ORIGINAL

Niger J Paed 2013; 40 (3) : 295 –298

Frank-Briggs AI

Alikor EAD

Long term neurological

complications of bacterial

meningitis in Nigerian children

DOI:http://dx.doi.org/10.4314/njp.v40i3,19

Accepted: 11th March 2013

Abstract Background: Neurologi-

cal disorders in children are com-

mon occurrence in clinical prac-

tice. The disorder account for

more than 170,000 deaths world-

wide each year and contributes to

the world's disease burden with

majority of people affected living

in Africa. When affected by such

illnesses, a person's memory, mo-

tor and cognitive abilities, con-

centration, speech, and physique

can be drastically altered. Many

of these disorders are chronic,

frustrating to caregivers and par-

ents and require adequate under-

standing to cope with manage-

ment. Bacterial meningitis con-

tributes significantly to this mor-

bidity and mortality in sub-

Saharan Africa, known as the

Paediatric neurology unit of the

University of Port Harcourt Teach-

ing Hosp_si_ttal, Nigeria between

Jan_s_tuary 1 2010 and December,

31 2012. Descriptive analysis

(

)

Frank-Briggs AI

Alikor EAD

Department of Pediatrics & Child

Health University of Port-Harcourt

Teaching Hospital,

®

was done using SPSS version 17.

Port-Harcourt, Nigeria

Result and Conclusion: Out of

7,644 patients seen in the depart-

ment, 624 of them were diagnosed

with meningitis given a prevalence

of 8.16%.These patients were fol-

lowed up at least one year in the

neurological outpatient clinic to

assess the outcome post admission.

Those with neurological sequelae

were 94 cases (given a prevalence

of 15.06%) comprising 58 males

and 36 females which gave a ratio

of 1:0.6. The most common com-

plication was recurrent seizure

disorder in 28(29.79%) of them

and motor developmental delay in

almost 20% of them. Others are

focal neurologic deficits and neu-

ropsychologic impairment. The

impact and consequences of men-

ingitis is grave, it is important to

prevent the disease at all cost.

“

meningitis belt”.

This study highlights the long

term neurological complications

of bacterial meningitis amongst

children who were on follow up at

the neurology unit at the Univer-

sity of Port Harcourt Teaching

Hospital (UPTH), a tertiary hospi-

tal in Southern Nigeria.

Key words: Meningitis, children,

Neurologic complications, long-

term.

Method: This is a three year

follow up prospective study of

children with meningitis at the

Introduction

Survivors of bacterial meningitis risk lifelong sequelae.

The incidence, type and severity of sequelae is influ-

enced by the infecting organism, the age of the child and

the severity of the acute illness, but it can be difficult to

predict which children will develop sequelae. The po-

tential impact of the illness is further complicated by the

fact that some of these sequelae may not become appar-

Bacterial meningitis is a serious, often disabling and

potentially fatal infection resulting in 170,000 deaths

worldwide each year . Young children are particularly

vulnerable to bacterial meningitis, and when exposed

poor outcomes may occur due to the immaturity of their

immune systems. The consequences are life threaten-

1

2

4,5

ent until months or years after the acute illness. These

ing. Two thirds of meningitis deaths in low-income

countries occur among children under 15 years of age.

The main bacterial pathogens causing meningitis beyond

the neonatal period are Streptococcus pneumoniae

complications comprise a range of findings with impli-

cations for child development and functioning and in-

clude such deficits as hearing loss, visual loss, recurrent

seizures, cognitive delay, speech/language disorders,

6,7,8

behavioral problems and motor delay/impairment.

(

pneumococcus), Haemophilus influenzae typ_,e₃ b (Hib)

2

and Neisseria meningitidis (meningococcus). Serious,

long-term neuropsychological complication further in-

crease the population impact of Paediatric meningitis.

Others include attention deficit hyperactivity disorder

and altered mental status. These long-term problems

pose serious hardship for families with limited means to

2

96

care for a disabled child, especially in resource-poor

settings. The objective of this study was to present a

systematic review of the complications following acute

bacterial meningitis in children between the ages of 1

month and 15 years who were managed and discharged

to the neurology out-patient’s clinic for follow up in

UPTH.

complications among the study population was thus

15.06%. The demographic data of the group showed that

there were 58 males and 36 females which gave a ratio

of 1:0.6. The groups with the largest complications were

the 1-5 year olds which made up of 28 males and 16

females, this constituted 46.81%. (Table1). The most

common sequelae was recurrent seizure disorder in 28

(

29.79%) of the study group. The others were cerebral

palsy17 (18.09%), hearing impairment and neuropsy-

chological problems. Table 2 shows the pattern of com-

plications in the study group. The aetiological agent

identified in the cerebrospinal fluid culture included

streptococcus pneumonia in 31(32.97 %) of the children

at the initial presentation prior to treatment. In 46

(48.94%) no pathogen was isolated. The other identified

aetiological agents are shown on Table 3.

Patients and Method

This was a three year follow up prospective study of

children with meningitis at the Paediatric neurology unit

of the University o_s_tf Port Harcourt Teachin_s_tg Hospital,

Nigeria between 1 January, 2010 and 31 December

2

012. The Teaching Hospital was established in 1979. It

is the only tertiary hospital located in the metropolis of

Port Harcourt, the capital of Rivers State. Nigeria. Port

Harcourt lies between longitudes 60 55' and 70 15' east

and latitudes 40 35' and 40 46' north. The hospital offers

tertiary level of care for its patients and serves as a gen-

eral/referral centre for neighboring states. Basic demo-

graphic details such as, age, sex, tribe, religion, address,

occupation of parents, and educational levels of parents

were all obtained. The complaints (symptoms) at presen-

tation included recurrent afebrile seizures, recurrent

headache, inability to see since discharge from the hos-

pital, inability to walk, inability to attain motor mile-

stones, not hearing, abnormal behavior, stiffness of the

body, restlessness, abnormal posturing, hyperactivity

and poor learning/ poor academic performance at

school. The examination findings ( signs obtained) were

hypertonia( spasticity of the limbs), hyperreflexia and

reduced motor power for those with hemiplegia, visual

loss, low intelligence quotient. The patients who were

not able to see were referred to the ophthalmology clinic

for further evaluation and confirmation of visual loss.

The patients with mental retardation and learning dis-

ability were assessed using the simple tests for intellec-

tual achievement. Audiological evaluation was done for

those with hearing impairment. Radiological investiga-

tions such as Computed tomography and/ or magnetic

resonance imaging of the brain were carried out when

needed. Other parameters recorded included duration of

stay in the hospital, duration of antibiotic treatment.

Long term complications of meningitis were regarded as

the symptoms and signs (sequelae) that were present and

observed from three months after meningitis infection.

Data were analyzed using descriptive statistics.

Table 1: Demographics of the Study group

Age (years)

Sex

Total

Male

15

28

12

3

Female

>

1

9

16

7

4

36

24

44

19

7

1

6

1

-5

-10

1-16

Total

58

94

Table 2: Types of Neurological sequelae amongst the study

group

Type

Number

Female

Percentage

Male

19

10

4

6

5

4

2

Seizure disorder

Cerebral palsy

9

7

5

3

2

1

3

2

29.79

18.09

9.57

7.45

6.38

5.32

3.19

5.32

2.13

Hearing impairment

Learning disability

Mental retardation

Speech impairment

Hemiplegia

Visual impairment

Sleep disturbance

Behavioral problem

ADHD

2

0

Table 3: Aetiological agent and number of children with

Complications

Aetiological agent

Number affected

Percentage

Streptococcus pneumonia

Mycobacterium Tuberculosis

Haemophilus inflenzae

Meningococcal meningitis

No pathogen identified

31

8

5

4

32.97

8.51

5.32

4.26

46

48.94

Discussion

Result

In the study the under fives were mainly affected with

post meningitic n_, e₉urologic complication. This is similar

Total admissions in the Paediatric unit over the period of

three years were 7,644 patients. Out of this, 624 of them

were diagnosed with meningitis given a prevalence of

7

to other reports. This age bracket heralds the period of

maximal brain development and any assault or insult to

the developing brain results in neurophysiologic seque-

lae. Twenty eight (29.79%) of children with long term

complications presented with recurrent seizure disorder.

This is similar to other studies where seizures occur in

8

.16%.These patients were followed up over a period of

one year in the neurology outpatient clinic to assess the

outcome post admission. Those with neurologic compli-

cations were 94 cases. The prevalence of long term

2

97

2

gitis. The pathogenesis of seizures in meningitis is

0 to₂3_,0₁₀percent of children with acute bacterial menin-

children with mild to severe intellectual disability

(mental retardation). Other sequelae seen in the study

included learning disability, behavioral disorder includ-

ing attention deficit hyperactivity disorder; these have

been reported in several prospective studies where out-

comes in survivors of bacteria₁l₅_-₂m₀ eningitis have been

not well understood. Although fever may be a cofactor

in very young children, cerebrovascular inflammation or

secondary neurochemical changes are presumably the

cause of most seizures. Seizures that occur early in the

course of bacterial meningitis are easily controlled and

are rarely associated with permanent or long term neu-

rologic complications. In contrast, seizures that are pro-

longed, difficult to control, or begin more than 72 hours

after hospitalization are more likely to be associated

with neurologic sequelae, suggesting that₂a_,₄c_,₉e_,₁r₁ebrovas-

shown to have similar results.

The main causative

organisms identified in our study was streptococcus

pneumonia (32%). This is different from that reported

by Taylor₁₅e_.₂t₁_.₂a₂l where about 37% was caused by H. in-

fluenza .

In 48.94% of cases no pathogen was

identified. This may be due to prior use of antibiotics by

most of our patients who buy and practice self medica-

tion at home many days before presenting to a health

facility for proper treatment and management. The inap-

propriate use of antibiotics gives false negative result in

the analysis of the cerebrospinal fluid and blood culture.

The correct causative organism will not be obtained in

the culture and this may lead to inaccurate drug

treatment.

cular complication may have occurred.

In our

study 5.38% of the children had a significant motor im-

pairment that presented as hemiparesis / hemiplegia.

This is a focal neurologic complication of bacterial men-

ingitis which is devastating to the affected children and

caregivers. Paresis resulting from meningitis generally

improves with time. In a study which reviewed about

2

00 children with bacterial meningitis, hemiparesis and

or quadriparesis was noted in 30 patients (12%) shortly

after discharge, but persisted in 5 (2 %) one year after

7

discharge. Paresis typically results from an intracranial

abnormality such as cortical vein or sagittal vein throm-

bosis, cerebral artery spasm, subdural effusion or em-

pyema, cerebral infarct or abscess amongst others.

Conclusion

4

,9

Bacterial meningitis continues to result in substantial

morbidity and mortality despite the availability of effec-

tive antimicrobial therapy. The risk of developing long

term sequaelae /complications is related to the age and

underlying condition of the patient, the causative patho-

gen, the severity and duration of illness at the time of

presentation, and, occasionally, due to delays in the ini-

tiation of appropriate antibiotic therapy. It is important

for clinicians that treat these children to follow them up

closely so as to identify those with serious neurological

complications. This is important as early detection, insti-

tuting prompt management including rehabilitation will

go a long way to reduce the incidence of very serious

disabilities and improve the quality of life of affected

children.

Other forms of focal deficit amongst the study group

was hearing loss in 9(9.57%). This is similar to perma-

nent sensorineural hearing loss which occurred in as

m₇_,₁a₂ny as 11 percent of children with bacterial meningitis.

It is known that hearing loss after bacterial meningi-

tis may be transient or permanent. Transient hearing loss

may be secondary₁₃to a conductive disturbance in many

affected patients. However, sensorineural hearing loss

(

transient or permanent) can result from damage to the

eighth cranial nerve, cochlea, or labyrinth, induced by

direct bacterial invasion and/or the₁₃_,i₁n₄flammatory

response elicited by the infection.

The other very important complication was the neuro-

psychologic impairment s which we found. 7(7.45%) of

the children had mental retardation.₁₅This has been recog-

nized in other studies by Peltola H who reported 4% of

Conflict of Interest: None

Funding: None

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