Dec 11, 1978 - the next 6 days he became confused and lethar- gic. When he was admitted to the University of. Iowa Hospitals, he was obtunded and his tem-.
Vol. 9, No. 2
JOURNAL OF CLINICAL MICROBIOLOGY, Feb. 1979, p. 280-281
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NOTES Haemophilus influenzae Type D Meningitis JOHN P. VINER* AND R. MICHAEL MASSANARI Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Hospitals and Clinics and Veterans Administration Medical Center, Iowa City, Iowa 52242
Received for publication 11 December 1978
This report describes an unusual pathogen associated with post-traumatic meningitis. Haemophilus influenzae type D was isolated from both cerebrospinal fluid and blood of this patient with meningitis.
Haemophilus influenzae, a frequent cause of bacterial meningitis in children, is uncommonly associated with infection of the central nervous system in adults (12). Haemophilus infections in humans are almost exclusively associated with serotype B, one of six serotypes of H. influenzae (14). This report describes an unusual case of pyogenic meningitis associated with H. influenzae type D occurring in an adult after head trauma. To our knowledge, this represents the first detailed report of meningitis due to H. influenzae type D. In addition, this case illustrates several diagnostic pitfalls which may delay early identification of the organism. The patient was a 49-year-old livestock farmer who was hit on the head by a wooden post. Over the next 6 days he became confused and lethargic. When he was admitted to the University of Iowa Hospitals, he was obtunded and his temperature was 38.8°C. Marked nuchal rigidity without rhinorrhea, otorrhea, focal neurological defects, or Battle's sign was noted. The peripheral leukocyte count was 20,400/mm3 with 19,000 granulocytes. Examination ofthe cerebrospinal fluid (CSF) revealed an opening pressure at 480 mm of water; protein, 620 mg/dl; and glucose, 3 mg/dl. The CSF leukocyte count was 11,500/mm3, 97% of which were polymorphonuclear leukocytes. Gram stain of the CSF performed on the ward was interpreted as containing rare gram-positive diplococci. Counterimmunoelectrophoresis of the CSF revealed neither Streptococcus pneumoniae nor H. influenzae (type B) antigens. Skull films and tomography of the temporal bones demonstrated no recent fracture. Computerized tomograms, electroencephalogram, and radioisotope brain scan demonstrated no specific abnormality. Radioiodinated serum albumin cisternography showed
a CSF leak by radioactivity on a cotton pledget inserted in the right nasal cavity. Based upon the initial evaluation of the CSF, intravenous therapy with aqueous penicillin G (24 x 106 U/day) was started. Within 24 h, gramnegative coccobacilli were growing in cultures of the CSF and blood. Therapy was changed to intravenous chloramphenicol (6 g/day). When subsequent tests revealed that the organism did not produce beta-lactamase, intravenous therapy was finally changed to ampicillin (12 g/day). Preliminary identification of the gram-negative coccobacillus by the clinical laboratory was Haemophilus parainfluenzae. Further identification as to species by biochemical techniques (University Hygienic Laboratory, Iowa City, Iowa) indicated that the organism isolated from the CSF and blood was H. influenzae type D. Confirmation of this unusual serotype was provided by the Center for Disease Control, Atlanta, Ga. Although the clinical course of the patient was initially complicated by acute respiratory failure, requiring intubation and mechanical ventilation, progressive improvement followed institution of antimicrobial therapy. By hospital day 7, the patient was afebrile. After 2 weeks of parenteral antibiotic therapy, the patient had recovered full mental function. One year later, he had continued to feel well, with apparent resolution of the CSF leak. This report describes an unusual pathogen associated with post-traumatic pyogenic meningitis. The most likely portal of entry for the H. influenzae type D was through an occult meningeal tear. Deposition of radiolabeled albumin in the right nostril during the radioiodinated serum albumin cisternography scan supports this notion. 280
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VOL. 9, 1979
Bacterial meningitis occurring as a complication of previous head trauma is not unusual, particularly after basilar skull fracture (4). Al-
though S. pneumoniae is the most frequent organism associated with post-traumatic menin-
gitis, H. influenzae type B along with other upper respiratory tract commensals has also been associated with post-traumatic meningitis (9). This case is unique, however, in that posttraumatic purulent meningitis was associated
with a serotype of H. influenzae not generally considered a pathogen in humans. More than 90% of the H. influenzae isolated from throat cultures of children are nonencapsulated organisms. However, all six types of en-
capsulated H. influenzae are known to colonize the human pharynx. Among these commensals, type B is the most prevalent, whereas types C and D are rarely found (1, 11). H. influenzae type D has infrequently been associated with bacteremia (8), bronchiolitis in children (10), and conjunctivitis in infants (11). In addition, an extensive review of the literature indicates that the organism was isolated from the CSF once before in pyogenic meningitis but with no clinical information (13). Haemophilus infections of the central nervous system can pose several diagnostic problems. First, purple granules may be seen in Gram stain of these organisms and lead to the mistaken
impression, as in this case, of S. pneumoniae.
Variable Gram staining and pleomorphism may confound the interpretation (2, 3, 5, 15). Second, identification as to species of H. influenzae is dependent on nutrient requirements and hemolytic properties of the organism. Standard methods for identification depend upon satellite growth about disks containing nicotinamide adenine dinucleotide (factor V) and hemin (factor X). If trace nutrients from growth media are inadvertently transferred to subculture plates, misidentification may result (7). The recent development of biochemical techniques such as
281
porphyrin production may circumvent the technical problems associated with the use of disks
(6). We thank Franklin Koontz and Edward Renner and their laboratories for identifying the organisms.
LITERATURE CITED 1. Dawson, B., and K. Zinnemann. 1952. Incidence and type distribution of capsulated H. influenzae strains. Br. Med. J. 1:740-742. 2. Eykyn, S. J., R. D. Thomas, and I. Phillips. 1974. Haemophilus influenzae meningitis in adults. Br. Med. J. 2:463-465. 3. Gladstone, R. M., and N. A. Russel. 1969. Hemophilus influenzae: meningitis in an adult. Can. Med. Assoc. J. 101:719-720. 4. Hand, W. L., and J. P. Sanford. 1970. Post-traumatic bacterial meningitis. Ann. Intern. Med. 72:869-874. 5. Holdsworth, D. E. 1960. Haemophilus influenzae meningitis in an adult. Arch. Intern. Med. 106:653-656. 6. Kilian, M. 1976. A taxonomic study of the genus Haemophilus, with proposal of a new species. J. Gen. Microbiol. 93:9-62. 7. Lund, M. E., and D. J. Blazevic. 1977. Rapid speciation of Haemophilus with the porphyrin production test versus the satellite test for X. J. Clin. Microbiol. 5:142144.
8. McGowin, J. R., Jr., J. D. Klein, and L Bratton, et al. 1974. Meningitis and bacteremia due to Haemophilus influenzae: occurrence and mortality at Boston City Hopsital in 12 selected years, 1935-1972. J. Infect. Dis. 130:119-124. 9. Merselis, J. G., Jr., T. F. Sellers, Jr., and J. E. Johnson, III, et al. 1962. Hemophilus influenzae meningitis in adults. Arch. Intern. Med. 110:837-846. 10. Sell, S. H. W. 1960. Some observations on acute bronchiolitis in infants. Am. J. Dis. Child. 100:7-15. 11. Sell, S. H. W. 1970. The clinical importance of Haemophilus influenzae infections in children. Pediatr. Clin. North Am. 17:415-426. 12. Snyder, S. N., and S. Brunjes. 1965. Hemophilus influenzae meningitis in adults. Am. J. Med. Sci. 250:658667. 13. Swartz, M. N., and P. R. Dodge. 1965. Bacterial meningitis-a review of selected aspects. N. Engl. J. Med. 272:779-787. 14. Turk, D. C., and J. R. May. 1967. Haenwphilus influenzae: its clinical importance, 1st ed, p. 35. English Universities Press, London. 15. Weinstein, L. 1970. Type B Haemophilus influenzae infections in adults. N. Engl. J. Med. 282:221-222.
