There was no history of travel or expo¬ to sick animals. The peripheral WBC






phonuclear leukocytes, Measles Meningoencephalitis: An Unusual Presentation

Measles meningoencephalitis occurs in approximately 0.1% of cases of measles.1 The prognosis is poor, with a 10% to 30% mortality and 20% to 50% morbidity.2 With its variable course, an accurate diagnosis is extremely important. Isolation of the measles virus from the CSF is most difficult, and has been successful only on postmortem specimens.3,4 As a result, the diagnosis of measles meningoencephalitis is based on clinical and serological data. Most commonly, measles meningoencephalitis, as with other forms of aseptic meningitis, is associated with a CSF lymphocytosis. The patient described herein is unusual because of the initial and prolonged CSF poly-

morphonuclear leukocyte response.

Report of a Case.\p=m-\A10-year-old girl was admitted to The Hospital for Sick Children, Toronto. Two weeks prior to admission, she had been in contact with a neighbor with the clinical diagnosis of measles. Ten days prior to admission, cough, coryza, and a low-grade fever had developed. Five days prior to admission, anorexia and conjunc¬ tivitis developed. Three days prior to admission, a maculopapular rash had devel¬ oped and the patient was prescribed erythromycin by her private physician. On the day of admission, the patient exhibited aimless walking and odd behavior. Subse¬ quently she developed facial twitching, decreased sensorium, and irritability. She was taken to a hospital, where she experi¬ enced a generalized grand mal seizure last¬ ing approximately three minutes. She was treated with intravenous diazepam and parenteral phénobarbital. A lumbar punc¬ ture was performed and showed a WBC count of 201/cu mm, 91% of which were polymorphonuclear leukocytes. The glucose level was 75 mg/dL, and protein content was 39 mg/dL. A Gram stain of the CSF showed no organisms. Following the lum¬ bar puncture, another grand mal seizure ensued. On admission to The Hospital for Sick Children, her temperature was 37.8 °C; pulse rate was 80 beats per minute; respi¬ rations were 20/min; and blood pressure was 98/60 mm Hg. She had nuchal rigidity, a generalized maculopapular rash, cervical

lymphadenopathy, bilateral conjunctivitis, nasal discharge, and pharyngitis. Funduscopic examination results were normal, and there were no Koplick spots.

with 84% polymor¬ 13% lymphocytes,

and 3% monocytes. Re-examination of the CSF obtained at the referral hospital confirmed a pleocytosis with polymorphonuclear leukocyte pre¬ dominance (WBCs, 113/cu mm, 93% poly¬ morphonuclear leukocytes, 3% monocytes, 4% lymphocytes, and eight RBCs per cubic millimeter). Bacterial cultures were nega¬ tive. Countercurrent immunoelectrophoresis was negative for Hemophilus influenza B, pneumococcal, and meningococcal group A,B,C, and D antigens. The seizures, altered sensorium, neuro¬ logic abnormalities, and the presence of the CSF polymorphonuclear leukocyte pleocytosis suggested the possibility of a partial¬ ly treated bacterial meningitis. For this reason, the patient was treated with ampi¬ cillin, 400 mg/kg/day, and chlorampheni¬ col, 100 mg/kg/day, intravenously. The patient's condition quickly im¬ proved. By the second day of hospitaliza¬ tion her temperature was normal, she was awake and oriented, and nuchal rigidity had diminished. A repeat lumbar puncture was performed and revealed a WBC count of 225/cu mm, 70% polymorphonuclear leukocytes, 30% lymphocytes, and an RBC count of 35/cu mm. The glucose content was 65 mg/dL with a corresponding blood glucose level of 102 mg/dL. The Gram stain again was negative, and countercurrent immunoelectrophoresis for Haemophilus influenza B, pneumococcal, and meningo¬ coccal antigens was negative. An EEG showed a diffuse abnormality consistent with a generalized disturbance without seizure activity. In view of the negative Gram stain, bacterial cultures, and countercurrent im¬ munoelectrophoresis as well as her rapid clinical improvement, antibiotic therapy was discontinued, despite the persisting

polymorphonuclear leukocyte pleocytosis. The patient continued to improve clinically and was discharged home with normal neurological examination results. Subsequently, her measles titer obtained at admission


less than 1:1 in the CSF

by complement fixation and 1:2 in serum by hemagglutination inhibition. The pa¬ tient was seen two weeks after discharge. Results of her neurological examination

normal. A convalescent titer was acute and convalescent titers run simultaneously showed a rise in measles antibody titer from 1:2 to 1:32, which was consistent with a recent measles infection. Cultures for measles, mumps, enteroviruses, and herpes viruses were negative on both CSF specimens. Serological tests for coxsackie virus and echoviruses, as well as heterophile antibodies, were

drawn, and



Comment.—This case is an example of measles meningoencephalitis con-

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firmed by a five-fold rise in measles hemagglutination inhibition titer. Vi¬ ral meningoencephalitis can often be

differentiated from bacterial menin¬ gitis by the findings of a normal CSF glucose and lymphocyte pleocytosis together with a negative Gram stain and culture. However, as many stan¬ dard textbooks5-7 have pointed out, a

polymorphonuclear leukocyte predom¬ inance can be an early finding in viral meningitis. The shift from early CSF polymorphonuclear response to later lymphocyte predominance can be very

useful when taken in context with the patient's clinical appearance. The ac¬ tual timing of this cellular shift in the course of viral meningitis was studied by Feigin and Shackelford.8 They reported that approximately 87% of patients with viral meningitis showed a shift from polymorphonuclear to

lymphocyte predominance by eight 94% converted within 12 to 72 hours of the initial lumbar puncture. Our patient had her second lumbar puncture approximately 18 hours after the first. Her initial as well as her prolonged polymorphonu¬ clear leukocyte pleocytosis is most unusual. Numerous reports of measles me¬ ningoencephalitis have shown that a

hours, and that

lymphocyte predominance usually oc¬ curs both early and late in the course

of the illness. In all 83 cases described by Sharma et al,9 Meulen et al·' and Katiyar and Agrawal1" lymphocytes predominated. Of the 74 cases of measles meningoencephalitis de¬ scribed by Appelbaum et al,11 70 had a lymphocyte predominance and four had an initial polymorphonuclear pre¬ dominance that later shifted to

lymphocytes. Although Feigin

and Shackelford8 have shown that echovirus, coxsackie virus, and occasionally mumps viruses can cause this polymorphonuclear re¬ sponse, they made no mention of measles. Our case demonstrates that measles must be added to the list of viruses that can manifest with a predominance of polymorphonuclear leukocytes in the CSF, and that this predominance can persist for more than the first 12 to 24 hours and lead to difficulty in distinguishing measles meningoencephalitis from bacterial


WILLIAM ROBERT JARVIS, MD Division of Infectious Disease The Hospital for Sick Children Toronto, Canada

Viral serologie studies and cultures were kindly performed by the Department of Virology, The Hospital for Sick Children, Toronto. 1. Blattner RJ: Measles, in Nelson WE, Vaugh VC, McKay RJ (eds): Textbook of Pediatrics, ed 10. Philadelphia, WB Saunders Co, 1975, p 653. 2. LaBoccetta AC, Tornay AS: Measles encephalitis: Report of 61 cases. Am J Dis Child 107:247,

1964. 3. Meulen V, Muller D, Kackell Y, et al: Isolation of infectious measles virus in measles encephalitis. Lancet 2:1172-1175, 1972. 4. Shaffer MF, Rake G, Hodes HL: Isolation of virus from a patient with fatal encephalitis complicating measles. Am J Dis Child 64:815-819, 1942. 5. Katz SL: Encephalitis, in Barrett HL, and Rudolph AM (eds): Pediatrics, ed 16. New York, Appleton-Century-Crofts, 1977, p 1876. 6. Ray CG: Measles, in Thorn GW, Adams RD, Braunwald E, et al (eds): Harrison's Principles of Internal Medicine, ed 8. New York, McGraw-Hill Book Co Inc, 1977, pp 1011-1013. 7. Horstmann DM: Viral meningitis, in Beenson PP, McDermott W (eds): Textbook of Medicine, ed 12. Philadelphia, WB Saunders Co, 1967, pp 57-60. 8. Feigin RD, Shackelford PG: Value of repeat lumbar puncture in the differential diagnosis of meningitis. N Engl J Med 289:571-573, 1971. 9. Sharma U, Saxena S, Desai K: Measles encephalitis. Ind J Pediatr 42:101-105, 1975. 10. Katiyar GP, Agrawal SP: Measles encephalitis. Ind J Pediatr 41:390-397, 1974. 11. Appelbaum E, Dolgopol VB, Dolgin J: Measles encephalitis. Am J Dis Child 77:25-48, 1949.

Associated With

Endophthalmitis Group-B Streptococcal Meningitis in



In newborns, group-B streptococcal (GBS) infections occur most often as septicemia with or without meningitis and pneumonia.1 Less frequently, in-

fections at many sites are due to this organism. The following report describes GBS meningitis associated with endophthalmitis in a neonate. We are unable to find another report of an intraocular infection associated with this organism.

Report of a Case.\p=m-\An8-day-old girl was admitted to the Children's Hospital of Orange County California on Jan 12, 1976. There was a two-day history of diarrhea and decreased feeding along with periods of lethargy and irritability. The patient was a 3,350-g product of an uncomplicated pregnancy, labor, and delivery. On admission, the patient's temperature was 38.6 \s=deg\C rectally, the pulse rate was 120 beats, respirations were 32/min, and weight was 3,345 g. The infant was very irritable, with a sharp, shrill cry. The neck was supple and the anterior fontanelle was soft and pulsatile. Moderate periorbital edema and erythema were noted on the right side. The bulbar conjunctiva was quite injected. An ophthalmologic examination showed no fixation to light or response to threatening gestures by the right eye. Corneal opacifi-

cation was present and a hypopyon was seen in the temporal area. The left eye was normal. The results of the rest of the physical examination were unremarkable. Admission complete blood cell count showed WBCs to be 14,500/cu mm (57% polymorphonuclear leukocytes, 17% band forms, 3% metamyelocytes, 21% lympho¬ cytes, and 2% monocytes). The CSF contained WBCs, 13,400/cu mm (95% poly¬ morphonuclear leukocytes), and RBCs, 640/cu mm. The CSF glucose level was 18 mg/dL and the protein value was 340 mg/ dL. Gram stain of the CSF showed Grampositive cocci in chains. Meningitis as well as right endophthal¬ mitis and early panophthalmitis was diag¬ nosed. An anterior chamber tap was considered, but was not done because of the infant's precarious condition and the risk of anesthesia. The infant received ampicil¬ lin sodium, 150 mg/kg daily intravenously, and gentamicin sulfate, 7.5 mg/kg daily intramuscularly. Neomycin sulfate and


ophthalmic drops were begun.

Oxacillin sodium, 80 mg, was injected subconjunctively on four occasions during a period of nine days. A hippicuricase-positive nonhemolytic streptococcus later identified as group-B serotype III grew from cultures of the CSF and blood. A co-




from a superficial culture of the right eye. The infant's condition began to improve soon after initiation of treatment. The cornea cleared and the hypopyon resolved. Therapy with the parenteral antibiotics was discontinued after ten days. The spinal fluid at that time showed a WBC count of 186/cu mm (70% polymorphonuclear leuko¬ cytes and 30% lymphocytes), a glucose level of 24 mg/dL, and a protein level of 85 mg/dL. Gram stain and culture of the CSF were negative. Two days later, the infant was discharged. She has been seen at regu¬ lar intervals for 26 months and her devel¬ opment has been normal. A right temporal¬ ly dislocated lens occurred with attachment of the iris to the nasal lens equator. This required lens aspiration and synechiolysis. A sector iridectomy was also performed. Presently, she is fitted with glasses and discerns light with her right eye. Fundoscopic examination of the right eye shows a prominent choroidal pattern and a tempo¬ ral conus. The macula and the disc are within normal limits. The left eye is normal.

Comment.—In the last six years, the GBS has emerged as a major cause of neonatal infections. The "early onset syndrome" and the "late onset syn¬ drome" of the GBS infection in neonates have been well described.1 This patient's clinical picture is consis¬ tent with the late onset syndrome. The type III organism is responsible for the majority of late cases.2 In addition, GBS have caused asympto-

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bacteremia, septic arthritis, osteomyelitis, impetigo, otitis media, cellulitis, ethmoiditis, empyema thoracis, and conjunctivitis.'·4 There seems to be no difference clinically

between infants infected with nonhemolytic strains and those infected with the more common /?-hemolytic organisms."1 This report adds the eye to the list of sites that can be affected by GBS. Most commonly bacterial endoph¬ thalmitis is a complication of surgery or trauma, but an association with meningitis in infants and children has been described.7" Ocular infection may be the first indication of septi¬ cemia." The process may be limited to anterior (iridocyclitis) or posterior structures (choriditis and/or retini¬ tis). The infection may include both the ocular cavities and adjacent struc¬ tures (endophthalmitis), and sur¬ rounding soft tissues may become involved (panophthalmitis). Bacterial ocular infections are usually due to

staphylococci, meningococci, strepto¬ cocci, or pneumococci.7" A recent report described a man with endoph¬ thalmitis and meningitis caused by Streptococcus suis (group R).1" Cul¬ tures from either

or both chambers should be obtained to guide treatment when the patient's condition permits.7 With prompt parenteral and local therapy, some vision may be pre¬ served.7" We recognize that this patient did not have bacteriological confirmation of the intraocular infection as due to GBS, but the clinical course and the response to treatment indicate that the causal agent most likely was the same as that found in the blood and CSF. This case of endophthalmitis adds another presentation to the spec¬ trum of disease already documented for this important neonatal patho¬



WILLIAM L. CARROLL, MD Pius A. MOROZUMI, MD Department of Pediatrics University of California at Irvine FLORENCIO C. CHING, MD Department of Ophthalmology Children's Hospital of Orange

County Orange, Calif

Bascomb Anthony, MD, and his laboratory at Harbor General Hospital, serotyped the organ¬ ism. Sheldon Nankin, MD, permitted us to review this patient's current records, and Meri Carson, MD, of Children's Hospital of Orange County Calif, allowed us to report this ease.

Measles meningoencephalitis: an unusual presentation.

There was no history of travel or expo¬ to sick animals. The peripheral WBC sure count was 8,400/cu mm phonuclear leukocytes, Measles Meningoenc...
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