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Bacterial meningitis in cirrhosis: review of 16 cases
A Pauwels1, E Pinès, M Abboura
1Service d'Hépato-Gastroentérologie, Hôpital Saint-Antoine, Paris, France.
Background:
Although bacterial infections are frequent in patients with liver cirrhosis, only isolated cases of bacterial meningitis have been reported.
Methods:
We have reviewed a series of 16 cases of bacterial meningitis in patients with cirrhosis, diagnosed in a single hospital over a 30-year period.
Results:
Thirteen patients had alcoholic cirrhosis. On presentation, all patients had fever and most of them had an abnormal mental status (coma in 11 cases), but neck stiffness was not present or was delayed for more than 24 h in seven (43.7%) patients. The cerebrospinal fluid white cell count was always elevated, higher than 1000/microl in ten cases. The cerebrospinal fluid culture was positive in 14 (87.5%) patients. Gram-negative bacilli (mainly E. coli) and L. monocytogenes were the most frequent pathogens, accounting for nine cases. In contrast, S. pneumoniae and N. meningitidis were found in only four cases. Concurrent bacteremia was present in 12 (75%) cases. Ten patients (62.5%) died. Death was meningitis-related in seven patients and due to decompensated liver cirrhosis after clinical recovery from meningitis in the three other patients. Child-Pugh class C was associated with a higher mortality rate (80%, versus 33% for Child-Pugh class A-B), although the difference did not reach statistical significance.
Conclusions:
Bacterial meningitis should be suspected in every patient with cirrhosis presenting with a febrile coma. If lumbar puncture must be delayed, or if no causative agent can be identified on cerebrospinal Gram stain despite elevated cerebrospinal fluid white cell count, empirical antimicrobial therapy should be started straightaway with ampicillin plus a third-generation cephalosporin in sufficient doses.
Insights
Bacterial meningitis is a serious complication in liver cirrhosis patients, often presenting with fever and altered mental status. Early suspicion and prompt empirical antibiotic treatment are crucial for improving outcomes in these high-risk individuals.
Area of Science:
- Infectious Diseases
- Hepatology
- Neurology
Background:
- Bacterial infections are common in liver cirrhosis patients.
- Bacterial meningitis is rarely reported in this population.
Purpose of the Study:
- To review cases of bacterial meningitis in patients with cirrhosis.
- To identify clinical features, pathogens, and outcomes.
Main Methods:
- Retrospective review of 16 bacterial meningitis cases in cirrhosis patients over 30 years.
- Analysis of clinical presentation, cerebrospinal fluid findings, and microbiology.
Main Results:
- Alcoholic cirrhosis was common (13 patients).
- Fever and altered mental status were prevalent; neck stiffness was often absent or delayed.
- Gram-negative bacilli (E. coli) and L. monocytogenes were frequent pathogens.
- Mortality was high (62.5%), with deaths related to meningitis or decompensated cirrhosis.
Conclusions:
- Bacterial meningitis should be suspected in cirrhotic patients with febrile coma.
- Empirical antibiotic therapy with ampicillin and a third-generation cephalosporin is recommended if lumbar puncture is delayed or Gram stain is negative.