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CSF leakage associated with high bacterial meningitis recurrence
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Despite steps to block infection, such as surgical repair or vaccination, patients with cerebrospinal fluid, or CSF, leak-associated bacterial meningitis have a high recurrence rate, according to findings from a prospective nationwide cohort study conducted in the Netherlands.
Writing in Clinical Infectious Diseases, Diederik van de Beek, MD, PhD, a professor at the University of Amsterdam, and colleagues explained that CSF leakage is a risk factor for developing bacterial meningitis.
“In patients with skull base fracture due to head trauma, CSF leakage resolves spontaneously within 24 hours after onset, but once persistent, meningitis occurs in 7% [to] 30% of patients,” they wrote. “CSF leakage has previously been reported in 3% [to] 8% of patients with community-acquired bacterial meningitis and in 38% of patients with recurrent meningitis.”
The researchers analyzed 2,022 episodes of community-acquired bacterial meningitis confirmed by culture between January 2006 and December 2017. Of them, CSF leakage was identified in 65 episodes (3%), among 53 patients. According to the study, the cause of CSF leakage was identified in 75% of the episodes, of which ear-nose-throat surgery was the cause of 29% and remote head trauma was 23%.
Recurrent meningitis episodes occurred in 59% of patients, and among those, 71% had known CSF leakage, with 53% reporting a previous surgery. Of patients with known CSF leakage, 38% were vaccinated.
They identified Streptococcus pneumoniae in 51% of the episodes, and Haemophilus influenzae in 17%, according to the study. Moreover, among the 10 episodes that had a known capsule type, the researchers said H. influenzae was unencapsulated in all episodes.
The researchers reported an unfavorable outcome in 12% of cases, but no deaths.
“In conclusion, this study shows that patients with CSF leak associated bacterial meningitis have a relatively high recurrence rate, despite attempts to repair the leak or vaccination,” the researchers wrote. “The majority of patients [have] a relatively mild disease course with a generally favorable outcome. CSF leakage should be suspected in those patients with bacterial meningitis presenting with liquorrhea, recurrent meningitis or with disease caused by H. influenzae. In these patients, cranial imaging and otolaryngology consultation is recommended.” – by Marley Ghizzone
Disclosures: Van de Beek reports receiving a grant to his institution from AMC, the European Research Council and ZonMw. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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Mark T. Curtis, MD, PhD
Bacterial meningitis is a serious disorder that includes inflammation of the leptomeninges and subarachnoid space. This immune-mediated inflammation can result in significant damage to the CNS. One risk factor for community-acquired bacterial meningitis includes leakage of CSF resulting from anatomic deficits in the barriers that normally keep the brain infection free. Dr. ter Horst and colleagues performed an extensive analysis of community acquired meningitis in patients with CSF leaks. Their study revealed several important facts including 1) CSF leak-associated bacterial meningitis should be suspected in infected patients presenting with recurrent meningitis, liquorrhea, or infection by H. influenzae; 2) patients with CSF leak associated bacterial meningitis have a high recurrence rate, even following steps (attempted to repair leak and administer appropriate vaccinations) aimed at blocking another infection; 3) patients with CSF leak-associated bacterial meningitis had relatively mild disease courses and more favorable outcomes. The ter Horst team’s characterization of this subgroup of patients with bacterial meningitis provide treating physicians with information useful in caring for these patients, including 1) recommendation for vaccination of the patients who are at high risk for recurrent meningitis, 2) knowledge of a probable better outcome in these patients and 3) recurrent episodes of bacterial meningitis and infection by H. influenza are clinical findings that should prompt a search for a CSF leak.
The findings of the ter Horst team will be of significant help in care of patients by all physicians but especially neurosurgeons, intensive care neurologists and infectious disease physicians.
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