Neonatal pneumococcal meningitis

Pneumococcus is a major cause of invasive and noninvasive community infections. Invasive pneumococcal infections, especially meningitis, remain serious, with a mortality rate of over 8% and a high risk of sequelae [1]. Data on invasive pneumococcal disease in newborns are limited, studies have rarely focused on meningitis and published series have generally focused on infants up to 90 days of age [2]. The largest cohort of patients with S. pneumoniae meningitis under 28 days included 19 cases [3]. The diagnosis of pneumococcal meningitis is much more diffi cult. The severity of such infections leads to recall, In addition to the diagnostic criteria.


Introduction
Pneumococcus is a major cause of invasive and noninvasive community infections. Invasive pneumococcal infections, especially meningitis, remain serious, with a mortality rate of over 8% and a high risk of sequelae [1]. Data on invasive pneumococcal disease in newborns are limited, studies have rarely focused on meningitis and published series have generally focused on infants up to 90 days of age [2]. The largest cohort of patients with S. pneumoniae meningitis under 28 days included 19 cases [3]. The diagnosis of pneumococcal meningitis is much more diffi cult. The severity of such infections leads to recall, In addition to the diagnostic criteria.

Patients and methods
This is a retrospective study with a descriptive and analytical aim covering the period from January 2014 to July 2020 carried out at the level of the neonatology and neonatal resuscitation service of the Mohamed VI CHU of the mother and children hospital of MOHAMMED VI Marrakech. The usable medical fi les of all newborns aged less than 28 days hospitalized for pneumococcal meningitis were retained. For each patient, we collected the age, sex, infectious history, mode of delivery, duration of symptoms, laboratory parameters, analysis of cerebrospinal fl uid, medical care as well as evolution.

Consent and ethics:
Informed consent from parents was obtained prior to patient recruitment.

Results
The six newborns were the result of unsuccessful term pregnancies, so we do not know the bacteriological status, blood cultures and peripheral samples of mothers. The delivery was vaginally for fi ve newborns and by cezariene for the third case for suspected acute fetal distress. The admission age was one day, two days for 2 patients, and three days for the fourth patient, respectively. Therefore the most likely route of transmission is transplacental. The other 2 patients are aged 6 to 15 days, which suggests the probability of exogenous transmission. The clinical picture is variable and atypical,

Summary
Neonatal pneumococcal meningitis is rare, but serious due to its high mortality and severe psychomotor and neurosensory sequelae.
We report six cases of pneumococcal meningitis collected at the neonatal and neonatal resuscitation department of the CHU Mohamed VI, from January 2014 to July 2020. The aim of our work is to study the peculiarities, clinical, bacteriological, evolutionary of this pathology, and to analyze its transmission during the neonatal period. four patients are aged respectively, one day for one patient, 2 two days for 2 patients and three days for the 4th patient, so the most probable transmission route is transplacental. The other 2 patients were between 6 days and 15 days old, which suggests the probability of exogenous transmission. The clinical picture is variable and atypical, the fever associated with refusal of suckling is found in 100% of patients thus representing the most constant sign. Direct examination of the Cerebrospinal Fluid (CSF) identifi ed the germ in all six cases. thermal disturbances associated with refusal of suckling are found in 100% of patients, Axial hypotonia was found in fi ve newborns. The clinical features of the six newborns are illustrated in Table 1. The biological characteristics of the six newborns are shown in the Table 2. Transcontanellar ultrasound and brain scan revealed hydrocephalus in one newborn and signs of ventriculitis in four patients.
All newborns were put on third-generation cephalosporin at a dose of 100 mg / kg per day for ten days. associated with vancomycin 15 mg / kg / day for 14 days + ciprofl oxacin 20 mg / kg / day for 21 days, in 4 patients with the presence of signs of ventriculitis.
Gardenal loading dose 20 mg / kg then maintenance dose 5 mg / kg in cases of convulsions.
The short-term outcome was favorable for three newborns and one newborn presented with hydrocephalus and four patients presented with ventriculitis, and in the long term one case of epilepsy and two cases of psychomotor retardation. a mortality rate greater than 8% and a high risk of sequelae (30%) and their clinical expression may be atypical [5].

Discussion
Pneumococcal meningitis is rare during the neonatal period (2.2%) [6]. Data on invasive pneumococcal disease in newborns are limited, studies have rarely focused on meningitis, and published series have generally focused on infants up to 90 days of age [7]. A study done at the Marrakech CHU in 2016 and published in 2018, pneumococcal meningitis represents 15% of neonatal meningitis [8].
During our series, two newborns were older than four days (between 6-15 days), which suggests an acquisition of pneumococcus from the nasopharyngeal fl ora of older siblings and family members, this is consistent with the literature [6] and four patients Sixty-six percent of pneumococcal meningitis fall within the framework of early neonatal infections (age <4 days), this is in favor of direct transmission either when crossing the mother's birth canal or by transplacental approach.   bulging of the fontanel, so evocative when it exists, is only present in a third of cases. Hypotonia of the neck or abnormal stiffness when mobilizing the spine with head thrown back [7,9].
The blood count may include several abnormalities (hyperleukocytosis, leukopenia, thrombocytopenia), there remains an examination orienting towardsthe infectious origin and has no specifi city in pneumococcal meningitis. of White Blood Cells (WBC) in the CSF is often increased, as for the leukocyte formula, it typically shows a predominance of polynuclear neutrophil [11]. A variegated (lymphocytic) reaction can however precede the appearance of polymorphonuclear cells. Such a reaction can also be linked to the precocity of the examination or to an inadequate or insuffi cient prior antibiotic therapy (decapitated meningitis). The biochemical examination of the CSF namely glycorachia which is a very important element both for the diagnosis positive for meningitis only for orientation to its bacterial origin. The blood glucose-collapsed ratio is very suggestive. In newborns, a ratio less than or equal to 0.6 is considered abnormal [12]. A CSF glucose concentration of less than 20 mg/L is associated with a higher rate of auditory sequelae [13], in the case of bacterial meningitis, an abnormal proteinorachia (> 0.45 g/L). Direct examination (Gram stain on centrifugation pellet) often allows the probabilistic diagnosis of the responsible germ even before the results of the culture Pneumococcal meningitis is life-threatening and functional (10% mortality and 30% sequelae). The elements of poor prognosis are above all the delay in starting a bactericidal treatment, but also the pneumococcal germ, the severity of the initial neurological picture, the existence of an associated collapse or signs of intracranial hypertension, treated late [5].
In our series, the evolution was favorable, and three patients presented sequelae (one case of epilepsy and two cases of psychomotor retardation).

Conclusion
It emerges from this study the non-specifi city of the signs of purulent meningitis in the neonatal period.Lumbar puncture remains the fundamental examination for the diagnosis.
Both routes of transmission are possible (direct and indirect transmission). Given the immediate severity of the disease and its many sequelae, sometimes disabling, early treatment with generalized pneumococcal vaccination is justifi ed.