Berliner Elihay, Bar Meir Maskit, Megged Orli
Department of Pediatrics and Infectious Diseases Unit, Shaare Zedek Medical Center, Jerusalem.
Harefuah. 2012 Aug;151(8):472-5, 497.
Bacterial meningitis is a life threatening disease. Most patients will experience only one episode throughout life. Children who experience bacterial meningitis more than once, require further immunologic or anatomic evaluation. We report a 9 year old child with five episodes of bacterial meningitis due to a congenital defect of the skull base. A two and a half year old boy first presented to our medical center with pneumococcal meningitis. He was treated with antibiotics and fully recovered. Two months later he presented again with a similar clinical picture. Streptococcus pneumoniae grew in cerebrospinal fluid (CSF) culture. CT scan and later MRI of the brain revealed a defect in the anterior middle fossa floor, with protrusion of brain tissue into the sphenoidal sinus. Corrective surgery was recommended but the parents refused. Three months later, a third episode of pneumococcal meningitis occurred. The child again recovered with antibiotics and this time corrective surgery was performed. Five years later, the boy presented once again with clinical signs and symptoms consistent with bacterial meningitis. CSF culture was positive, but the final identification of the bacteria was conducted by broad spectrum 16S ribosomal RNA PCR (16S rRNA PCR) which revealed a sequence of Neisseria lactamica. CT and MRI showed recurrence of the skull base defect with encephalocele in the sphenoid sinus. The parents again refused neurosurgical intervention. A year later the patient presented with bacterial meningitis. CSF culture obtained after initiation of antibiotics was negative, but actinobacillus was identified in the CSF by 16S rRNA PCR. The patient is scheduled for neurosurgical intervention. In patients with recurrent bacterial meningitis caused by organisms colonizing the oropharynx or nasopharynx, an anatomical defect should be carefully sought and surgically repaired.
细菌性脑膜炎是一种危及生命的疾病。大多数患者一生中只会经历一次发作。经历过不止一次细菌性脑膜炎的儿童需要进一步进行免疫学或解剖学评估。我们报告一名9岁儿童因先天性颅底缺陷而发生了五次细菌性脑膜炎发作。一名两岁半的男孩首次因肺炎球菌性脑膜炎就诊于我们的医疗中心。他接受了抗生素治疗并完全康复。两个月后，他再次出现类似的临床症状。脑脊液（CSF）培养中培养出肺炎链球菌。脑部CT扫描及随后的MRI显示前中颅窝底部有缺损，脑组织突入蝶窦。建议进行矫正手术，但家长拒绝了。三个月后，发生了第三次肺炎球菌性脑膜炎发作。孩子再次通过抗生素治疗康复，这次进行了矫正手术。五年后，男孩再次出现与细菌性脑膜炎相符的临床体征和症状。脑脊液培养呈阳性，但最终通过广谱16S核糖体RNA聚合酶链反应（16S rRNA PCR）对细菌进行鉴定，结果显示为乳酸奈瑟菌。CT和MRI显示颅底缺损复发，蝶窦内有脑膨出。家长再次拒绝神经外科干预。一年后，患者出现细菌性脑膜炎。开始使用抗生素后获得的脑脊液培养结果为阴性，但通过16S rRNA PCR在脑脊液中鉴定出放线杆菌。该患者已安排进行神经外科干预。对于由定植于口咽或鼻咽部的微生物引起的复发性细菌性脑膜炎患者，应仔细寻找解剖学缺陷并进行手术修复。
