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July 1988, Volume 38, Issue 7

Letters To Editor

STREPTOCOCCUS PYOGENES MENINGITIS AF1ER MYELOGRAPHY

Sir,

Bacterial or chemical meningitis are rare complications of lumbar puncture performed for diagnostic, therapeutic or anaesthetic purposes.
The incidence of chemical meningitis after myelo­graphy reported by Mayher et al. was 0.05%; acute bacterial meningitis was not recorded in this series of 6,000 myelograms performed over a 10-year period1. We report the first case of Strep­tococcus pyogenes (group A beta.haemolytic streptococcus) meningitis following myelography.
A 63 year old retired engineer was admitted with a 24 hour history of weakness of the lower limbs. Six weeks previously, he had an influenza-like illness and interscapular backache. Examination revealed a sensory loss to all modali­ties at the level of his costal margin; bilateral upper motorneurone weakness and spasticity of the legs were found; anal tone was decreased and there was painful distension of the bladder. He was referred for urgent neurological assessment.
Myelography with tomography showed no abnormality. The cerebrospinal fluid (CSF) obtained at the time of myelograph was clear, colourless, at normal pressure; the white cell count was 78/cu mm (mostly lymphocytes), red cell count 5/cu mm, protein 2.96 g/l and glucose was normal. A diagnosis of transverse myelitis, possibly viral in origin, was made. He was treated with dexamethasone and his neurological condition improved.
Seven days after myelography he developed sudden onset of fever, disorientation, aphasia, marked neck rigidity and brisk reflexes in all limbs. He deteriorated rapidly and became uncon­scious with minimal response to painful stimuli and his breathing was irregular. The peripheral white cell count was 41.0 x 109/i with 90 neutrophils. A lumbar puncture was performed following a normal CT brain scan. The cerebros­pinal fluid was yellow and cloudy, with a white cell count of 28,000/cu mm (mainly polymorphs). Streptococcus pyogenes, which was sensitive to penicillin and chioramphenicol, was cultured. He was treated with intravenous benzyl penicillin, 2 mega units six times daily and chloramphenicol 1 gram four times daily for 12 days. Subsequently he was given 500 mg penicfflin V orally four times daily for a further four days. He made a significant clinical recovery and though 10 days later he developed a large sacral ulcer which became infected with Streptococcus pyogenes which necessitated further treatment with intravenous erythromycin lactobionate 1 gram four times daily for 2 weeks followed by oral therapy for a week. His pressure sore took two months to heal, at which time he had made a significant general and neurological recovery. He was discharged home, where he subsequently fully recovered.
Meningitis due to Streptococcus pyogenes is uncommon and occurs mostly in children3; ear, nose and throat infections, erysipelas, arthritis and trauma are predisposing factors. Various species of streptococci have been reported to cause meningitis following lumbar puncture3. The most likely source of infection is the colonised nasopharynx of the operator, or con­taminated instruments and solutions used for injection where pseudomonas species, Gram-. negative enteric bacilli and Staphylococcus aureus were the causative organisms4.
Acute chemical meningitis may mimick acute bacterial meningitis5. Bacterial culture is necessary to make a definitive diagnosis. Post­myelography meningitis often occurs within the first 24 hours of the procedure but can occur between 12 hours and 10 days6. Lumbar puncture followed by CSF examination and culture should •therefore, be performed in all cases of suspected meningitis.

Nizamuddin N. Damani* Anthony T.L. Chin
Dept. of Medical Microbiology, St. Helier Hospital, Carshalton, Surrey SM5 IAA, England, U.K.
*Current address for correspondence: Belfast city Hospital, Dept. of Bacteriology, Lisburn Road, Belfast BT9 7AD N. IRELAND.

REFERENCES

1. Mayer, W.E., Daniel, E.F., and Allen, M.B. Acute meningeal reaction following pantopaque myelography. J. Neurosurg., 1971; 34: 396-404.
2. Murphy, D. Group A streptococcal meningitis. Paediatrics, 1983; 71: 1-5.
3. Schlesinger, JJ., Salit, I.E., and McCormack, G. Streptococcal meningitis after myelography. Arch. Neurol., 1982; 39: 576-7.
4. Swartz, M.N., and Dodge, P.R. Bacterial meningitis - a review of selected aspects. N. Engl.J.Med., 1965; 272: 898-902.
5. Gibbons, R.B. Chemical meningitis following spinal anaesthesia. JAMA., 1969; 210: 900-902.
6. Cutler, M., and Cutler, P. latrogenic meningitis. JJ. Med. Soc., 1953; 50: 510.

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