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Brief Reports Indian Pediatrics 2002; 39:663-667 |
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A Clinical Study of Chronic Morbidity in Children Following Pyogenic Meningitis |
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Ciji N. George
Bacterial meningitis is one of the most serious infections in children associated with a high rate of acute complications, mortality and risk of chronic morbidity. The risk of infection is greatest among infants. 95% of cases occur under 5 years of age(1). The bacteria that cause meningitis in children include Gram-negative bacteria causing neonatal meningitis, Haemophilus influenzae type b, Streptococcus pneumoniae and Nisseriae meningitides causing meningitis in infants and older children. Severe neurodevelopmental sequelae occur in 10-20% of patients recovering from bacterial meningitis and as many as 50% may have some neurobehavioral morbidity(1). The most common neurologic sequelae include hearing impairment, behavioral problems and learning disabilities. Poor prognostic indicators include age at onset of illness less than six months, occurrence of seizures more than four days into therapy, acute complications like coma and focal neurological signs, low CSF glucose and more than 106 CFU bacteria/ml in the CSF(1). Numerous studies have been conducted to analyze the sequelae of bacterial meningitis in children. Very few studies have been reported from developing countries(2-6). The present study, which was conducted during a period of 1 year from August 1999 to July 2000, was designed to analyze the pattern of chronic sequelae in children following pyogenic meningitis and to find out any statistical relationship with certain factors at acute presentation. Subjects and Methods A total number of 252 cases were registered as pyogenic meningitis, including 31 cases of neonatal meningitis, during the years 1993, 1994 and 1995, in the Institute of Child Health, Medical College, Kottayam. One hundred and sixty two cases were included for morbidity analysis, of whom only 100 responded which included 9 cases of neonatal meningitis also. Thus the total number of cases included in this study was one hundred. The included cases were aged between 0 to 5 years at the time of onset of illness. The diagnosis of pyogenic meningitis was made by CSF analysis with or without positive cultures. Those cases with doubtful CSF findings, cases with psychomotor delay from birth, those with history of perinatal insults, family history of seizure disorder, deafness and mental retardation were excluded. Those children with a history of seizures prior to the onset of meningitis were also excluded. The mode of initial presentation of each case was available from the hospital record (case sheet). The various factors at initial presentation that might contribute to long-term morbidity were specially looked into. These included age at onset, sex, CSF cytology, biochemistry and organisms grown on culture. Acute complications like coma, focal neurological signs, subdural effusion, hydrocephalus and occurrence of seizures within 4 days of onset of illness were also documented. During the evaluation of the patients, detailed antenatal, perinatal and family history of each case was taken with a view to find out such factors that could produce neurophysiological outcome similar to that produced by pyogenic meningitis. Development history was taken to look for any delay in acquisition of milestones, following the acute illness. Any history of seizures that occured at any time following acute illness was looked for. This was followed by detailed physical examination, which included anthropometry, CNS examination including fundus examination, developmental assessment and formal tests for vision and hearing. All the cases were reassessed by the ophthalmologist for visual acuity and fundus examination. An audiogram of every child was done in consultation with the otolaryngology department. Children who were not co-operative for audiometry and those with mental retardation were assessed by Brain Stem Evoked Response Audiometry (BERA), Clinical psychologist at the School of Behavioral Sciences, Mahatma Gandhi University, Kottayam, did intelligence quotient (IQ), and behavioral assessment of all children. The three IQ tests used in this study were BKT (Binet Kammath Test-Indian version of Stanford Bailey Test), VSMS (Vineland Social Maturity Scale), and Seguinform board test(7). To assess behavioral problems, behavioral problem check list developed by NIMH (National Institute of Mental Health) Secunderabad was used. Based on the data analysis, cases were classified into those with "no morbidity" and those with "some form of morbidity" (major/minor)". The various factors at acute presentation that might contribute to long term morbidity were tested for statistical significance. Results The total number of cases included was 100, with male female ratio of 3:2. Mean age of children at the time of follow up was 6.5 years with a range of 4-11 years. Forty per cent of children had morbidity; 23% had developmental delay and 20% had mental retardation. Behavioral problems were noticed in 15%, 13% had seizure disorder, 6% had some form of motor deficits, 7% had deafness, 3% developed specific learning disability and 1% had ataxia, (Table I). On statistical analysis it was found that male sex, occurrence of seizures more than 4 days after onset of acute illness and presence of motor deficit during acute presentation were significantly associated with chronic morbidity (Table II). However, onset of acute illness, presence of subdural effusion, hydrocephalus, seizures occuring early in the course of illness and low CSF glucose had no significant predictive value in chronic morbidity. Discussion Despite the improvement in our knowledge in the pathophysiology of bacterial meningitis and development of newer antibiotics with better permeability, the long term complications of pyogenic meningitis remain almost the same. The study was conducted to find out the long-term morbidity of pyogenic meningitis in our country. Forty per cent of children had morbidity. Pomeroy et al. in 1990 reported a follow up study of 158 children with pyogenic meningitis; the mean duration of follow up was 8.9 years. Only 26 children were found to have persistent neurological abnormalities(8). Table I- Observed Chronic Sequelae (n=100)
The presence of deafness in our study is lower in comparison to other reports from developed and developing countries(2-6, 9). Out of 7 cases of deafness, 6 children had sensorineural deafness and 1 had mixed type of deafness. Deafness was bilateral in 4 cases and unilateral in 3 cases. Profound deafness was present in 5 cases. We used audiometry for the assessment of hearing except in those children who were not co-operative and in those with mental retardation. Motor deficits were observed in 6%, of which 5 had hemiparesis and one had quadriparesis. Seizure disorder was seen in association with motor deficits in 5 cases. Two children with motor deficits had severe mental retardation also. The occurrence of spasticity in the present study is high as compared to other studies(10-13). In the present study, mental retardation was observed in 20%. Severe form of mental retardation was seen in 2 cases only. Mild mental retardation (IQ 51-70) was seen in 4 cases, 14 cases had borderline MR (IQ 71-90). The incidence of severe form of MR is comparable to that reported from developed countries(14). Twenty three per cent of study group had developmental delay of which 15% had a permanent delay. Delayed acquisition of milestones was noted in 8 children of whom 3 had specific delay in language acquisition. Seizure disorder as a sequel was present in 13% of cases; 12 patients had generalized seizures and one had complex partial seizures. All children had adequate seizure control with routine anticonvulsants. When compared to other studies, the incidence of seizures as a sequelae is much higher in our study. In the study of Baraff et al.(14) the incidence was 4.2% and in Pomeroy et al. study(8) it was 7% Studies from developing countries also show a lower incidence(2-4). Fifteen per cent of children were observed to have behavioral disorder; 4% had Attention Deficit Hyperactive Disorder(ADHD), 8% had temper tantrums and 3 had nonspecific behavioral problems. Three per cent of children had specific disability in reading and writing language. Similar figures have been reported earlier(15). Gait ataxia was present in only one case. The same child also had bilateral sensorineural deafness. Ataxia following meningitis is often associated with cochlear damage and deafness, though it may also occur independently(16). When compared to adults incidence of ataxia after meningitis is rare in children(8). Table II__ Factors Associated with Chronic Morbidity
Our study affirms that pyogenic meningitis still produces many chronic sequelae in children. It emphasizes the need of following up children who had pyogenic meningitis. Detailed evaluation including ophthalmologic, audiologic and psychologic evaluation is necessary. Early evidence of motor deficits should be picked up to initiate physiotherapy at the earliest. Seizures if present should be adequately controlled. Because of the probable behavioral, learning and speech problems and impaired intelligence, they may need special training at school. Contributors: SSB co-ordinated the study; SL drafted and designed the study and will act as the guarantor. CNG collected data and participated in drafting. Funding: None. Competing interests: None stated.
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