Clinical features and prognostic factors in childhood pneumococcal meningitis

Despite progress in antibiotic therapy and intensive care, childhood pneumococcal meningitis remains a devastating disease, with morbidity and mortality rates among the highest of any cause of bacterial meningitis. We conducted this study to find the factors associated with disease outcome in clinical settings.

All pediatric medical charts during the period from January 1984 to December 2003 with the diagnosis of pneumococcal meningitis were reviewed. We recorded patients' symptoms and signs, laboratory data and treatments. Outcome and neurological complications were also analyzed.

In total, 40 episodes of pneumococcal meningitis from 37 patients aged 3 months to 10 years were identified. Predisposing factors were found in 13 patients (35.1%), and included recent history of head injury, immunocompromised states and cranial base anomaly. All patients had fever during illness. Patients older than 24 months of age tended to complain of nuchal rigidity (19/21, 90.5%) and those younger than 6 months of age tended to present irritability (6/7, 85.7%). The overall mortality rate was 25% (10 out of 40 episodes). The following variables were associated with mortality after statistical analysis: consciousness disturbance, shock, endotracheal tube intubation and hyponatremia (sodium <130 mEq/L) at admission (p=0.001, p<0.001, p<0.001, and p=0.012, respectively). Also, laboratory findings of less than 20/mm3 white cell count in cerebrospinal fluid (CSF), lower CSF glucose level and CSF-to-blood glucose ratio were significantly higher in non-survivors (p=0.003, p=0.009, p=0.027). Variables associated with morbidity were seizure attack and focal neurological sign occurring hospitalization (p=0.017, p=0.017).

The mortality of childhood pneumococcal meningitis remains high. If a child with pneumococcal meningitis presents with consciousness disturbance, hypotension, endotracheal intubation or hyponatremia at admission, the disease mortality rate increases. CSF findings with low white cell count, low glucose level and CSF-to-blood glucose ratio are also warning signs of a bad outcome. Seizure attack and focal neurological sign are the factors associated with further neurological sequelae.