METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS MENINGITIS WITH BELL'S PALSY
Shalini Avasthi*, O P Bhatt**, Sunil Taneja**, Samarth Vohra**
Department of Pediatrics,*UHM, Hospital, Kanpur, ** Madhuraj Hospital, Kanpur
Address for Correspondence
Dr Shalini Avasthi, L-30 GSVM campus, Swaroop Nagar, Kanpur.
Email
shalini.avasthi@rediffmail.com
Keywords
community acquired MRSA, CA-MRSA, pyogenic meningitis
A 4 month old girl presented with right sided Bell's palsy. There was history of fever for 1 week for which she had received intravenous antibiotics. There was no history of ear discharge, head trauma and birth asphyxia. All the developmental milestones were normal as per the age. On examination she had right sided lower motor neuron type facial nerve palsy. Other systems were normal. Investigations showed hemoglobin of 9gm%, white cell count of 24,200/cumm (83% polymorphs, 14% lymphocytes, 1% eosinophils, 2% monocytes), platelet count of 65,000/cumm. Cerebrospinal fluid (CSF) showed 640 cells/cumm (60% polymorphs. 40% lymphocytes), proteins 53 mg% and sugar 37 mg%. CT scan brain was normal. Diagnosis of partially treated pyogenic meningitis was made. She was treated with intravenous ceftriaxone and amikacin. After 72 hours on this treatment, child continued to have fever and suddenly developed bilateral lateral rectus palsy. Repeat CSF examination showed 1100 cells/cumm (52% polymorphs, 48% lymphocytes), protein 58gm% and sugar 27mg%. At the same time the report of the first CSF culture showed growth of MRSA sensitive to Vancomycin. MRI brain was done which showed meningitis. Child was started on Vancomycin at 60 mg/kg/day. After Vancomycin, patient improved clinically, was afebrile, she was able to close right eye and right nasolabial fold appeared. CSF examination, after 21 days of intravenous Vancomycin was normal and the repeat culture was sterile. However bilateral lateral rectus palsy persisted.

Traditionally Methicillin resistant Staphylococcus Aureus (MRSA) infections have been acquired almost exclusively in hospitals, long-term care facilities, or similar institutional settings. (1) Risk factors for MRSA colonization or infection in the hospital include prior antibiotic exposure, neurosurgery, admission to an intensive care unit, surgery, and exposure to an MRSA-colonized patient. (2) Community acquired MRSA infection (CA-MRSA) is associated with a history of recent hospitalization, close contact with a person who has been hospitalized, or other risk factors, such as previous antimicrobial drug therapy. CA-MRSA infections in the absence of identified risk factors have been reported infrequently. A study done at Chicago demonstrated that that the prevalence of CA-MRSA among children without identified risk factors is increasing. (3) Pyogenic meningitis due to MRSA has been rarely reported. One case of MRSA pyogenic meningitis in an adult has been reported in which also the MRSA meningitis was spontaneous however it was not associated with any focal neurological deficits. (4) Bell's palsy as a presentation of pyogenic meningitis without predisposing factors is also rare. In a case report, authors have reported an unusual case of bilateral simultaneous facial palsy occurring during the course of a persistent otitis media in a 7 month-old child. (5) Similarly there is a case report of a patient with Streptococcus pneumoniae meningitis, multiple cranial nerve involvement, and cerebellar signs suggestive of basilar meningitis. (6)Two cases with Bell's palsy due to Varicella Zoster virus in children are reported. These children were also had pyogenic meningitis. (7)

Thus MRSA infections in children can occur without predisposing factors and can lead to pyogenic meningitis with focal neurological deficits.

Competing interests- none
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Funding
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Conflict of Interest
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Last Updated : Tuesday, May 01, 2012 Vol 9 Issue 5 Art #29
DOI: 10.7199/ped.oncall.2012.29
How to Cite URL :
Avasthi S, Bhatt P O, Taneja S, Vohra S. METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS MENINGITIS WITH BELL'S PALSY. Pediatric Oncall [serial online] 2012[cited 2012 May 1];9. Art #29. Available From : http://www.pediatriconcall.com/Journal/Article/FullText.aspx?artid=478&type=J&tid=&imgid=&reportid=188&tbltype=
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