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Review: Ewout S Schut, Jan de Gans, and Diederik van de Beek Community-acquired bacterial meningitis in adults PRACTICAL NEUROLOGY 2008; 8: 8-23 [Abstract] [Full text] [PDF]

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recurrent meningitis, right to left shunts, and blood cultures

oscar,m jolobe   (18 February 2008)

recurrent meningitis, right to left shunts, and blood cultures 18 February 2008
oscar,m jolobe, retired geriatrician manchester medical society, c/o john rylands university library, oxford road, mancheste, M13 9PP Send letter to journal: Re: recurrent meningitis, right to left shunts, and blood cultures oscarjolobe{at}yahoo.co.uk oscar,m jolobe	Dear Editor For the sake of completeness, mention must also be made of the role of right to left shunts, exemplified by pulmonary arteriovenous malformations attributable to hereditary haemorrhagic telangiectasia(1)(2), and also exemplified by patent dusctus arteriosus with shunt reversal(3), in the aetiopathogenesis of recurrent bacterial meningitis, both meningococcal(1), and pneumococcal(3), as well as cerebral abscess(1)(2), which may simulate partially treated bacterial meningitis. In a review of 31 instances of recurrent intracranial infection(including bacterial meningitis) attributable to intrapulmonary right to left shunts blood cultures were sterile in every single instance(2). In the event of intrapulmonary right to left shunts being a risk factor for strile blood cultures in patients with suspected blood borne intracranial sepsis, this would entail greater reliance on the clinical index of suspicion for these disorders, an index of suspicion that would embrace even more exotic causes of intrapulmonary shunts such as the hepatopulmonary syndrome, now acknowledged to be one of the rare risk factors fro metastatic cerebral abscess(4). This does not diminish the role of blood cultures in the "work up" of suspected bactrial meningitis(5), given the fact that in bacteraemic patients with pneumococcal meningitis, positive blood culture results can be obtained within 1.2 to 10.9 hours of being ordered(6). This could amount to a decisive diagnostic advantage in cases where the initial cerebrospinal fluid is sterile and has low cellularity(7). Oscar M Jolobe References (1) Hazouard E., Ritz-Quillacq L., Herbreteau D et al Weber-Rendu-Osler disease:pulmonary arterio-venous malformation with shunt disclosed after 5 occurences of purulent meningococcal encephalitis(article in French: abstract in English)Revue des Maladies Respratoires 1999:16:95-7 (2) Press OW., Ramsey PG Central nervous system infections associated with hereditary hemorrhagic telangiectasia American Journal of Medicine 1984:77:86-92 (3) Spencer SE., D'Cruz IA., Tenholder MF Recurrent meningitis and severe hypoxemia in a 77 year old man CHEST 1997:112:1120-3 (4) Molleston JP., Kaufman BA., Cohen A et al Brain abscess in hepatopulmonary syndrome Journal ogf Pediatric Gastroenterology 1999;29;225-6 (5) Schut ES., de Gans J., van de Beek D Community-acquired bacterial meningitis in adults Practical Neurology 2008:8:8-23 (6)Peralta G., Rodriguez-Lera MJ., Garrido JC et al Time to positivity in blood cultures of adults with streptococcus pneumoniae bacteraemis BMC Infectious Diseases 2006:6:79 (7)Rapkin RH Repeat lumbar puncture in the diagnosis of meningitis Pediatrics 1974:54:34-6