Abstract
Introduction
Bacterial meningitis is associated with a high mortality and a high incidence of neurological sequelae. Parainfectious vasculitis leading to ischemic brain damage is a known complication of bacterial meningitis but its treatment is uncertain.
Methods and Results
We report the case of a 53-year-old man with pneumococcal meningitis who developed numerous ischemic lesions in the brainstem and basal ganglia caused by parainfectious vasculitis. Clinical and radiological improvement was observed after delayed corticosteroid initiation. Symptomatic vasculitis relapsed after steroid withdrawal and stabilized after reintroduction of the immunosuppressive therapy. Although the cerebrospinal fluid (CSF) contained high levels of MMP-9 at the time of symptomatic vasculitis, a significant decrease of the enzyme accompanied the introduction of corticotherapy and the regression of vasculitic symptoms. No relation between the level of MMP-9 and the white blood cell count in CSF could be found.
Conclusion
Parainfectious vasculitis may respond to late corticosteroid treatment. MMP-9 level in CSF may be a marker of vasculitic complication in bacterial meningitis.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Durand ML, Calderwood SB, Weber DJ, et al. Acute bacterial meningitis in adults. A review of 493 episodes. N Engl J Med 1993;328:21–28.
Pfister HW, Feiden W., Einhaupl KM. Spectrum of complications during bacterial meningitis in adults. Results of a prospective clinical study. Arch Neurol 1993;50:575–581.
de Gans J, van de Beek D. Dexamethasone in adults with bacterial meningitis. N Engl J Med 2002;347:1549–1556.
Shackley F, Knox K, Morris JB, et al. Outcome of invasive pneumococcal disease: a UK based study. Oxford Pneumococcal Surveillance Group. Arch Dis Child 2000;83:231–233.
Schuchat A, Robinson K, Wenger JD, et al. Bacterial meningitis in the United States in 1995. New Engl J Med 1997;337:970–976.
Nau R, Bruck W. Neuronal injury in bacterial meningitis: mechanisms and implications for therapy. Trends Neurosci 2002; 25:38–45.
Kastenbauer S, Pfister HW. Pneumococcal meningitis in adults: spectrum of complications and prognostic factors in a series of 87 cases. Brain 2003;126:1015–1025.
Tauber MG, Moser B. Cytokines and chemokines in meningeal inflammation: biology and clinical implications. Clin Infect Dis 1999;28:1–11; quiz 12.
Meli DN, Christen S, Leib SL. Matrix metalloproteinase-9 in pneumococcal meningitis: activation via an oxidative pathway. J Infect Dis 2003;187:1411–1415.
Williams PL, Leib SL, Kamberi P, et al. Levels of matrix metalloproteinase-9 within cerebrospinal fluid in a rabbit model of coccidioidal meningitis and vasculitis. J Infect Dis 2002;186:1692–1695.
Leppert D, Lindberg RL, Kappos L, Leib SL. Matrix metalloproteinases: multifunctional effectors of inflammation in multiple sclerosis and bacterial meningitis. Brain Res Brain Res Rev 2001; 36:249–257.
Yushchenko M, Weber F, Mader M, et al. Matrix metalloproteinase-9 (MMP-9) in human cerebrospinal fluid (CSF): elevated levels are primarily related to CSF cell count. J Neuroimmunol 2000;110:244–251.
Leib SL, Clements JM, Lindberg RL, et al. Inhibition of matrix metalloproteinases and tumour necrosis factor alpha converting enzyme as adjuvant therapy in pneumococcal meningitis. Brain 2001;124:1734–1742.
Leib SL, Leppert D, Clements J, Tauber MG. Matrix metallopro-teinases contribute to brain damage in experimental pneumococcal meningitis. Infect Immun 2000;68:615–620.
Backstrom JR, Lim GP, Cullen MJ, Tokes ZA. Matrix metalloproteinase-9 (MMP-9) is synthesized in neurons of the human hippocampus and is capable of degrading the amyloid-beta peptide (1–40). J. Neurosci 1996;16:7910–7919.
Gottschall PE, Yu X, Bing B. Increased production of gelatinase B (matrix metalloproteinase-9) and interleukin-6 by activated rat microglia in culture. J Neurosci Res 1995;42:335–342.
Pagenstecher A, Stalder AK, Kincaid CL, Shapiro SD, Campbell IL. Differential expression of matrix metalloproteinase and tissue inhibitor of matrix metalloproteinase genes in the mouse central nervous system in normal and inflammatory states. Am J Pathol 1998;152:729–741.
Lou J, Gasche Y, Zheng L, et al. Interferon-beta inhibits activated leukocyte migration through human brain microvascular endothelial cell monolayer. Lab Invest 1999;79:1015–1025.
Azeh I, Mader M, Smirnov A, Beuche W, Nau R, Weber F. Experimental pneumococcal meningitis in rabbits: the increase of matrix metalloproteinase-9 in cerebrospinal fluid correlates with leucocyte invasion. Neurosci Lett 1998;256:127–130.
Kieseier BC, Paul R, Koedel U, et al. Differential expression of matrix metalloproteinases in bacterial meningitis. Brain 1999; 122:1579–1587.
Paul R, Lorenzl S, Koedel U, et al. Matrix metalloproteinases contribute to the blood-brain barrier disruption during bacterial meningitis. Ann Neurol 1998;44:592–600.
van de Beek D, de Gans J, McIntyre P, Prasad K. Steroids in adults with acute bacterial meningitis: a systematic review. Lancet Infect Dis 2004;4:139–143.
McIntyre PB, Berkey CS, King SM, et al. Dexamethasone as adjunctive therapy in bacterial meningitis. A meta-analysis of ran-domized clinical trials since 1988. JAMA 1997;278:925–931.
Gasche Y, Fujimura M, Morita-Fujimura Y, et al. Farly appearance of activated matrix metalloproteinase-9 after focal cerebral ischemia in mice: a possible role in blood-brain barrier dysfunction. J Cereb Blood Flow Metab 1999;19:1020–1028.
Chaudhuri A. Adjunctive dexamethasone treatment in acute bacterial meningitis. Lancet Neurol 2004;3:54–62.
Koedel U, Scheld WM, Pfister HW. Pathogenesis and pathophysiology of pneumococcal meningitis. Lancet Infect Dis 2002;2:721–736.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Pugin, D., Copin, JC., Goodyear, MC. et al. Persisting vasculitis after pneumococcal meningitis. Neurocrit Care 4, 237–240 (2006). https://doi.org/10.1385/NCC:4:3:237
Issue Date:
DOI: https://doi.org/10.1385/NCC:4:3:237