Pneumococcal meningitis is a cause of death in patients with severe liver cirrhosis

Abstract number: 1733_702

Pagliano P., Fusco U., Attanasio V., Rossi M., Conte M., Faella F.

Bacterial infections are frequently observed in patients with cirrhosis because of depression of neutrophil granulocyte functions and humoral and cell-mediated immunity. Poor data are available about pneumococcal meningitis in such patients. Aim of the study was to evaluate characteristics of pneumococcal meningitis in cirrhotic patients.

Methods: Fourteen patients with cirrhosis and pneumococcal meningitis (mean age 58.5±11 years; 9 males), referred to our tertiary care centre in the period 1997–2005, were evaluated as part of a prospective surveillance study of pneumococcal meningitis in adult. Pneumococcal meningitis was defined by CSF pleocytosis (>10 cells/mL) and positive CSF and/or blood culture. Diagnosis of cirrhosis had to be recorded by liver histology or unequivocal clinical, laboratory, ultrasonographic and endoscopic findings. Data about clinical presentation, laboratory investigations, treatment and neurological outcome were collected.

Results: All patients had viral cirrhosis. Other conditions predisposing to pneumococcal meningitis were present in 10 cases: 6 had diabetes mellitus, 5 recurrent otitis, 3 asplenia, 3 previous neurosurgery. Three patients had pneumonia. All patients were comatose at admission. Twelve patients reported fever before admission. Meningeal signs were present in 11 cases. Exam of the cerebrospinal fluid showed always pleocytosis, low CSF/serum glucose ratio and elevated protein. White blood cell count was 11,100/mL (range 3,900–30,000). Three of 5 patients presenting with CSF cell count below 500/mL died. Penicillin-susceptible strains of S. pneumoniae grew in 10 cases; in the remaining 4 cases penicillin-nonsusceptible strains were cultured. Patients received combined treatment with ceftriaxone associated to ampicillin (5 cases), vancomycin (5 cases), rifampin (2 cases) or linezolid (2 cases) as empirical treatment. Four patients died, 2 had neurological sequelae. Three deaths occurred in patients with Child–Pugh C cirrhosis. Child–Pugh score improved in surviving cases.

Conclusions: Pneumococcal meningitis should be suspected in cirrhotic patients with fever and changes in mental status, particularly when predisposing factors are present. Outcome and mortality are related to the severity of liver disease. The increasing incidence of penicillin-nonsusceptible strains must be considered in establishing the empirical treatment.