I apologize at the outset for my seemingly incessant ramblings. I think
there are three key questions.
1. Can one get pyogenic meningitis with minimal CSF
Bacterial meningitis has been well described with minimal CSF
inflammation/pleiocytosis. If you review Steihm and Damrosch's poor
prognostic criteria for meningococcal meningitis it is one of them. These
kids however are very sick with overwhelming meningitis. The other setting
where this may occur is a low grade meningitis with say Staph epidermidis,
as may occur in a patient with a shunt/immunocompromized state or if the
patient has preexisting severe peripheral leukopenia. I suspect all these
pre-morbid conditions could be clarified on history.
2. The other question is whether one accepts that the rate of complications
of pyogenic and non pyogenic (assume "viral" for now) are different?
I disagree with Dr. Newdow on this. Most viral meningitides are self
limiting without any major complications in an immunocompetent host.
Compare this with the rate of complications with acute bacterial
meningitis.The first few days however, of an acute pyogenic(bacterial)
meningitis are usually when the most devastating complications are seen.
Subsequently there is the risk of deafness ( which may be of the order of
30-40 %, for pneumococcal meningitis, depending on
who you read) and hydrocephalus. It is therefore not surprising, that we
have to be very very aggressive with the management of these cases with IV
abx and close vigilance. I cannot imagine how this could be achieved as an
outpatient?? And I am not aware of any data supporting this outpatient
strategy. Try getting a study in pediatric patients, with this question,
through an IRB!!!
It is also true, as mentioned, that the "aseptics" can worsen and have the
complications like meningoencephalitis BUT not as far I know, at a requency
comparable with the other pyogenic complications that one sees with
I would also agree with the discussants and add that "aseptic" is not the
same as "viral". One has to keep TB, Lyme's disease, cryptococcoal dis (in
the SW region especially), brain abscess, neoplasia etc...in mind.
3. How RISK AVERSE ONE IS?
I am comfortable having my own child sent home with Dr.Kates patient's
CSF picture and watching her at home off antibiotics to be reseen in 12-24
THIS DEBATE IS CERTAINLY NOT A $$$ ISSUE. I think it is one of the many
fascinating aspects of the art of medicine.
I would NOT fault anyone for admitting everybody with any level of
pleiocytosis (11 cells or 100) in the CSF and starting them on antibiotics
BECAUSE the GOLD STANDARD IS STILL CULTURE!! Let me now pose this
hypothetical question to someone who prefers this strategy. I was reading
the July issue of Journal of Pediatrics where a fatal case of immune
mediated hemolysis was reported after one dose of Ceftriaxone. This is
probably the third or fourth episode described in the literature. Certainly
one could make a case for not using this antibiotic because of this small
risk. Would you then not use this in the future?
Would welcome further thoughts............
"We care for wee folks"
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