremost step in the development of bacterial meningitis. Alternatively,
meningitis can occur as a consequence of direct invasion of the central nervous system (CNS)
which may result from dural defects or local infection of the CNS. Contagious spread of
infection from sinuses and internal ear is also a recognized cause of meningitis in a small
portion of patients. But usually the infection of the meninges follows a high grade bacteremia.

27 | Page
The exact site at which the transmission of the bacteria from blood to the CNS occurs is
uncertain. The choroid plexus is believed to be associated with this transmission. This was
demonstrated by Daum et al. in 1978, who observed the transmission of H. influenzae via the
9 choroid plexus. Recently, with the advancement in imaging and laboratory techniques,
certain other sites that may also serve as a potential point of entry to the CNS have been
identified. Studies have documented the presence of meningococci in the meninges in
addition to the choroid plexus. Similarly, pneumococcal infiltration of the leptomeningeal
vessels has also been documented . The blood brain barrier (BBB) and the sophisticated tight
junctions restrict the bacterial entry to the CNS. The breach of the BBB or the blood-CSF
barrier is therefore crucial to the entry of the bacteria into the CNS. This is achieved by the
presence of certain proteins on the surface of the bacteria which cause a breach in the BBB.
The identified proteins include Streptococcal proteins such as CbpA, meningococcal PilC1
adhesin and outer membrane proteins that assist in bacterial adhesion and subsequent
endocytosis. Similar adhesive molecules are also identified in GBS and E. coli, both of which
are a common cause of meningitis in newborns. The opacity proteins expressed on the outer
membrane of N. meningitidis (Opa and Opc) serve the purpose of bacterial adhesion and
endocytosis. Inflammatory response: With the bacterial invasion occurs the inflammatory
response of the endothelial cells. This inflammatory response leads to the leukocyte
infiltration which is a multi step process involving the accumulation of leukocytes particularly
the granulocytes. The presence of granulocytes in the CSF is therefore important in the
diagnosis of bacterial meningitis. The process of bacterial invasion and inflammation seem to
occur parallel, with the later assisting the former by increasing the permeability of the BBB.
The products of leukocyte activations which include the matrix metalloproteinases, nitric
oxide and others affect the BBB and the blood-CSF barrier by causing it to break . This
provides bacteria the opportunity to infiltrate the barrier and gain entry into the CNS. Once
inside the sub-arachnoid space, the bacteria replicate. The increase in number of bacteria
along with their autolysis enhances the process of inflammation which is the basis of
pathogenesis of bacterial meningitis. The inflammatory response to the bacteria is a complex
process involving a variety of inflammatory cells notably endothelial cells, mast cells and
perivascular macrophages. Bacterial components capable of inducing host inflammatory
response include peptidoglycans, lipoprotein, lipopolysaccharides and lipoteichoic acid.
Experiments showed that their potential to 10 trigger the inflammatory mediators remains
unaltered even if heat killed bacteria are inoculated into the host Neuronal damage.

28 | Page
 CHAPTER 3
CLINICAL FEATURE & DIAGNOSIS

29 | Page
 Clinical feature
Early clinical features of bacterial meningitis are nonspecific and include fever, malaise and
headache; and later on, meningismus (neck stiffness), photophobia, phonophobia and
vomiting develop as signs of meningeal irritation .Headache and meningismus indicate
inflammatory activation of the trigeminal sensory nerve fibers in the meninges and can be
blocked experimentally by 5-HT1B/D/F receptor agonists (triptans).However the role of triptans
for headache control in patients with bacterial meningitis remains to be clarified.
Meningismus may be absent very early in the disease, in deeply comatose patients, in children
and in immunocompromised patients such as in liver cirrhosis. It is important to consider that
the classical triad of fever, neck stiffness and altered mental state is present in less than 50%
of adults with proven bacterial meningitis ; van de Beek . Approximately 33% of patients
develop focal neurological signs, such as epileptic seizures or paresis of a limb, and up to
69% present with impaired consciousness or 14% with coma, Inspection of the integument
may reveal petechiae suggestive of meningococcal infection or Osler's nodes indicative of
bacterial endocarditis. Meningitis occurs in about 7% of patients with bacterial endocarditis,
often as a presenting symptom. The most frequent pathogens in this context are S. aureus,
otherwise uncommon in bacterial meningitis, and pneumococci. Occasionally, pneumococcal
meningitis, endocardits and pneumonia may be diagnosed simultaneously (Austrian's
syndrome)Meningococcal disease may present as a fulminant gram-negative sepsis with
prominent cardiovascular insufficiency and disseminated intravascular coagulation,
threatening ischemic tissue damage. Notably, a petechial skin rash is not unique to
meningococcal disease but may also be present in septicemia caused by, amongst others,
streptococci or S. aureus.

symptoms

 sudden fever
 sudden headache
 sudden stiff neck
 nausea
 vomiting
 sensitivity to light
 confusion
 drowsiness

30 | Page
 convulsions
 rash
 joint pain
 cold hands and feet
 coma

In infants

Infants may exhibit different symptoms to adults. Symptoms of bacterial meningitis in

infants include.

 poor feeding
 being difficult to wake
 sleepiness
 crying when handled
 irritability
 grunting or difficulty breathing
 fever
 stiff neck
 bulging soft spot on top of the head
 high-pitched crying
 convulsions
 vomiting
 pale or blotchy skin
 abnormal reflexes
 coma

31 | Page
Meningitis Rash

The rash usually starts as small, red pinpricks before .

spreading quickly and turning into red or purple blotches.

It does not fade if you press the side of a clear glass firmly against the skin

The rash can be harder to see on brown or black skin.

Check paler areas, such as the palms of the hands,
soles of the feet, roof of the mouth, tummy, whites of the eyes or the inside of the eyelids.

32 | Page
Laboratory diagnosis

Lumbar puncture
Cerebrospinal fluid (CSF) analysis and culture remains the definitive method for diagnosis of
meningitis. Issues in respect of indications, contraindications, and safety of lumbar puncture
have been covered recently.

Whether to perform lumbar puncture (LP) in a child with petechial rash is still a matter of
debate. Some in the UK hold that an unwell child with petechial rash is pathognomonic of
meningococcal disease and so a lumbar puncture would add very little in terms of diagnosis
and carries a high risk of making the haemodynamically unstable child worse.Others contend
that identification of the organism in the CSF is important for treatment, prophylaxis, and
epidemiological studies.We side with the latter view but recognise that there are reasons for
delaying LP until it is safe.Whether the decision is to perform LP or not, antibiotic treatment
should not be delayed.

CSF sterilisation following antibiotic use occurs rapidly. “Sterilisation” of meningococci may
occur within two hours, whereas for pneumococci at least four hours of antibiotic therapy is
needed. If live bacteria are to be cultured, the LP must be performed before or, if that is not
possible, immediately following the administration of antibiotics. The introduction of
molecular techniques has, however, meant that live organisms are not required for
identification, so there is less need for an early CSF. Blood polymerase chain reaction (PCR)
may be negative, whereas PCR performed on CSF collected after treatment and stabilisation
can still be informative (see below for further discussion of molecular techniques).

Traditional teaching holds that when white cells found in CSF are primarily polymorphs,
meningitis is bacterial in origin. However, viral infections, especially those caused by
enterovirus, may initially cause a predominant polymorph response in the CSF, which may
persist throughout the illness.

The rapid antigen latex agglutination test on CSF or blood has the benefit that it can be done
locally and rapidly, but its lack of sensitivity can limit its clinical use.Ultrasonic enhancement
has increased the sensitivity of these tests. Commercial kits are available that cover Neiserria
meningitidis serogroup B, a combination of meningococcal serogroups (W135, A, C, and
Y), Streptococcus pneumoniae, Haemophilus influenzae type b, Escherichia coli K1, and
group B streptococcus. Where specimen volume is limited, guiding the microbiology

33 | Page
laboratory as to what the clinician thinks is the presumptive infecting organism is important in
prioritizing the tests.

Diagnosis bacterial meningitis,CSF culture is the “gold standard” for diagnosis,and it is

obligatory to obtain the in vitro susceptibility of the causative microorganism and to
rationalize treatment.CSF Gram staining,latex agglutination testing,and PCR are additional
diagnostic tools that might aid in etiological diagnosis,especially for patients with negative
CSF culture (i.e.,after antibiotic pretreatment).however,the incremental yield of these
techniques is sometimes limited. If lumbar puncture cannot be performed,serum inflammatory
marker,blood culture,skin biopsy,and urine antigen testing may provide supportive evidemce
to diagnose bacterial meningitis will be discussed.

CSF Cell Count, Glucose, and protein

Characteristic CSF finding for bacterial meningitis consist of polymorphonuclear

pleocytosis,hypoglycorrhachia, and raised CSF protein levels. A prediction model based on
422 patients with bacterial meningitis showed that individual predictors of bacterial
meningitis consisted of a glucose concentration of less than 0.34 gm/liter (1.9 mmol per
liter), a ratio of CSF glucose to blood glucose of less than 0.23, a protein concentration of
more than 2.2 g per liter, or a white cell count of more than 2,000 cells per mm3. However,
CSF protein (>0.5 g/liter) and neutrophil count (≥100) thresholds are also indicative of
bacterial meningitis, with odds ratios (ORs) of 14 and 12, respectively. The majority of
patients presenting with community-acquired bacterial meningitis have CSF parameters
characteristic of bacterial meningitis . However, low CSF white blood cell counts do occur,
especially in patients with septic shock and systemic complications. Experimental
pneumococcal meningitis studies also showed a relationship between a large bacterial CSF
load, a lack of response of CSF leukocytes, and intracranial complications probably indicating
excessive bacterial growth and a lack of a CSF leukocyte response.

In a prospective cohort study of 258 adults with culture-proven meningococcal meningitis,

CSF leukocyte counts of less than 1,000 leukocytes per mm3 were found for 19% of patients .
CSF examination was reported to be normal for five (1.7%) of these patients . For three of
five patients, the CSF Gram stain showed bacteria.

Patients with listerial meningitis often do not have characteristic CSF findings, with relatively
low CSF leukocyte counts and high CSF protein concentrations . A mononuclear cell
predominance in the CSF is found more frequently than for other types of bacterial meningit.
For patients with listerial brainstem encephalitis, the CSF typically shows low-grade

34 | Page
pleocytosis, with a lymphocytic predominance and slightly elevated protein levels.
Hypoglycorrhachia is found in only 21% of cases . CSF white blood cell counts are
inconclusive for many neonates with meningitis due to S. agalactiae. In a study including 276
children with meningitis due to S. agalactiae (83% neonates), a normal CSF examination was
found for 6% of patients . Adults with S. agalactiae meningitis have typical CSF findings.

CSF Cultures
CSF culture remains the gold standard for the diagnosis of bacterial meningitis; aerobic
culturing techniques are obligatory for community-acquired bacterial meningitis. Anaerobic
culture may be important for postneurosurgical meningitis or for the investigation of CSF
shunt meningitis. In a retrospective series of 875 meningitis patients for whom the diagnosis
was defined by a CSF white blood cell count of over 1,000 cells per mm 3 and/or more than
80% polymorphonuclear cells, the CSF culture was positive for 85% of cases in the absence
of prior antibiotic treatment . CSF cultures were positive for 96% of patients if meningitis was
due to H. influenzae, 87% of patients with pneumococcal meningitis, and 80% of patients
with meningococcal meningitis . A study of 231 children showed positive CSF cultures for
82% of patients . However, lower yields of CSF cultures were reported. For 3,973 meningitis
cases from Brazil, cultures were positive for 67% of cases when culture-negative cases were
defined by the CSF profile . In a study from the United Kingdom including 103 patients with
clinically defined meningococcal meningitis, only 13% had positive CSF cultures .

The yield of CSF culture is lower for patients who have received antibiotic pretreatment
before lumbar puncture. Two large case series reported decreases in yield from 66 to 62% and
88 to 70% if patients were pretreated with antibiotics . In one of those studies, pretreatment
for more than 24 h was associated with a further decrease of positive CSF cultures to 59% . A
decrease in culture positivity from 19 to 11% was seen for pretreated patients with clinically
defined meningococcal meningitis in a study from the United Kingdom . Another study of 21
patients with meningococcal meningitis diagnosed either by culture or by PCR showed
positive CSF cultures for 9% of patients receiving pretreatment and 50% for those who did
not.

CSF Gram Stain

CSF Gram staining may swiftly identify the causative microorganism for patients with
suspected bacterial meningitis. It is a cheap and well-validated diagnostic tool. Several studies
have shown the additional value of Gram staining for CSF culture-negative patients. For
3,973 patients with bacterial meningitis defined by CSF parameters, 1,314 (31%) had negative
CSF cultures; 581 (45%) of the CSF culture-negative patients had a positive Gram stain .

35 | Page
Forty-four percent of patients in this cohort were pretreated with antibiotics. In an Indian
study of 535 suspected meningitis cases, CSF Gram staining identified the causative
organisms for 36 (65%) of 55 pretreated patients, while CSF culture was positive for only 5
(9%) patients . In a large study from Denmark, CSF Gram staining was the only positive
laboratory finding for 4% of 875 patients with bacterial meningitis . In a recent French study,
24 (6%) of 363 CSF culture-negative children with meningococcal meningitis were diagnosed
by CSF pleocytosis and a positive Gram stain .

The yield of CSF Gram staining may be decreased in antibiotic-pretreated patients compared
with antibiotic-naïve patients. Pretreatment with antibiotics decreased the yield of CSF Gram
staining only slightly, from 56 to 52% for 481 Danish patients . A study of U.S. children
showed similar yields of CSF Gram staining for pretreated patients . For 73 meningococcal
meningitis patients, the reported yield of Gram staining decreased slightly, from 34 to 27%
for pretreated patients.

The reported sensitivities of CSF Gram staining vary considerably for different
microorganisms. CSF Gram staining correctly identifies the organism in 50 to 65% of
children and in 25 to 33% in adults with H. influenzae meningitis . Gram staining correctly
identifies the pathogen in 69 to 93% of patients with pneumococcal meningitis. The reported
yield for meningococcal meningitis is highly variable and ranged from 89% for untreated
adult patients in the Netherlands to 73% for U.S. children, 62% for Greek children, 49% for
Spanish children, and 30% for patients of all ages in the United Kingdom. The yield of Gram
staining for Listeria meningitis is low, ranging from 23 to 36% for both children and adults
and was even lower (14%) for patients with Listeria rhombencephalitis.

Latex Agglutination Tests

Latex agglutination is a diagnostic test that has been utilized for the etiological diagnosis of
bacterial meningitis, providing results in less than 15 min .These tests utilize serum containing
bacterial antibodies or commercially available antisera directed against the capsular
polysaccharides of meningeal pathogens and have been recommended for patients with
suspected bacterial meningitis with no bacteria seen upon CSF Gram staining and negative
CSF cultures . The reported sensitivities of latex agglutination testing of CSF samples from
patients with bacterial meningitis ranged from 78 to 100% for H. influenzae type b meningitis,
59 to 100% for pneumococcal meningitis, and 22 to 93% for meningococcal meningitis.
However, in a 10-year retrospective study of 176 children with culture-negative meningitis

36 | Page
who were pretreated with antibiotics before lumbar puncture, none had a positive CSF latex
agglutination result (95% confidence interval, 0 to 2%) . In another study of 28 patients with
negative CSF cultures who had clinical presentation and CSF parameters compatible with
bacterial meningitis, CSF latex agglutination had a sensitivity of only 7% for detecting
bacteria . A third study showed only 7 positive agglutination tests out of 478 CSF samples
tested; all 7 patients had a CSF Gram stain showing the causative microorganism . A study of
meningococcal meningitis patients showed a strong decline in the sensitivity of latex
agglutination, from 60% for patients without antibiotic pretreatment prior to lumbar puncture
to 9% for antibiotic-pretreated patients . The limited additional value of latex agglutination
testing was also shown by several other studies, and its use is therefore
limited .Meningococcal antigens may also be detected in urine by these techniques. However,
the diagnostic accuracy of this test is limited since false-positive results are common; it had
no additional diagnostic value above that of CSF Gram staining .

PCR Nucleic acid amplification tests such as PCR assays have been evaluated for their
effectiveness in detecting the presence of bacterial DNA in CSF from patients with suspected
and proven bacterial meningitis. One study including 65 patients with culture-confirmed
community-acquired bacterial meningitis evaluated the diagnostic accuracy of a broad-range
PCR including primers for H. influenzae, S. pneumoniae, and N. meningitidis. The sensitivity
for H. influenzae was 92%, that for S. pneumoniae was 100%, and that for N.
meningitidis was 88%; the specificity was 100% for all organisms . In another study of 139
bacterial meningitis patients defined by positive CSF culture in 94 cases and positive CSF
Gram stain in 12 cases and based on clinical suspicion with negative cultures in 31 cases
found sensitivities for H. influenzae (88%), S. pneumoniae (92%), and N. meningitidis (94%)
using a multiplex PCR assay, with a specificity of 100% for all three microorganisms . The
sensitivities of multiplex PCR for CSF from 409 bacterial meningitis patients in Burkina Faso
(diagnosed by either CSF culture, latex agglutination test, PCR, or Gram stain) were
considerably lower: 72% for H. influenzae, 61% for S. pneumoniae, and 88% for N.
meningitidis, with specificities of 95%, 95%, and 97%, respectively . In that study, the
incremental value of PCR next to culture, Gram stain, and latex agglutination was high: 29
(43%) of 68 patients with H. influenzae meningitis, 43 (27%) of 162 with pneumococcal
meningitis, and 66 (37%) of 179 with meningococcal meningitis were diagnosed with only
PCR .

Meningococcal DNA detection by PCR has been used widely and is performed routinely for
patients with suspected meningococcal meningitis and negative CSF cultures in many parts of

37 | Page
the world . In the United Kingdom, a large proportion of meningococcal disease cases are
now diagnosed by PCR without culture . PCR detection of meningococcal DNA requires
special techniques and is expensive and, therefore, not widely available. A prospective French
study including 363 children with clinically defined meningococcal meningitis and negative
CSF cultures showed that PCR for meningococcal DNA was positive for 205 children (57%);
for 169 (47%) children, meningococci were identified by PCR only. Pretreatment with
antibiotics may decrease the sensitivity of PCR of CSF samples. In a prospective study
including 28 patients with clinically defined meningococcal meningitis, PCR of
meningococcal DNA was positive for 13 (81%) of 16 patients who were treated with
antibiotics prior to lumbar puncture, compared to all 21 patients without pretreatment . PCR
can also be a useful tool for the swift typing of meningococcal strains in an evolving
epidemic.An initial study of the PCR detection of L. monocytogenes in patients with bacterial
meningitis showed that a high concentration of bacteria in the CSF is needed for PCR
detection . Recent studies of multiplex PCRs including L. monocytogenes showed lower
detection thresholds .The sensitivity, specificity, and incremental value of PCR in L.
monocytogenes meningitis are unclear, as only one patient was included in each of these
studies . Data on PCR detection of group B streptococci in CSF are limited, and group B
streptococci have been tested only with multiplex PCR detection assays. Streptococcus
suis DNA was detected by PCR in CSF samples from 149 of 151 patients (sensitivity, 99%)
in a cohort study, with unknown specificity .A high bacterial load determined by quantitative
PCR has been associated with unfavorable outcomes of both pneumococcal and
meningococcal disease , but it remains unclear whether this information has any additional
value for clinical prognosis .

sTREM-1
Soluble triggering receptor expressed on myeloid cells 1 (sTREM-1) in CSF was found to be
a biomarker for the presence of bacterial meningitis in a retrospective study of 85 bacterial
meningitis patients, 8 viral meningitis patients, and 9 healthy controls. At a cutoff level of 20
pg/ml, the sensitivity of sTREM-1 in CSF was 73% (95% confidence interval, 0.65 to 0.80),
the specificity was 77% (95% confidence interval, 0.57 to 0.89), the positive predictive value
was 0.94 (95% confidence interval, 0.88 to 0.98), and the negative predictive value was 0.34
(95% confidence interval, 0.23 to 0.48). High levels of sTREM-1 were associated with
unfavorable outcomes. A second study found immeasurably low sTREM-1 levels for 12 viral
meningitis patients and an increased level for 7 of 9 patients .The incremental yield compared
to those of other CSF diagnostic tests must be determined before the test can be recommended
in clinical practice.

38 | Page
Blood Culture
Blood cultures are valuable to detect the causative organism and establish susceptibility
patterns if CSF cultures are negative or unavailable. Blood culture positivity differs for each
causative organism: 50 to 90% of H. influenzae meningitis patients, 75% of pneumococcal
meningitis patients and 40% of children and 60% of adult patients with meningococcal
meningitis . The yield of blood cultures was decreased by 20% for pretreated patients in two
studies .

TREATMENT
The choice of antibiotic depends on the organism isolated. In most cases the initial treatment
has to be empirical, but nonetheless based on epidemiological knowledge of the commonest
organisms for each age group and local antibiotic resistance patterns. The chosen antibiotic
should have bactericidal activity in the CSF. Patients with pneumococcal or Gram negative
bacillary meningitis who are treated with bacteriostatic antibiotics may have a poor clinical
outcome.Animal studies have shown that a bactericidal effect is necessary for sterilisation of
the CSF and survival.

There are three factors affecting antibiotic activity: ability to penetrate the CSF,
concentration, and intrinsic activity in infected fluid. When the blood-brain barrier is intact,
penetration is limited, because transport across cells is minimal and the junctions between
endothelial cells of the cerebral microvasculature are tight. In meningitis, the integrity of the
barrier is altered, resulting in increased permeability and enhanced CSF penetration of most
antibiotics. The antibiotic concentration in CSF needed for optimal bactericidal activity is
uncertain. However, in experimental studies, maximal bactericidal activity occurs when the
concentration of an antibiotic is approximately 10–30 times the minimal bactericidal
concentration against the organism in vitro.

Bactericidal antibiotics promote the release of bacteria cell wall products such as endotoxins,
teichoic acid, and peptidoglycans. These products provoke the production of the inflammatory
mediators such as tumour necrosis factor α (TNF-α), interleukin 1 (IL-1), and platelet
activating factor (PAF). The release of inflammatory mediators can be associated with
worsening of disease and poor outcome. However, one experimental study showed that the
release of bacterial toxins after initiation of antibiotics was much less than that released by
bacteria not exposed to antibiotics.

In a child with suspected meningitis, urgent transfer to hospital, followed by concurrent

microbiological investigation and antibiotic treatment are the cornerstones of management.

39 | Page
Lack of adequate blood and CSF culture may result in difficulty deciding on the duration of
treatment and uncertainty over the antimicrobial susceptibility of the organism.

Partially treated meningitis

As the early symptoms and signs of bacterial meningitis are non-specific, up to 50% of cases
may initially receive oral antibiotics. This partial treatment may delay the child’s presentation
to hospital and result in a diagnostic dilemma. The CSF findings may be altered; Gram stain
and growth of organism may be negative, however antibiotics rarely interfere with CSF
protein or glucose. In this situation CSF should be sent for both PCR and bacterial antigen
detection, as these are not affected by prior antibiotic administration.

Duration of treatment and choice of antibiotic

The duration of antibiotic therapy depends on the organism isolated. For S pneumoniae and H
influenzae, 10–14 days treatment is generally recommended while for N meningitidis a seven
day course is sufficient. In Listeria monocytogenes and group B streptococcal meningitis,
antibiotics should be given for 14–21 days. For Gram negative bacilli a minimum of three
weeks is needed.

In most cases of bacterial meningitis a broad spectrum cephalosporin (cefotaxime or

ceftriaxone) is the most appropriate empirical choice in children over 3 months old. These
cover Neisseria meningitides, Streptococcus pneumoniae, and Haemophilus influenzae, and
penetrate CSF well. Ampicillin should be added in young infants (less than 3 months old) to
cover Listeria monocytogenes. The treatment of choice for Gram negative bacillary
meningitis is cefotaxime or ceftriaxone. Aminoglycosides are sometimes used in addition, but
not alone as they often do not exceed the minimum inhibitory concentrations (MIC) for Gram
negative bacteria and may not be successful in eradicating the pathogen.

Ceftriaxone may be effective when given as a single daily dose (80–100 mg/kg) to treat
serious bacterial infections including meningitis in children. Although this regimen may be
cost effective, safe, and convenient, one concern is that missing a single dose or delaying it
may result in inadequate CSF drug concentration. A randomised trial in 100 infants who were
already showing signs of recovery revealed that four days of ceftriaxone treatment is as
effective as seven days with no difference in complications. We suggest that confirmation is
required from larger studies of these encouraging results before recommending a shorter
treatment period.

Antibiotic therapy may need to be modified once a pathogen is cultured and antibiotic
susceptibility testing becomes available. If pneumococcal meningitis is high on the
differential diagnosis and there is a clear history of anaphylaxis to β lactams, and keeping in

40 | Page
mind that perhaps 10% of those allergic to penicillin cross react to cephalosporin, a
combination of vancomycin and chloramphenicol is an alternative. Vancomycin is added
because of the risk of penicillin resistant pneumococci and the possibility of failure of
chloramphenicol in this group.For more complicated cases such as immunosuppressed
patients or those with recent history of head trauma or neurosurgery, and those with
cerebrospinal fluid shunts, broad spectrum antibiotics against Gram positive and Gram
negative organisms should be given, such as a combination of vancomycin and
ceftazidime.Studies comparing the use of rifampicin with ceftriaxone in experimental S
pneumoniae meningitis support the use of rifampicin because of a reduction in the release of
proinflammatory mediators, decreased secondary brain injury, and a lower early mortality
rate. As the release of bacterial cell wall products and the production of proinflammatory
mediators may be associated with more severe disease and worse outcome in some patients
with bacterial meningitis, the initial use of rifampicin (for say 1–2 hours) followed by
addition of a β lactam may result in reduction of tissue damage and a better outcome.
However this approach is not human evidence based.

Other less frequently used carbapenem antibiotics, such as imipenem and meropenem, are
very active in vitro against most isolates of S pneumoniae, although some penicillin resistant
strains have shown reduced susceptibility. Fluroquinolones, such as trovafloxacin,
gatifloxacin, and moxifloxacin are potentially effective in the treatment of multiply resistant
pneumococcal isolates because of their activity and CSF penetration, even when
dexamethasone is also given.

41 | Page
 Dosage and frequency of the common antibiotics used in bacterial meningitis

DRUG Frequency (times dose Maximum daily dose

daily)

Penicillin G 50 mg/kg 4-6 14.4 gm

Cefotaxime 50 mg/kg 4 3 gm
Ceftriaxone 80-100 mg/kg 1 4 gm
Ampicillin 100 mg/kg 4 3 gm
Ceftazidime 50 mg/kg 3 6 gm
Vancomycin 15 mg/kg then 10 mg/kg 4 2gm
Table 4

CSF cell count in bacterial meningitis

Cerebrospinal fluid is a clear fluid which is formed as a ultra filtrate of plasma. CSF is present
in both the intracranial and spinal compartments. It is continuously being secreted by the
choroidplexus at a constant rate inside the ventricles of the brain and circulates in the
subarachnoid space of the brain and spinal cord through CSF pathways. The total volume of
CSF in the adult is approximately 140 mL. CSF is produced at a rate of 0.2–0.7 mL per
minute or 500–700 mL per day.The main function of the CSF is to reduce buoyancy of the
brain. It also supplies nutrients as well as helps in removal of various substances like amino
acids, neurotransmitters, metabolic byproducts and cells.The composition of the CSF and its
pressure is maintained relatively constant by various mechanisms. However in disease
conditions the composition and pressure of CSF can be altered.

Hence analysis of CSF by various methods will help in diagnosis as well as prognostication
and response to therapy. CSF analysis is particularly useful in various acute infectious
conditions and helps in rapid diagnosis of the conditions and initiate therapeutic measures.
CSF analysis usually consists of opening pressure measurement, biochemical analysis,
cytology, biomarkers assay,and microbiological evaluation. In some clinical conditions,
lumbar puncture and drainage of can be a therapeutic measure also.Cerebrospinal fluid (CSF)
is secreted by the epithelial cells of the choroid plexuses. These cells like those of other
secretory epithelia are polarised so that the properties of their apical membrane differ from
those of the basolateral membrane . Both membranes have a greatly expanded area (apical
membrane is made up of numerous microvilli, and the basolateral membrane has many

42 | Page
infoldings), so that the total area available for transport is similar to that of the blood- brain
barrier.
CSF: Formation and Composition
Cerebrospinal fluid (CSF) is a clear, colourless fluid formed by the choroid plexus of the
lateral, third and fourth ventricles of the brain. The choroid plexus produces around 70% of
this fluid by ultrafiltration and secretion. The rest of the CSF is produced by the ependymal
lining of the ventricles and the cerebral subarachnoid space. On average 500 ml of CSF are
formed daily, but at any given moment only 90-150 ml of CSF is present in an adult.
Arachnoid villi are responsible for reabsorption of the CSF. In children between the age of 4 -
13 years at any given time a volume of 65 – 150 ml are found . In a lumbar puncture a volume
of 3-5 ml may be taken depending on the age. The volume removed during the lumbar
puncture can be restored within an hour of the procedure . Normal intracranial pressure is the
result of well a balanced system between CSF production and reabsorption which is
dependent on venous pressure as all the reabsorbed fluid is drained in to venous system.
Though continual balance of CSF is maintained there is a significant pooling in the lumbar
sac site located between L4 to L5. This location is used for Lumbar puncture for acquisition
of CSF for analysis because of the pooling and due to lower risk of damaging the roots.

Composition of Normal CSF

Colour Clear
Specific gravity/PH 1.006-1.007/7.4
Opening pressure 50-200 mm H2O
RBCs count Nill
WBC Count 0-5(up to 30 neonates)
WBC Types Lymphocytes
CSF proteins 15-40 mg/dl
CSF lactate 1-3 mmol/litre
CSF Glucose 50-80 mg/dl(2/3 of blood glucose)
Microbial examination No microorganisms found
Table 5

Total volume of cerebrospinal fluid (infant) = 50 ml

Turnover of entire volume of cerebrospinal fluid = 3 to 4 times per day
Rate of production of CSF = 0.35 ml/min (500 ml/day)
pH of cerebrospinal fluid = 7.33 (from Kandel et al., 2000, p. 1296)
Specific gravity of cerebrospinal fluid = 1.007
Colour of normal CSF = clear and colourless.
The CSF has 4 main functions.

43 | Page
1. Mechanical protection for the spinal cord and the brain by providing buoyance.
2. Homeostasis of interstitial fluid and regulation of neurological function
3. Delivery of nutrients to the brain and removal of waste material
4. Regulation of the intracranial pressure
The CSF is composed of 99% water, which contains a small amount of glucose, electrolytes,
minerals, proteins and other nutrients.The chemical composition is strictly controlled to
maintain chemical balance. The electrolytes like K + , Ca2+, Mg2 are regulated by a specific
transport system. Glucose, urea, creatinine and proteins enter the CSF by passive diffusion via
pinocytosis. The protein concentration in the CSF is strictly related to plasma concentration of
the protein. In case of damaged BBB eg. In bacterial meningitis, albumin, which is found in
higher concentration in the plasma crosses the BBB causing increase in protein concentration
in the CSF. Though the CSF is considered as acellular a very small amount of cells can be
found. The parameter of cells found in the CSF varies according to the age. A cell count of 0 -
5 WBC and RBC in the CSF are considered normal in adults but in children may vary from 0-
20 cells and In neonates it may be even higher due to BBB prematurity and may range from
0-30 cells. CSF contains a higher concentration of Na2+ and Clin comparison with plasma
while the levels of K + , Ca2+ and Mg2+ are lower. The average concentration of electrolytes
is: sodium (Na2 ) 140mEq/l; potassium (K); 2mEq/l, chloride 115mEq/l; calcium 2,5 to
3mEq/l; phosphorus 1,6mEq/l and magnesium of 2,2mEq/. Table 8 Demonstrates all the
characteristics of the CSF according to the various ages. Only disease can affect the
permeability of BBB and permit the entry of elements that usually have no access to the
barrier and allow entry of erythrocytes and leukocytes from blood vessel damage or from
meningeal reaction. However, in case of neonates, these have a premature BBB and allow
passage of leukocytes and proteins in higher concentration during the first 4 to 6 weeks of life,
but once maturation occurs, the number of leukocytes and amount of protein fall to become
similar as in infants . In case of meningitis the BBB is also affected.

44 | Page
 Normal Reference Ranges of Cerebro Spinal Fluid According Different Age groups

CSF Neonates Children 5-18 years Adults

Characteristics 1-4years
Opening 50-80mmH2O 100-200mmH2O
pressure
Leukocytes 0-30cellsx 0- 0-10cellsx 0-5cellsx
106/L 20cells 106/L 106/L
x 106/L
Differential
Lymphocytes 5-35% 40-80%
Monocytes 50-90% 15-45%
Polymorphonucl 0-8% 0-6%
er
Leukocytes
Erythrocytes 0–675cellsx
106/L 0-10cellsx 106/L
Proteins 70 mg/dL 20-45mg/dl
Glucose >50%ofseru 40-70mg/dl
m
glucose
Specific gravity 1005 1000-1006
Bilirubin None None
Table 6

CSF alterations in bacterial meningitis

The cell count is essential as the cell morphology can help in differentiating between the
different types of meningitis and can be performed within 30 min. Normal CSF is acellular or
has few leukocytes,1 cells usually less than 10 cell/ml with one polymorphonucleocyte
(PMN) only . The CSF is usually colourless and clear, but in bacterial meningitis the CSF
colour may vary from clear to purulent. Turbidity of the CSF is a result of increased
leukocyte, red blood cells, protein concentration, glucose or presence of bacteria . The normal
CSF pressure is usually between 50 - 200 mm H20 depending on age. However, in bacterial
meningitis, it is usually increased except in the early stages of the disease. But in a later stage
of the disease the pressure is typically high. In 90% of cases the pressure may be higher than
200 mm H20 and in 10 -15% of cases may be as high as, or above 500 mm H20 in adult. In
children the opening pressure is also increased in bacterial meningitis and the median pressure
may be as high as 204 mm H20.The normal CSf WBC found in the CSF vary between 0-5
cells/mm3 with one ploymophonucleocyte observed. In case more than 2
polymorphonucleocytes are observed, CSF should be considered abnormal. In bacterial

45 | Page
meningitis cell count is usually altered, typical finding are presence of polymorphonuclear
pleocytosis (Pleocytosis is referred as cell count > 10 cells/µl), hypoglycorrhachia and raised
CSF protein level. The leukocyte count in bacterial meningitis varies. Typically the leukocyte
count is greater than 1000 cells/µl but in some cases may be as high as 10,000 cells/µl .
However, in rare cases, cell count may be lower than 100 cells/µl. When this occurs, it‟s
known as „normocelular‟ or „developing bacterial meningitis‟ usually observed in
immunosuppressed patients and is not very common. However, Fremont Smith in his study
observed that at least 1% of meningitis patient had cell count < 100 cells/µl as cited by. But
the predominance of PMN in the CSF should suggest the diagnosis of BM, though L.
Monocytogenes can cause lymphomonocytosis.Viral meningitis usually presents with a cell
count, which typically ranges from 10 - 1000 cell/µl, but usually lower than < 300 cell/µl with
predominance of monocytes and lymphocytes. In case of some viral infection like herpes,
enterovirus and arbovirus there could be predominance in PMN during the first 48 hours.In
general, there is an overlap between viral and bacterial meningitis therefore microorganism
identification is essential for confirming diagnosis.

Cranial CSF spaces

46 | Page
 Fig.08

Volume of CSF in ventricles may change-

Ventricular volume 25 ml(Normal) Ventricular volume 127 ml(Abnormal)

Fig.09

Volume of brain= 1400 ml

Volume of CSF= 150ml
CSF in ventricles around 25 ml
Volume of blood= 150 ml

47 | Page
 CSF Findings in Different Types of Meningitis

Table 7

CSF chemistries in bacterial meningitis

CSF glucose is usually reduced and in 75 % of patients is < 50 mg/dl and only in 25 % is
below 10 mg/dl.However, in case systemic glucose level is increased the CSF glucose will
also be high in these cases. So, many authors suggest for correction by calculating CSF:
serum / glucose ratio = 0.6.In viral meningitis it is often observed that there is a slight
decrease in the level of glucose in the CSF, but usually is normal, but in cases of TB
meningitis it is very low.Hypoglycorrhachia has a strong predictive value if accompanied with
pleocytosis and clinical signs of BM.The CSF protein is usually elevated in BM. The typical
findings are protein above 45 mg/dl. When the protein is above 80 mg/dl, it has a strong
predictive value for BM, as a slight increase in protein may also occur in viral and fungal
meningitis. A higher increase above 500 mg/dl is strongly associated with the development of
neurological deficits.Out of the 3 parameters, leukocytes and protein count are the least
influenced by antimicrobial therapy, glucose starts increasing after first 24-48 hours after
antibiotic administration. Protein and leukocyte may still be present until the end of treatment.

48 | Page
 The table below shows that the changes in the CSF in Bacterial meningitis

Conditions Leukocytes (µl) Protein Glucose(mg/dl)

(mg/dl)
Normal <5, 20-45 >50(or 75%of
≥75%Lymphocytes SerumGlucose)
AcuteBacte 100-10,000 100-500 <40(or <50%
rial 300-2,000PMNor serumglucose)
Meningitis >50%
Partially treated 5-10,000;PMNs 100-500 Normal or
bacterialmening usual, but decreased
itis mononucleocytes
prevalent when
prolongedtreatment
Table 8

49 | Page
 CHAPTER 4
MATERIALS AND METHODS

Materials and Methods

50 | Page
 Patients
In this study we have taken patient data from MEDICOVER HOSPITAL
(Hyderabad,Telangana) and the CSF sample were obtained from the out patient(OPD) and
In-patient(IPD) department.

The study period is for 6 month from April 2023 to November 2023 and the study of
population included 203. Out of 203, 37 patient was showing raised neutrophil counts which
was suspected to bacterial meningitis.

COLLECTION OF CEREBROSPINAL FLUID (CSF)

CSF samples were collected by lubar puncture.

Lumbar puncture

The kit for collectionof CSF contains:

1. Skin disinfectant
2. Sterile gauze and band-Aid
3. Lumbar puncture needles: 22 gauge/3.5 inch for adults ;23 gauge/2.5 inch for
children
4. Sterile screw cap tubes
5. Syringes and needles
6. Transport container
7. Trans-Isolate (T-I) medium (as CSF cannot be analyzed in the microbiological laboratory
immediately).

The patient was kept in either sitting up or lying on the side, with his or her back arched
forward so that the head almost touches the knees during the procedure. The skin was
disinfected along a line drawn between the crests of the two ilia with 70 % alcohol to clean
the surface and remove debris and oils. Then tincture of iodine or povidone-iodine was
applied. After drying, the needle was introduced, and the drops of fluid (1 ml minimum, 3-4
ml if possible) were collected into sterile, screw-cap tubes and also inoculated in Trans isolate
medium.

After proper labeling, it was carried to the laboratory as soon as possible avoiding exposure to
excessive heat or sunlight.

51 | Page
 Cytospin preparations

A cytospin is obtained by employing centrifugal force to isolate, concentrate and deposit a

monolayer of cells from a dilute cell suspension onto a circular area on a slide. The objective
is to keep cells intact enabling the morphology of the cells to be examined. This technique has
a wide variety of applications including cytology, histology and hematology.

Equipment, reagents and cell preparations

 Cytospin™ Centrifuge with cytofunnels and cytoclips (Thermo Scientific) - Figure 1

 Filter cards (Fisher Scientific 11630601)

 SuperFrost Plus Glass slides (VWR 631-0108)

 Cytofunnels (Fisher Scientific 11610591 or 11660591)

 Fixative: acetone (undiluted), methanol (ice-cold 100% methanol) or paraformaldehyde (2%) at

room temperature.

 Hydrophobic pen (Vector Laboratories H-4000)

 1% Virkon (Fisher Scientific) or bleach

 Glass pipettes

 Pencil

 Protein containing medium: RPMI 1640 medium (Sigma, R8758-500ML)+10%FBS

 Cells under study in a single cell suspension of 0.5 x 10 6 cells/ml in protein containing medium
(e.g. RPMI1640 containing 10% foetal calf serum, Sigma)

Procedure

 Label the slides indicating the cell line used with a pencil.

 Insert the slide into the slideclip (holder) ensuring that the frosted upper part of the slide is face
up. Put the filter card (with the absorbent surface touching the slide) and position the
cytofunnel next to the filter paper making sure that all the holes match up. Fasten the holder
(see Image 2).

 Place the mounted holder in the corresponding recess in the Cytospin. A maximum of twelve
slides can be centrifuged at once. Remember that the Cytospin must always be balanced.

52 | Page
>Prepare a cell suspension of not more than 0.5 x 10 6 cells/ml in the protein-containing
medium. Note that the optimal concentration of cells may have to be determined for each cell
line.

> Gently pipette the cell suspension into the cytofunnel. We recommend putting two and
three drops (corresponding to 100–200µl of cell suspension, respectively) in different
cytofunnels to establish the optimal volume necessary to result in a good monolayer of cells
with no overlapping of cells or cell clumps. The loading volume should be optimized for each
cell line used.

>Close the Cytospin lid and centrifuge at 1000 × g for 5 min.

>Remove the slides, filter cards, and cytofunnels from the centrifuge. Be careful not to move
the filter paper on the slide and so damage/smudge the cell preparation.

>If desired, then the glass slides and filter cards can be removed from the cytofunnel, turned
upside down before being placed with the cytofunnel and returned to the Cytospin. Cells can
then be added and centrifuged to produce a slide with two cell preparations.

>Place each slide on a slide tray with the cell preparation uppermost for at least 2h at room
temperature. We recommend leaving the slides overnight at room temperature to dry.

>Put the used funnels in a bucket of 1% Virkon for 30 minutes (alternative: bleach), rinse,
wash and rinse in distilled water. Dry them before any further use.

>Fix the air-dried slides for 10 min in acetone at room temperature (alternatives fixatives
include 10 min in 2% paraformaldehyde or 10 min in 100% methanol). The fixation method
should be optimized for each experiment.

>Let the slides dry for 2h, wrap in foil or put into sealed boxes and store at -20°C until use.

>Allow the slides come up to room temperature before unwrapping or removing them from
sealed boxes. This prevents problems with condensation on the slides.

>Mark the position of the cells on the slide with a hydrophobic marker. The slides are now
ready for use.

53 | Page
 Thermo Scientifi Cytospin Cytocentrifuge.

Preparation of a slide in cytospin holder for running in a Cytospin centrifuge.

(a) Cytospin preparation stained with haematoxylin to show the morphology of NPM-ALK COS
transfectants.
(b) Immunoperoxidase labeling of NPM-ALK COS transfected cells stained with anti-ALK
antibody.

54 | Page
Cell count:
With regard to the cytological parameters, high pleocytosis (>100 cells/mm 3) associated with
predominant polynuclear neutrophils (>80%) is a standard finding. However, these
parameters are often misleading, with an absence of pleocytosis (10% of cases) or
predominant polynuclears. This is seen in the van de Beek et al set, where out of 645 patients
with BM, 47 (7%) patients did not have pleocytosis.In the Durand set, which included 296
patients with Bacterial Meningitis, 10% did not have pleocytosis, and 20% did not have
predominant polynuclears.Furthermore, these two parameters have low discriminatory power
between Bacterial Meningitis and Viral Meningitis. This is shown in the study by Spanos et
al, where 205 episodes of Viral Meningitis were compared to 217 episodes of Bacterial
Meningitis, and CSF with predominant polynuclears was identified in only 40%.The
polynuclear discrimination threshold between viral and Bacterial Meningitis was 1,180, but
with a major overlap between the two groups in the median number (interquartile [IQ]) of
leukocytes/mm3 in CSF (VM 100 IQ [37–250] and BM 1,195 [330–4,400]). Finally, in
different published series of strictly pediatric populations, no pleyocytosis was found in ~15%
of patients with Bacterial Meningitis.

While meningococcal infection is relatively rare, affecting approximately 2,500 people each
year in the United States, it is a devastating disease. It kills 7 to 15 percent of those who
acquire the infection, and often causes permanent complications for survivors, such as brain
damage and hearing loss. Many patients also require amputation of limbs because the disease
can cause severe tissue damage.

55 | Page
Neutrophils are the most abundant type of white blood cells, acting as first responders to help fight infection, particularly bacterial infections.

Neutrophils are the most abundant type of white blood cells, acting as first responders to help
fight infection, particularly bacterial infections. Mature neutrophil cells are called segmented
neutrophils, and immature cells are known as band neutrophils.

Neubauer chamber

56 | Page
 General features of the Neubauer’s chamber

Neubauer’s chamber is a thick glass plate with the size of a glass slide (30x70x4mm). The
counting region consists of two square shaped ruled areas. There are depressions or the moats
on either side or in between the areas on which the squares are marked thus giving an “H”
shape.The ruled area is 3mm2 divided into 9 large squares each with a 1 mm2 area. The large
central square (which can be seen in its entirely with the 10X objective), is divided into 25
medium squares with double or triple lines.Each of these 25 squares are is again divided
into 16 small squares with single lines, so that each of the smallest squares has an area of
1/400 mm2.

57 | Page
The glass cover is a squared glass of width 22 mm. The glass cover is placed on the top of the
Neubauer chamber, covering the central area. The ruled area is 0.1 mm lower than the rest of
the chamber.

So that when a cover slip is kept on the counting region, there is a gap of 0.1 mm (1/10mm)
between the cover slip and the ruled area.

Cell counting areas in Neubauer chamber

The counting can be done either in the central large square or in the corner squares, depending
on the size of the cells under study.

WBC Counting Area

The four large sqaures placed at the corners are used for white blood cell count. Since their
concentration is lower than red blood cells a larger area is required to perform the cell count.

58 | Page
RBC Counting Area
The large center square is used for RBC counts. As already stated, this area is subdivided into 25
medium sqaures, which in turn are each divided into 16 squares.Of the 25 medium sqaures, only
the four corner squares and the center square within the large center square are used to
perform RBC counts.

Platelet Counting Area

The large center square is used to count platelets. Platelets in all 25 squares within the large
center square are counted.

Using the Neubauer chamber

1. Sample Preparation

Depending on the type of sample, a preparation of a dilution with a suitable concentration

should be prepared for cell counting. Typically, the concentration range for a cell count with
Neubauer chamber is between 250,000 cells / ml and 2.5 million cells / ml.

An appropriate dilution of the mixture with regard to the number of cells to be counted should
be used. If the sample is not diluted enough, the cells will be too crowded and difficult to
count.If it is too dilute, the sample size will not be enough to make strong inferences about the
concentration in the original mixture.

2. Preparing Neubauer Chamber

Clean the Neubauer chamber and the cover slip with 70% EtOH. Put the glass cover on the
Neubauer chamber central area. Use a flat surface to place the chamber, like a table or a
workbench.

3. Introducing the sample into the Neubauer chamber

With a pipette, carefully draw up around 20 ml of the cell mixture (dilution). Place the pipette
tip against the edge of the coverglass and slowly expel the liquid until the counting chamber is
full.

Capillary action will help to ensure that the counting chamber is full, but care should be taken
not to overfill the chamber. A volume of 10 ml is sufficient to fill one counting chamber.

59 | Page
4. Microscope focusing and Cell Counting

>Place the Neubauer chamber on the microscope stage. Using the 10X objective, focus both
onto the grid pattern and the cell particles.

>As 10X is appropriate for WBC counting, count the total number of cells found in 4 large
corner squares.
To count the RBCs and Platelets, the microscope must be switched to 40X objective. Count
the cells in the respective areas as stated early.

>Write down the amount of cells counted

If cells are touching the 4 perimeter sides of a corner square, only count cells on 2 sides,
either the 2 outer sides or 2 inner sides.

60 | Page
Calculating the cell counts
The total number of cells per microliter of sample can be calculated from the number of cell
counted and area counted. This is because the ruled areas of the chamber contain an exact
volume of diluted sample.Since only a small volume of diluted sample is counted, a general
formula must be used to convert the count into the number of cells/microliter.

The dilution factor used in the formula is determined by the blood dilution used in the cell count.
The depth used in the formula is always 0.1. The area counted will vary for each type of cell count
and is calculated using the dimensions of the ruled area.

Example :

Lets calculate total WBC count by using Neubauer counting chamber.

>Number of cells counted = N = 150 (suppose)

>Area Counted = 1 mm2 x 4 = 4 mm2 (area of four large corner squares)

>Depth = 1/10 mm

>Dilution = 1:20

>Hence WBC/Cubic mm of Whole Blood = N x 50 = 150 x 50 = 7,500

61 | Page
CHAPTER 5
62 | Page
 CSF CHEMISTRIES

CSF GLUCOSE
The normal glucose level in CSF varies from 2.6 mmol/L to 4.2 mmol/L and for glycemia
between 3.9 mmol/L and 6.7 mmol/L, that is, a CSF:serum glucose ratio in the region of 0.6.
When Bacterial Meningitis is present, the CSF glucose level falls <2.5 mmol/L with a
CSF:serum ratio of <0.4. Average levels described in Bacterial Meningitis sets in the
literature for these two parameters are in the region of 1–2 mmol/L for CSF glucose and 0.2–
0.4 mmol/L for its CSF:serum ratio. However, the CSF glucose level performance remains
inadequate for diagnosing Bacterial Meningitis . For example, in the study by Durand et al,
only 50% of patients had a CSF glucose level of <2.2 mmol/L.Furthermore, other Bacterial
Meningitis sets have demonstrated the normality of this parameter in 25%–40% of
patients. With a threshold of <0.4, the CSF:serum glucose ratio.Appears to be more
discriminatory for diagnosing Bacterial Meningitis than CSF glucose. This superiority was
clearly demonstrated in the study by Viallon et al by comparing the ROC curves of these two
parameters.Data published relating to children have shown similar result. For this marker, it is
preferable to select, as an indicator of Bacterial Meningitis , a threshold of <0.4 for the
CSF:serum glucose ratio rather than CSF glucose. Where there is associated hyperglycemia, it

63 | Page
is preferable to select the absolute value of CSF glucose with a threshold of <2.2
mmol/L.Glucose levels in CSF normally reflect the levels seen in the blood. There may be a
2–4 hour lag in the CSF level when compared to the blood level.Whilst not diagnostic, low
glucose levels, as compared to plasma levels, are seen in bacterial meningitis, cryptococcal
meningitis, malignant involvement of the meninges and sarcoidosis.Glucose levels are usually
normal in viral infections of the CNS.

Sample requirement

1 mL of CSF is approximately equal to 25 drops from the Luer connector of the

needle.Results on bloodstained samples will be unreliable.

CSF volume: Minimum 0.25 mL (6 drops)

Sample tube: 2mLfluoride-oxalate tube (grey top).

CSF glucose is normally >70% of the plasma glucose levels.

Turnaround times

The assays are run throughout the day and night. The in-lab turnaround time is less than 24
hours. The test can be ordered as an urgent request.Results should normally be available
within 1 hour of sample receipt for the acute unit, or within 24 hours for samples received
from outside the acute units.

CSF PROTEIN

CSF protein concentration increases in BM, with average levels between 1 g/L and 5 g/L. The
sensitivity (Se) and specificity (Sp) of this marker for the diagnosis of Bacterial Meningitis
were examined for thresholds ranging from 0.5 g/L to 2 g/L. The Se values varied from 60%
to 86% and from 60% to 100% for the Specificity . In the study by Viallon et al, which used
receiver operating characteristics (ROC) curves to compare the discriminatory power of the
various biochemical parameters of CSF, CSF protein concentration was one of the least
relevant markers. In this prospective study, 32 patients had Bacterial Meningitis , 90 had

64 | Page
 Viral Meningitis , and 57 patients were in the control group. At the 1.88 g/L threshold,
Senstivity and Specificity for Bacterial Meningitis diagnosis were 84% and 91%,
respectively.

Finally, in the various sets, 1%–10% of patients with BM had normal CSF protein
concentration, while for ~5%–25% of patients with VM, this level was >1 g/L.The spinal
fluid normally contains very little protein since serum proteins are large molecules that do not
cross the blood-brain barrier. Most of the protein that is normally present is albumin.CSF
protein concentration may rise due to 2 factors: either an increased permeability of the blood
brain barrier allowing more protein and higher molecular weight proteins to enter the CSF or
proteins may be synthesised within the cerebrospinal canal by inflammatory or other invading
cells.Mild protein elevation may be caused by viral meningitis, neurosyphilis, subdural
haematoma, cerebral thrombosis, brain tumour, multiple sclerosis (rarely >1.00 g/L)Moderate
or pronounced elevation may be caused by acute bacterial meningitis, tuberculous meningitis,
spinal cord tumour, cerebral haemorrhage, Guillain-Barre syndrome.When CSF protein levels
are low it can indicate rapid CSF production.

Sample requirements

1mL of CSF is approximately equal to 25 drops from the Luer connector of the needle.Results
on bloodstained samples will be unreliable.

 CSF volume: Minimum 0.25 mL (6 drops)

 Sample tube: PlainUniversal container (tubes containing gel or anticoagulant are not suitable for
analysis of CSF protein).

65 | Page
Reference ranges

CSF protein

Age Refrence range (mg/dL)

Up to 1 day old 40-120

1 day- 1 month 20-80

>1 monyh old 15-40

Table.9

66 | Page
CHAPTER 6
RESULT

67 | Page
In our study, data from the Pathology Department of Medicover Hospital (Hyderabad) was gathered for the
examination of cell count. The dataset comprises information on 203 patients, segmented by various age
groups and gender. Within this cohort, 38 patients exhibited a high neutrophil count. The study spanned a
period of six months, from April 2023 to November 2023.

Total no. of Sample 203

Bacterial meningitis cases 38

Incidence 18.7%

Table.10

Incidence of bacterial meningitis

Bacterial Meningitis
18.7%

Normal cases
80.3%

68 | Page
 Incidence of Bacterial Meningitis
CSF sample Bacterial meningitis

203

38

CSF Sample Bacterial Meningitis

In our study, the collected data was stratified into two age groups: 0-18 and 19 & above. The
total number of Bacterial Meningitis cases was 38, with 9 cases (18.7%) identified in the 0-18
age group and 29 cases (76.3%) in the 19 & above age group. Refer to Table 13 for details
Age wise Distribution of Meningitis cases

Age No. of cases Incidence

0-18 9 18.7%

19 & above 29 76.3%

Total 38 100%

Table.11

69 | Page
 Age Wise Distribution

24%

age 0-18
age19 & above

76%

The data collected for this study from MEDICOVER HOSPITAL has been categorized
according to gender, specifically male and female. Among the total 38 suspected cases of
Bacterial Meningitis, 20 (52%) were male, while 18 (47.3%) were female. The data indicates
a higher incidence in males compared to females, as illustrated in Table 14.
Gender Wise Distribution

Gender No. of cases Incidence

Male 20 53%
Female 18 47%

Total 38 100%

Table.12

70 | Page
 Gender Wise Distribution

MALE
47% FEMALE
53%

Subsequently, the cases of Bacterial Meningitis were categorized into two groups based on
neutrophil counts. Of the total cases, 23 (60.53%) displayed a neutrophil count between 10%
and 40%, while 15 (39.47%) exhibited a neutrophil count exceeding 40%. Higher neutrophil
counts (>40%) were associated with an increased likelihood of Bacterial Meningitis, as
illustrated in Table 15.
Distribution of suspected cases of B.M in two ranges on the basis of neutrophil count 10-40%, >40% as shown
in following table

Neutrophil No.of cases %

Count
10-40% 23 60.53
>40% 15 39.47

Table.13

71 | Page
 Distribution based on Neutrophil
Count

10-40% Neutrophil count

39% >40% Neutrophil count

61%

72 | Page
Biochemistry analysis of Data
In our study, we investigated 38 cases of Bacterial Meningitis. Out of these, 23 cases
underwent analysis of Biochemistry parameters, including glucose and protein. Among the
analyzed cases, 14 (60.86%) showed high protein levels, with 10 being male and 4 female.
Furthermore, 6(26.08%) cases exhibited low glucose concentration, with 5 being male and 1
female.
Total High protein Low glucose
level(%) conc.(%)

23(100%) (60.86% 26.08%

Table.14

Chemistries
Low glucose
conc.
14%

Total
High protein level
Low glucose conc.

High protein level Normal case

33% 53%

73 | Page
 Review of Literature

Our study, based on data from 203 patients at MEDICOVER HOSPITAL Hyderabad over a
6-month period, indicates a higher incidence of bacterial meningitis in males compared to
females. Out of 203 patients, 52% were male (n=20), and 48% were female (n=18).A similar
trend is seen in other studies. For example, a study on bacterial meningitis characteristics in
Bangladesh during 2003-2004 found that out of 1841 cases, 70.99% were males (n=1307).
Additionally, during a meningococcal epidemic in Gondar in 2001-2002, out of 1619
probable cases, 59.29% were males (n=960). Comparing these studies with our findings, it
appears that the incidence of bacterial meningitis tends to be higher in males than females.

Comparison of Our study with other studies

Our study 18.7%

Emily et al(2004) 70.99%
Getahun et al(2002) 59.29%
Table.15

A study conducted between 2007 and 2011 in two hospitals in Ethiopia, a country within the
meningitis belt of Sub-Saharan Africa, revealed significant occurrences of bacterial
meningitis. Past decades in Ethiopia have seen several meningitis epidemics. A specific study
at Gondar University Hospital found a higher percentage of bacterial meningitis cases in
males compared to females, with males accounting for (63%) and females for (37%).In our
study, we observed a similar trend, noting that (53%)of cases were in males and (47%)in
females. This indicates a higher occurrence in males compared to the previously reported
percentage for females. Another study conducted at Awassa Referral Hospital from 2009 to
2011 revealed that (65.7%) of bacterial meningitis cases occurred in males, whereas females
constituted (34.3%)of the cases. This indicated a higher prevalence of bacterial meningitis in
males in that study.Similarly, our study corroborates these findings, showing a higher
predominance of bacterial meningitis in males compared to females. The consistency in these
observations across studies underscores the potential gender-related patterns in the occurrence
of bacterial meningitis.
The higher male-to-female ratio observed at both study sites may be influenced by various
factors. Based on existing literature and the results of the studies mentioned, bacterial
meningitis-causing organisms appear to show susceptibility patterns that result in a higher
prevalence among males. This tendency could be magnified in settings where males have
better access to healthcare facilities, as assumed in this study.Social and cultural factors might
contribute to easier healthcare access for males. Males may encounter fewer obstacles in
reaching healthcare facilities, while females could face challenges, depending more on males
for transportation to more distant healthcare centers. Barriers to female access to hospitals
may also include limited financial resources and additional family responsibilities, such as
childcare duties. These factors collectively contribute to the observed gender disparity in
bacterial meningitis cases at the study sites.

74 | Page
In our study, we categorized the data into two age groups: 0-18 years and 19 years and above.
We noted that 24% of bacterial meningitis cases were in the 0-18 age group, while 76% were
in the 19 years and above age group. This differs from the findings at Gondar University
Hospital, where the data suggested a higher percentage of bacterial meningitis cases in
neonates and adolescents (75%), with a lower percentage (25%) in those aged 19 and above.
The variation in our study's age distribution compared to the Gondar University Hospital data
may be attributed to differences in healthcare facilities, geographic regions, cultural factors,
and financial conditions specific to each region. These factors can significantly influence the
prevalence of bacterial meningitis across age groups in different populations.further we
categorized bacterial meningitis cases into two groups based on neutrophil count. There were
23 patients with a neutrophil count ranging from 10% to 40%, and 15 patients with a
neutrophil count exceeding 40%. Notably, patients with over 40% neutrophil count have a
significantly higher likelihood of having bacterial meningitis. This is crucial because various
studies consistently indicate that bacterial meningitis is associated with elevated neutrophil
counts. Distinguishing neutrophil counts is considered one of the most important factors for
differentiating bacterial meningitis from other types of meningitis.
In our detailed study of 38 cases of Bacterial Meningitis, we specifically looked closely at 23
cases to understand the Biochemistry parameters, focusing on glucose and protein levels. In
this group, 60.86% of cases had higher protein levels, with 10 cases in males and 4 in females.
Also, 26.08% had lower glucose levels, involving 5 males and 1 female. This thorough
examination of these Biochemistry details adds useful information to what is already known
about Bacterial Meningitis.
When diagnosing bacterial meningitis, analyzing the cerebrospinal fluid (CSF) is crucial.
Looking at CSF protein levels and CSF glucose can provide important clues. High CSF
protein levels, as we found in our study, often indicate the presence of bacterial meningitis.
On the other hand, low CSF glucose levels, also observed in our cases, can be another sign of
this infection. This information contributes to the broader understanding of how we can
diagnose bacterial meningitis.

75 | Page
 Discussion

Our study, conducted at Medicover Hospital Hyderabad, focused on 203 patients over a six-
month period, examining cell counts and categorizing data by age and gender. Among the
patients, 38 showed a high neutrophil count, emphasizing a potential link to Bacterial
Meningitis.
In our age-based analysis, we observed a higher prevalence of Bacterial Meningitis in
individuals aged 19 and above (76.3%), contrasting with Gondar University Hospital's
findings. Gender-wise, our data indicated a notable male predominance (52%) compared to
females (47.3%), aligning with other studies in Ethiopia and Awassa Referral Hospital.
The consistent male-to-female ratio across studies implies a potential gender-related pattern in
Bacterial Meningitis incidence. This might be influenced by healthcare access, social factors,
and cultural nuances, contributing to the observed disparities.
Further stratification by neutrophil counts revealed a significant association between counts
exceeding 40% and Bacterial Meningitis, aligning with established literature. This
underscores the importance of neutrophil count in distinguishing bacterial meningitis from
other types.
We looked at 38 cases of Bacterial Meningitis, focusing on 23 in detail. We found that
60.86% of these cases had high protein levels. More males (10) than females (4) were affected
by this.Also, 26.08% of cases had low glucose levels. Out of these, 5 were males, and 1 was
female. This matches what we know about Bacterial Meningitis and its connection to low
glucose levels.When we looked at age groups, we found 24% of cases were in people aged 0-
18 years, and 76% were in those 19 years and above. This is different from another study at
Gondar University Hospital, showing that diseases can vary between regions and groups of
people.Our study shows that Bacterial Meningitis is not the same for everyone. Factors like
where people live, their culture, and how they access healthcare can change how the disease
looks. This is important to understand for predicting and treating Bacterial Meningitis in the
future.
In considering etiology, our study contributes to the broader understanding of the causes of
Bacterial Meningitis, particularly in regions like India, where serogroup A is the primary
culprit. The study's findings suggest a potential burden of the disease among adolescents and
adults, calling attention to the need for targeted preventive measures.
The epidemiological aspect, as reviewed in 32 publications, including case reports,
emphasizes the significant global burden of meningococcal disease. In India, limited
surveillance and healthcare access present challenges in accurate data reporting, potentially
leading to underestimation.

76 | Page
 CONCLUSION
Studying the cells and chemical components in the cerebrospinal fluid (CSF) has proven
crucial in diagnosing and managing bacterial meningitis. The analysis of CSF cell count and
chemistry provides valuable insights into the presence and severity of the infection. It helps in
determining appropriate treatment and monitoring the progression of the disease.continued
research in this area is essential for further improving the accuracy and effectiveness of
diagnosing and treating bacterial meningitis.
Our study at Medicover Hospital in Hyderabad identified 38 cases of Bacterial Meningitis
among 203 patients. Trends showed a higher prevalence in individuals aged 19 and above
(76.3%) and a consistent male predominance (52%). The diagnostic importance of neutrophil
counts exceeding 40% was underscored, along with associations with high protein (60.86%)
and low glucose levels (26.08%).
Disease prevalence varied with age, emphasizing the importance of tailored approaches. Our
study highlighted serogroup A as a significant cause, urging targeted preventive measures for
adolescents and adults.
Reviewing 32 publications revealed challenges in accurate reporting, urging enhanced
surveillance and healthcare access in India.

77 | Page
 Refrence
1).A history of bacterial meningitis
https://www.sciencedirect.com/science/article/pii/S0072975208021283
2).A history of acute bacterial meningitis
https://www.tandfonline.com/doi/abs/10.1080/0964704X.2011.595653?
casa_token=8Pq4oOxvrhcAAAAA:v7aSElKwr4Yh5Ioq4V38XvIg8maadN7YZ3W_JCb1yF
HYrKQEl4vIy9mRR8YICS5oC4o1GwpWhqLU

3).A history of bacterial meningitis from antiquity to modern times

https://www.cabidigitallibrary.org/doi/pdf/10.1079/9781780641621.0000#page=14

4).The history of bacterial meningitis

https://europepmc.org/article/med/15179458

5).Bacterial meningitis—1978
https://www.sciencedirect.com/science/article/pii/S0011502978800030

6).Length of prediagnostic history related to the course and sequelae of childhood bacterial
meningitis
https://journals.lww.com/pidj/abstract/1993/03000/
length_of_prediagnostic_history_related_to_the.2.aspx

7).Continual raving: a history of meningitis and the people who conquered it

https://books.google.com/books?
hl=en&lr=&id=mkK1DwAAQBAJ&oi=fnd&pg=PP1&dq=history+of+bacterial+meningitis&
ots=oOyG9Zvlm2&sig=Tcf0S8PngLOJyafnZbcJBq2-Y-M

8).Global etiology of bacterial meningitis: a systematic review and meta-analysis

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.019877

9).Epidemiology, etiology, pathogenesis, and diagnosis of recurrent bacterial meningitis

https://journals.asm.org/doi/abs/10.1128/cmr.00009-08

78 | Page
10).Etiology and mortality of bacterial meningitis in northeastern Brazil
https://academic.oup.com/cid/article-abstract/12/1/128/317903

11).A hospital-based study on etiology and prognosis of bacterial meningitis in adults

https://www.nature.com/articles/s41598-021-85382-4

12).Acute bacterial meningitis in the intensive care unit and risk factors for adverse clinical
outcomes: retrospective study
https://www.sciencedirect.com/science/article/pii/S0883944113004668

13).Incidence, etiology, and outcome of bacterial meningitis in infants aged< 90 days in the
United kingdom and Republic of Ireland: prospective, enhanced, national …
https://academic.oup.com/cid/article-abstract/59/10/e150/2895279

14).Bacterial meningitis in the United States, 1998–2007

https://www.nejm.org/doi/full/10.1056/NEJMoa1005384

15).oxford academic =pathophysiology of bacterial meningitis: mechanism of neuronal injury

https://academic.oup.com/jid/article/186/Supplement_2/S225/2191544

16).annual review=pathogenesis and pathophysiology of bacterial meningitis

https://www.annualreviews.org/doi/abs/10.1146/annurev.me.44.020193.000535

17).index Copernicus=pathogenesis and pathophysiology of acute bacterial meningitis

https://journals.indexcopernicus.com/api/file/viewByFileId/1859734

18).infectious disease clinic =pathogenesis of bacterial meningitis

https://www.id.theclinics.com/article/S0891-5520(05)70093-3/pdf

19).research gate=pathophysiology of bacterial meningitis

https://www.researchgate.net/figure/Pathophysiology-of-bacterial-meningitis-The-
pathophysiology-of-acute-meningitis-involves_fig1_14260805

20). Bmc medicine= Clinical features of bacterial among hospitalised

79 | Page
https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-021-01998-3

21). The new England journal of medicine= Clinical features and progonstic factor in
bacterial meningitis
https://www.nejm.org/doi/full/10.1056/nejmoa040845

22). Dove Medical press=Main clinical and laboratory of children with bacterial meningitis
https://www.dovepress.com/main-clinical-and-laboratory-features-of-children-with-bacterial-
menin-peer-reviewed-fulltext-article-PHMT

23). Infection disease clinics clinical presentation diagnostic and prognostic factor of
bacterial meningitis
https://www.id.theclinics.com/article/S0891-5520(05)70095-7/fulltext
24). Wiley online library=The clinical p…

25).Bmc medicine= Clinical features of bacterial among hospitalised

https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-021-01998-3

26). The new England journal of medicine= Clinical features and progonstic factor in
bacterial meningitis
https://www.nejm.org/doi/full/10.1056/nejmoa040845

27). Dove Medical press=Main clinical and laboratory of children with bacterial meningitis
https://www.dovepress.com/main-clinical-and-laboratory-features-of-children-with-bacterial-
menin-peer-reviewed-fulltext-article-PHMT

28). Infection disease clinics clinical presentation diagnostic and prognostic factor of
bacterial meningitis
https://www.id.theclinics.com/article/S0891-5520(05)70095-7/fulltext

29). Wiley online library=The clinical p…

80 | Page
30-national institute of health=laboratory diagnosis of bacterial meningitis
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC358232/

31).wikidoc=bacterial meningitis laboratory findings

https://www.wikidoc.org/index.php/Bacterial_meningitis_laboratory_findings

32).research gate=laboratory diagnosis of bacterial meningitis: usefulness of various test for

the determination of the etiological agent
https://www.researchgate.net/publication/24365382_Laboratory_diagnosis_of_bacterial_meni
ngitis_usefulness_of_various_tests_for_the_determination_of_the_etiological_agent

33).science direct =laboratory diagnosis of bacterial meningitis by direct detection

https://www.sciencedirect.com/science/article/abs/pii/S0890850821000931

34).Science direct
35).world health organization=laboratory method for diagnosis of meningitis
http://www.who.int/emc
36).Asm journals=laboratory diagnosis of bacterial meningitis
https://journals.asm.org/doi/10.1128/cmr.5.2.130

37).oxford academic=laboratory diagnosis of bacterial meningitis

https://doi.org/10.1016/0035-9203(91)90332-S

38). World health organization

39).Author=Tyler J. Runde1; Fatima Anjum2; John W.
Hafner3.https://www.ncbi.nlm.nih.gov/books/NBK470351/#:~:text=Bacterial%20meningitis
%20was%20previously%20more,median%20age%20of%20patients%20infected

40).Author=Ronald Gold MD, MPH

https://www.sciencedirect.com/science/article/abs/pii/S0891552005700921

41).Author=Matthijs C. Brouwer,1 Allan R. Tunkel,2 and Diederik van de

Beek1,*https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2901656/
42): Diederik L H Koelman, Merel N van Kassel, Merijn W Bijlsma, Matthijs C Brouwer,
Diederik van de Beek, Arie van der Ende Author
Notes=https://academic.oup.com/cid/article/73/5/e1099/6008501
Rodrigo Lopez Castelblanco, MD MinJae Lee, PhD

81 | Page
43)Dr Rodrigo Hasbun,
MD=https://www.thelancet.com/article/S1473-3099(14)70805-9/fulltext
H M Fortnum, A C Davis=https://adc.bmj.com/content/68/6/763
44): Rodrigo Hasbun, MD, MPH, FIDSA==https://medilib.ir/uptodate/show/1294
45.) Treatment. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3002609/ author Olaf
Hoffman, (2009)Department of Neurology, Charité – Universitaetsmedizin Berlin, Berlin,
Germany;

46.)D.O. — https://www.medicalnewstoday.com/articles/9276By Anna Smith Haghighi —

Updated on February 16, 2023
47) (https://pubmed.ncbi.nlm.nih.gov/19706918/= Etiologies of bacterial meningitis in
Bangladesh: results from a hospital-based study).
48) ETIOLOGY OF BACTERIAL MENINGITIS IN ETHIOPIA, 2007 – 2011: A RETROSPECTIVE
STUDY,core.ac.uk

82 | Page
 THANK
YOU!

83 | Page