Injury (1986) 17.407-409 Printedin Great Britain 407

Post-traumatic meningitis in children

Y. L. Lau and A. P. Kenna

Department of Paediatrics, Newcastle General Hospital, Newcastle upon Tyne

Summary A retrospective survey over a h6-month period of children admitted with head injury who subsequently developed meningitis within the same period yielded six cases (five boys, one girl), giving an incidence of 0.38 per cent. Two of the six died, and four survived with no sequelae. Four cases occurred within the first week. One patient, who had received prophy- lactic antibiotics, developed Escherichia coli meningitis after 14 days and one had meningitis 2 years after the head injury. The most common organism was pneumococcus (four cases). Three patients had periorbital haematomas and none had cerebrospinal fluid leakage. Increasing drowsiness and fever were the most consistent features. Radiography of the skull was of little use in demonstrating fracture of the base of the skull. Two of the four surviving patients had craniotomy with successful dural repair.

INTRODUCTION HEAD injury accounts for a substantial proportion of children’s admission to hospitals. Jamieson and Kaye (1974) reported 857 cases of head injury admitted over a 2-year period to a paediatric unit, representing 16 per cent of all admissions. Fortunately, only a minority develop complications such as extradural (1 per cent) and subdural (5 per cent) haematomas (Hardwood- Nash et al., 1971). Meningitis following head injury is relatively rare and no incidence of post-traumatic meningitis was given in Hendrick’s series of 4465 children with head injury admitted consecutively in Toronto (Hendrick et al., 1964). Jamieson and Kaye (1974) reported 1 case of post-traumatic meningitis among 857 children admitted with head injury in New- castle and Burkinshaw (1960) also 1 case among 238 children. The aim of this survey was to establish the incidence of post-traumatic meningitis among children admitted to hospital with head injury and to review the clinical features of this complication.

PATIENTS AND METHODS This is a retrospective survey of children aged 16 years or less who were admitted with head injury to New- castle General Hospital (NGH) between January 1979 and June 1984 and developed post-traumatic meningitis. Newcastle General Hospital is the regional neuro- logical centre for the north of England. Children with head injury coming to the casualty department are seen initially by a casualty officer and then referred to a paediatrician if hospital admission is deemed necessary. The child is admitted if there is a history of altered conscious state, the presence of neurological symptoms or signs or fracture of the skull. Cases referred from other hospitals are also admitted under the joint care of

Table 1. Clinical features of post-traumatic meningitis

No of cases (total=6)

Periorbital haematoma 3 Nasal bleeding 3 CSF leakage 0 Fever at the time of diagnosis 6 Fracture on initial skull radiograph 2 Skull fracture established finally 5 Mortality 2 Craniotomy for dural repair 2

paediatrician and neurosurgeon. There were 1587 acute admissions with head injury (boy:girl ratio of l-89:1) and 6 children later developed meningitis giving an incidence of 0.38 per cent. Five were boys and one was a girl; they were aged from 9 months to 15 years. Two died and the other four recovered with no sequelae. Organisms involved include pneumococcus (four cases), group A streptococcus (one case) and E. coli (one case). Case histories are given below and their clinical features are summarized in Table 1.

CASE REPORTS Case 1 A 9-month-old boy was involved in a car crash, when he was sitting on his mother’s lap in the back seat. He fell forwards but remained inside the car. He did not lose consciousness and was apparently well, with no obvious injuries on admis- sion to the local hospital, but he did have fever associated with upper respiratory tract infection. Skull radiographs did not show any fracture. Two days later, he started to vomit and became increasingly drowsy and limp. He was then transferred to NGH. He was febrile, with fits and a left third nerve palsy and he was moribund. Both cerebrospinal fluid (CSF) and blood culture grew Streptococcus pneumoniae. Despite resuscitation he died within 12 hours of arrival. Post-mortem examination demonstrated meningitis and an extensive fracture running into the medial end of the left petrous temporal bone, in close proximity to the middle ear cavity. Green pus, which also grew S. pneumoniae, was found in the left middle ear. A possible chain of events is that the boy suffered from a pneumococcal otitis media at and around the time of head injury. The resulting fracture created a passage for the pneumococcus from the middle ear to the meninges.

Case 2 A S-year-old boy fell out of a first-floor window onto concrete ground without loss of consciousness. He had facial bruising with a right periorbital haematoma and nasal bleeding with a deviated nasal septum. There was no sign of CSF leakage. A

408 injury: the British Journal of Accident Surgery (1986) Vol. 17/No. 6

skull radiograph was normal. However, he became in- creasingly drowsy and pyrexial the day after admission. Com- puterized tomography did not show any intracranial mass. Lumbar puncture yielded turbid fluid which grew Streptococ-

cus pneumoniae. After the meningitis was treated, repeat skull radiographs, including tomograms, did not demonstrate any fracture. An exploratory craniotomy showed a right anterior ethmoidal fracture with a dural defect measuring 1.5~1 cm leading into the right ethmoidal air cells; this was repaired successfully.

Case 3 A 5-year-old boy was knocked over by a car and lost con- sciouness for 7 minutes. He had nasal bleeding and a left periorbital haematoma. There was no leakage of CSF. A skull radiograph was normal. He was well for 3 days and then developed a fever of 39.5” C. He had no meningeal signs then, but developed neck rigidity 6 days after admission. Cerebro- spinal fluid grew group A haemolytic streptococci. Repeat skull radiography and computerized tomography were both normal. He had no anosmia. After the meningitis was treated successfully he was kept on penicillin for 4 weeks. No further action was taken.

Case 4 During a glue-sniffing session a 15-year-old boy fell from a wall 4.5m high. He was unconscious and bleeding from the right ear and nostril. There was no apparent CSF leakage. His plasma toluene level was 39mg/r_ on admission. He required endotracheal intubation and intensive care. A skull radio- graph showed a fractured right temporal bone. Computerized tomography showed fractures affecting the right occipital, petrous temporal and squamous temporal bones. He was given penicillin and sulphadimidine for 12 days. In the meantime, he had a right parieto-occipital craniotomy for removal of an extradural haematoma. He became pyrexial at 40.3”C on day 14. Cerebrospinal fluid via the ventricular route yielded E. cob, and he was treated with chlorampheni- co1 for 13 days. He was extubated on day 17 but was still unconscious with only flexion response of his upper limbs to painful stimulus. He deteriorated and died on day 30. Ex- amination post mortem demonstrated a fracture of the skull extending from the left orbital roof, across the pituitary fossa and petrous temporal bone to terminate in the right parietal region. Meningitis was obvious but both middle ears were free from pus.

Case 5 A 7-year-old girl fell from a verandah 4.5 m high. There was no loss of consciousness but, she was drowsy and she had vomited. She was seen in the casualty department of a local hospital and a skull radiograph was said to be normal. She was not admitted until after her third visit, 30 hours after the accident, when she was pyrexial, more drowsy and had neck rigidity.

Lumbar puncture yielded turbid fluid which grew pneumo- cocci, so she was transferred to NGH. She had a right periorbital haematoma but no evidence of CSF leakage. She recovered well on penicillin. Repeat skull radiographs demonstrated a right frontal fracture and no further action was taken.

Case 6 A 14-year-old boy fell off a motorcycle and was unconscious for 20 minutes. He sustained a fracture of his left maxilla and laceration of the left eyebrow. He was discharged from hospital after 3 days, when he was well. Six months later, he had a generalized convulsion lasting 10 minutes. Neurological examination was unremarkable. A skull radiograph was nor- mal. However, he had a constant frontal headache and was very irritable. An electroencephalogram revealed a massive

left anterior focus of slow delta wave activity. A compu- terized tomogram revealed an enhancing lesion in the left frontal lobe, which was drained of 20 ml of pus. Pneumococci were eventually cultured from the pus. He recovered well on penicillin and underwent drainage of his left frontal sinus and curettage of his left ethmoid sinus 1 week later. He was well for 18 months and was then seen with a 24-hour history of fever, headache and vomiting. He was photophobic and had marked neck stiffness. Lumbar puncture yielded turbid CSF which grew pneumococci. He improved rapidly on penicillin and had a bifrontal craniotomy which revealed a fracture of the anterior fossa with a large dural defect into the left ethmoid sinus. This was repaired successfully with muscle and pericranium.

DISCUSSION The ratio of five boys to one girl in our series probably reflects the predominance of boys over girls admitted with head injury (Hendrick et al., 1964). The incidence of post-traumatic meningitis (O-38 per cent) found by this survey could be overestimated because NGH serves as the regional neurological centre and receives referred cases, such as Cases 1 and 5. On the other hand, the incidence could be underestimated because post-traumatic meningitis may not develop till a long time after the initial head injury. Case 6 had a cerebral abscess and meningitis respectively 6 months and 2 years after the head injury. In a series of 16 adults with post-traumatic bacterial meningitis 8 were seen within 2 weeks of the injury while in 4, the delay was more than 1 year (Hand and Sanford, 1970). Therefore, it is possible for a patient to develop meningitis when the relevant head injury sustained many years previously has been forgotten.

Cerebrospinal fluid otorrhoea and rhinorrhoea after head injury are definite signs of dural tear which should alert one to the possibility of post-traumatic meningitis, the incidence of which was 18 per cent following otor- rhoea and 9 per cent following rhinorrhoea (Leech and Paterson, 1973). However, there was no CSF leakage in our six cases. Cerebrospinal fluid could be easily missed because it might be transient or mixed with blood and hence obscured. Another possible reason is that those who develop CSF leakage after head injury in NGH are given penicillin and sulphadimidine and may thereby be prevented from developing post- traumatic meningitis. Other clinical signs indicating possible basal skull fractures, such as a periorbital haematoma, were present in only three out of the six cases. Therefore, using clinical signs of dural tears and basal fractures of the skull to predict the possibility of post-traumatic meningitis is unreliable. Also, some of the classic signs and symptoms of meningitis may already be present in children admitted with acute head injury; for example, in the 857 children admitted with head injury to NGH (Jamieson and Kaye, 1974) drowsiness was present in 63 per cent and vomiting in 55 per cent. The only indication that post-traumatic meningitis has developed may be deterioration in con- sciousness without other signs suggestive of tentorial herniation (Miller, 1976). Fever was present in all our six cases by the time that meningitis was diagnosed.

The value of and guidelines for radiography of the skull in the management of head injury have been discussed extensively (Clarke, 1972; Jennett, 1972; Royal College of Radiologists, 1983). However, the

Lau and Kenna: Post-traumatic meningitis in children

presence of fracture of the skull alone, without associa- ted clinical abnormalities, was concluded to be of little significance in a study of 1187 children with such frac- tures (Hardwood-Nash et al., 1971). In our six cases of post-traumatic meningitis, only two had fractures of the skull demonstrated initially on skull radiographs. Subsequently, three more were demonstrated to have fractures of the skull by tomogram, at operation or postmortem. Skull radiography is of limited use in demonstrating basal fracture of the skull. Nevertheless, Leech and Paterson (1973) did show that the risk of meningitis following otorrhoea was significantly higher if a fracture of the skull was demonstrated.

Prophylactic chemotherapy, usually penicillin and sulphadimidine, is recommended in most neurosurgical centres in Britain for any patient who develops CSF leakage or other signs of basal fracture of the skull following head injury (Miller, 1976). Good protection against meningitis following otorrhoea and rhinorrhoea was obtained by giving penicillin and sulphadimidine from the time of injury until 1 week after the CSF leakage had ceased (Leech and Paterson, 1973). However, a smaller prospective study did not find any benefit from using ampicillin mainly as prophylaxis in basilar fractures of the skull (Ignelzi and VanderArk, 1975). Case 4 was the only patient who received prophylactic chemotherapy (penicillin and sulphadimi- dine) in our six cases and he developed E. coli menin- gitis 2 days after the prophylaxis was stopped. Four patients had pneumococcal meningitis. It is evident that pneumococcus is the most common pathogen if no anti- biotic has been given but Gram-negative organisms may be more likely if a prophylactic antibiotic has been used.

In most cases, CSF otorrhoea ceases spontaneously and exploration of the middle cranial fossa with dural repair is rarely carried out (Leech and Paterson, 1973). For persistent CSF rhinorrhoea, most will recommend surgical exploration for dural repair (Jennett, 1977), but there is a difference of opinion if it is transient. Earlier workers stressed the high incidence of menin- gitis (up to 2.5 per cent) in cases treated conservatively, and advocated repair in all cases of rhinorrhoea (Lewin, 1966). However, recent work showed that there was no significant difference in the incidence of meningitis between the groups treated conservatively and surgically if the rhinorrhoea lasted less than 7 days (Leech and Paterson, 1973). Dural repair was recom- mended if rhinorrhoea lasted longer than 7 days (Leech and Paterson, 1973). The problem posed by single or recurrent meningitis following head injury but without any evidence of CSF leakage is less simple of solution Lancet, 1972). For our four surviving patients who had no evidence of CSF leakage, two underwent successful

409

dural repair (Casrs 2 and 6) and two were not submitted to exploratory craniotomy. This apparent inconsistency reflects the differing practices of the neurosurgeons in NGH. For the two fatal cases, post- traumatic meningitis was the major cause of death in Case I, but in Case 4 both the severe head injury and the very high plasma toluene level were the main contributing factors to death, with meningitis as a ter- minal event (King et al., 1981).

In conclusion, post-traumatic meningitis is a rare complication of head injury in children and can occur with no sign of dural tear or basal skull fracture. Increasing drowsiness with no sign of tentorial hernia- tion and fever without obvious focus of infection should alert one to the possibility of this complication.

REFERENCES Burkinshaw J. (1960) Head injuries in children. /I&z. I1i.s.

Child. 35, 205. Clarke P. R. R. (1972) Head injuries in children. Br. Med. J.

1, 570. Hand W. L. and Sanford J. (1970) Post-traumatic bacterial

meningitis. Ann. Intern. Med. 72, 869. Hardwood-Nash D. C., Hendrick E. B. and Hudson A. R.

(1971) The significance of skull fractures in children. Radiology 101, 151.

Hendrick E. B., Hardwood-Nash D. C. and Hudson A. R. (1964) Head injuries in children: a survey of 4465 con- secutive cases at the Hospital for Sick Children, Toronto. Canada. Clin. Neurosurg. 11, 46.

Ignelzi R. J. and VanderArk G. D. (1975) Analysis of the treatment of basilar skull fractures with and without anti- biotics. J. Neurosurg. 43, 721.

Jamieson D. L. and Kaye H. H. (1974) Accidental head injury in childhood. Arch. Dis. Child. 49, 376.

Jennett B. (1972) Head injuries in children. Dev. Med. Child. Neural. 14, 137.

Jennett W. B. (1977) An Introduction to Neurosurgery. Lon- don, Heinemann, 264.

King M. D,, Day R. E., Oliver J. S. et al. (1981) Solvent encephalopathy. Br. Med. J. 2, 663.

Lancet (1972) Looking for the leak. Lancet i, 134. Leech P. J. and Paterson A. (1973) Conservative and opera-

tive management of cerebrospinal-fluid leakage after closed head injury. Lancet i, 1013.

Lewin W. (1966) Cerebrospinal fluid rhinorrhoea. Clin. Neurosurg. 12, 231.

Miller J. D. (1976) Infection after head injury. In: Vinken P. J. and Bruyn G. W. (eds) Handbook of Clinical Neuro- logy, Vol. 24. Oxford, North Holland Publishing Com- pany, 215.

Royal College of Radiologists (1983) Patient selection for skull radiograph in uncomplicated head injury. Luncet i, 115.

Paper accepted 18 January 1986.

Requests fur reprints should be addressed too: Dr Y. L. Lau, Institute of Child Health, University of London, 30 Guilford Street, London WClN 1EH.