Neurology India
Open access journal indexed with Index Medicus
  Users online: 379  
 Home | Login 
  About Current Issue Archive Ahead of print Search Instructions Online Submission Subscribe Etcetera Contact  
  Navigate Here 
 Search
 
  
 Resource Links
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Article in PDF (815 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this Article
   References
   Article Figures

 Article Access Statistics
    Viewed207    
    Printed2    
    Emailed0    
    PDF Downloaded2    
    Comments [Add]    

Recommend this journal

 


 
Table of Contents    
LETTER TO EDITOR
Year : 2017  |  Volume : 65  |  Issue : 1  |  Page : 201-202

Recurrent meningitis with unusually delayed cerebrospinal fluid leak detected by magnetic resonance cisternography


Department of Pediatrics, University College of Medical Sciences and Guru Tegh Bahadur Hospital, New Delhi, India

Date of Web Publication12-Jan-2017

Correspondence Address:
Anju Aggarwal
Department of Pediatrics, University College of Medical Sciences and Guru Tegh Bahadur Hospital, New Delhi
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.198233

Rights and Permissions



How to cite this article:
Kumar S, Aggarwal A, Dabas A, Roy A. Recurrent meningitis with unusually delayed cerebrospinal fluid leak detected by magnetic resonance cisternography. Neurol India 2017;65:201-2

How to cite this URL:
Kumar S, Aggarwal A, Dabas A, Roy A. Recurrent meningitis with unusually delayed cerebrospinal fluid leak detected by magnetic resonance cisternography. Neurol India [serial online] 2017 [cited 2017 Feb 23];65:201-2. Available from: http://www.neurologyindia.com/text.asp?2017/65/1/201/198233


Sir

Meningitis, the inflammation of leptomeninges, is a potential life threatening infection that causes significant morbidity and mortality. Recurrent meningitis is defined as two or more episodes of meningitis, which are separated by a period of convalescence; in case the meningitis is caused by the same causative organism, the second episode has to be separated by at least a 3-week interval after completion of treatment of the previous episode.[1] Most of the cerebrospinal fluid (CSF) leaks present within 3 months of occurrence of trauma; rarely, they may occur after an year.[1],[2] We report a case of recurrent meningitis with traumatic CSF leak that manifested after 2 years.

A 5-year-old boy presented with fever, headache, and vomiting. He had the occurrence of similar episodes, 1 year and 4 months ago. The contrast-enhanced computed tomography (CECT) performed during the second episode was normal. His central nervous system examination revealed a normal fundus, muscle tone, and reflexes along with positive signs of meningeal irritation. Rest of the systemic examination was normal. The cerebrospinal fluid (CSF) picture was suggestive of acute meningitis and the culture was sterile. Meningitis was treated by administering intravenous ceftriaxone and vancomycin. Two years ago, he fell from a height and had an occasional watery discharge from the right nostril. The magnetic resonance imaging (MRI) of the brain was normal. MRI brain with cisternography revealed a breach through the fovea ethmoidalis and right cribriform plate with CSF rhinorrhea into the posterior ethmoidal air cells [Figure 1], with right-sided ethmoidal and bilateral maxillary sinusitis and hypertrophy of bilateral inferior turbinates. Repair of the defect was done endoscopically. Following the first surgery, the CSF rhinorrhea persisted and necessitated a bifrontal craniotomy for the repair of the dural and bony defect. After the second surgery, the CSF rhinorrhea stopped.
Figure 1: Herniation of fovea ethmoidallis through right cribriform plate with herniation of adjacent cerebrospinal fluid into posterior ethmoidal air cell (arrow) and sinusitis of right ethmoidal and bilateral maxillary sinus

Click here to view


CSF leaks commonly occur after trauma or are rarely congenital.[1],[2] Posttraumatic CSF rhinorrhea may heal spontaneously. Delayed CSF leak after 3 months had been reported in approximately 5% of patients; whereas, after 1 year, delayed CSF rhinorrhoea occurs rarely and is due to failure of the healing mechanisms or due to growing fracture phenomenon.[3] Tuygun et al., found that 36% patients with recurrent meningitis (n = 14) have a post-traumatic skull base defect and pneumococcus was the common organism isolated.[4] Khan et al., found that fever and vomiting were the most common symptoms (87%). Head trauma was present in 37% (n = 8) of the cases with CSF rhinorrhea.[5] Our patient also had the chief complaints of fever, vomiting, headache, and was found to be having posttraumatic delayed CSF leak; however, CSF culture was sterile every time it was done.

The diagnosis of recurrent meningitis is made by clinical and CSF examination. The detection of the predisposing conditions requires an elaborative work up, which include a high-resolution computed tomography (CT) or MRI of the brain with cisternography, and an immunological workup.[1] Our case had a history of head trauma and CSF leak so we performed an MRI cisternography upfront that revealed CSF leak along with fovea ethmoidalis breach.

The management includes treatment of meningitis with antibiotics and surgical repair of the dural defect.[6],[7] Surgical repair include intracranial and endoscopic extracranial approaches wherein an underlay, overlay, or a combined graft is placed. The intracranial approach has a higher morbidity and chances of anosmia as compared to the endoscopic repair. Our case required an intracranial repair.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Tebruegge M, Curtis N. Epidemiology, etiology, pathogenesis, and diagnosis of recurrent bacterial meningitis. Clin Microbiol Rev 2008;21:519-37.  Back to cited text no. 1
    
2.
Brodie HA, Thompson TC. Management of complications from 820 temporal bone fractures. Am J Otol 1997;18:188-97.  Back to cited text no. 2
    
3.
Talamonti G, Fontana RA, Versari PP, Villa F, D'Aliberti GA, Car P, et al. Delayed complications of ethmoid fractures: A“growing fracture” phenomenon. ActaNeurochir 1995;137:164-73.  Back to cited text no. 3
    
4.
Tuygun N, Tanir G, Aytekin C. Recurrent bacterial meningitis in children: Our experience with 14 cases. Turk J Pediatr 2010;52:348-53.  Back to cited text no. 4
    
5.
Khan EA, Choudhry S, Roohullah M, Hashmi I, Nazir R. Recurrent meningitis in children - Case series. J Pak Med Assoc 2013;63:274-6.  Back to cited text no. 5
    
6.
Fishman G, Fliss DM, Benjamin S, Margalit N, Gil Z, Derowe A, et al. Multidisciplinary surgical approach for cerebrospinal fluid leak in children with complex head trauma. Childs Nerv Syst2009;25:915-23.  Back to cited text no. 6
    
7.
Sannareddy RR, Rambabu K, Kumar VE, Gnana RB, Ranjan A. Endoscopic management of CSF rhinorrhea. Neurol India 2014;62:532-9.  Back to cited text no. 7
[PUBMED]  Medknow Journal  


    Figures

  [Figure 1]



 

Top
Print this article  Email this article
   
Online since 20th March '04
Published by Wolters Kluwer - Medknow