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30-day period of life It poses a number of special problems Infants, of course, cannot complain of headache, stiff neck may be absent, and one has only the nonspeci c signs of a systemic illness fever, irritability, drowsiness, vomiting, convulsions and a bulging fontanel to suggest the presence of meningeal infection Signs of meningeal irritation do occur, but only late in the course of the illness A high index of suspicion and liberal use of the lumbar puncture needle are the keys to early diagnosis Lumbar puncture is ideally performed before any antibiotics are administered for other neonatal infections An antibiotic regimen suf cient to control a septicemia may allow a meningeal infection to smolder and to are up after antibiotic therapy for the systemic infection has been discontinued A number of other facts about the natural history of neonatal meningitis are noteworthy It is more common in males than in females, in a ratio of about 3:1 Obstetric abnormalities in the third trimester (premature birth, prolonged labor, premature rupture of fetal membranes) occur frequently in mothers of infants who develop meningitis in the rst weeks of life The most signi cant factor in the pathogenesis of the meningitis is maternal infection (usually a urinary tract infection or puerperal fever of unknown cause) The infection in both mother and infant is most often due to gram-negative enterobacteria, particularly E coli, and group B streptococci and less often to Pseudomonas, Listeria, Staph aureus or epidermidis (formerly albus), and group A streptococci Analysis of postmortem material indicates that in most cases infection occurs at or near the time of birth, although clinical signs of meningitis may not become evident until several days or a week later In infants with meningitis, one should be prepared to nd a unilateral or bilateral sympathetic subdural effusion regardless of bacterial type Young age, rapid evolution of the illness, low polymorphonuclear cell count, and markedly elevated protein in the CSF correlate to some extent with the formation of effusions, according to Snedeker and coworkers Also, these attributes greatly increase the likelihood of the meningitis being associated with neurologic signs Transillumination of the skull is the simplest method of demonstrating the presence of an effusion, but computed tomography (CT) and magnetic resonance imaging (MRI) are the de nitive diagnostic tests When aspirated, most of the effusions prove to be sterile If recovery is delayed and neurologic signs persist, a succession of aspirations is required In our experience and that of others, patients in whom meningitis is complicated by subdural effusions are no more likely to have residual neurologic signs and seizures than are those without effusions.

Figure 13-10

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