May bacterial meningitis pave the way for a toxoplasmosis flare-up: a cross-sectional study from Egypt

The probable association of Toxoplasma gondii (T.gondii) flare-up/co-existence with bacterial meningitis is yet to be elucidated. This study aimed to investigate the possible incidence of T.gondii flare-ups in the cerebrospinal fluid (CSF) suspected of bacterial meningitis as a hidden co-morbid factor. The causative organisms of bacterial meningitis, antibiotic resistance patterns, and physiological aspects of CSF among various age groups were all assessed.

A cross-sectional study in Almaza Military Hospital, Emergency Department, involved 300 Egyptian patients with symptoms suggestive of meningitis, out of whom 51/ 300 (17.0%) were confirmed by chemical and physiological parameters and microbiological analysis to have bacterial meningitis. Based on age, the patients were divided into Group-1 (< 30 years old) and Group-2 (> 30 years old). The obtained CSF samples were assessed for bacterial growth, antibiotic sensitivity, physiological criteria, and chemical parameters (protein, glucose, and chloride). Toxoplasma was detected using both immune and molecular assays.

Overall, 51 (17%) out of 300 patients were confirmed for bacterial meningitis. Males constituted 66.7%. Group-1 consisted of 41 patients (80.4%) distributed as infants (n = 30, 58.8%), children (n = 7, 13.7%), and neonates (n = 4, 7.8%) (P < 0.001) (males 63.4% and females 36.6%). Group-2 involved 10 patients (19.6%), (males 80% and females 20%). Overall, 49% of the patients received empirical antibiotics, and bacterial growth was present in 51% of the cases. Enterobacter spp. was the most prevalent type of bacteria (15.7%), whereas Pseudomonas and Acinetobacter spp. were the least (2% each). Neonates and children (in subgroup-1) predominantly showed Methicillin-resistant Staphylococcus aureus. 73.7% of infants (subgroup-1) and 80% of group-2 had multidrug-resistant bacteria. Bacterial growth was associated with higher neutrophil count and lower glucose and chloride levels. In group-1, females had a significant increase in neutrophils. The CSF glucose was negatively correlated with neutrophils (r=-0.467) and positively correlated with chloride (r = 0.4). The CSF protein level was positively correlated with neutrophils (r = 0.308), while the chloride level was negatively correlated with neutrophils (r=-0.416) and protein (r = -0.601). The anti-Toxoplasma IgG was positive in 23.5% of cases, indicating exposure to Toxoplasma gondii. All patients were negative for anti-Toxoplasma IgM and the Repeat element (RE) gene. Chronic cerebral toxoplasmosis was higher in the female patients (P = 0.0016).

Despite the variable demographic data, bacterial species, antibiotic resistance, and altered CSF physiological and chemical parameters, toxoplasmosis flare-ups and bacterial meningitis lacked association.