Post GBS Meningitis Seizures

by Changge
(Alexandria, VA)

Doc, my friend’s newborn baby, who was born healthy, developed post GBS meningitis resistant seizures and development delay. Her daughter’s situation is shown below:

A female baby was born with a full-term natural delivery and birth weight 3.4kg on February 5, 2015 in Beijing.

At the age of 21 days she was diagnosed as a case of neonatal sepsis (GBS-) and neonatal purulent meningitis (GBS-). She had been treated with antibiotics from March 6 to April 3, 2015.

After being discharged from the hospital, the infant developed spasm-like symptoms from mild ones daily to severer ones once a week or a few weeks.

The mild spasm-like symptoms include a sudden whole body bending forward, clenched fist, curled up feet, eye strabismus to the top left, fast blinking eyes but no crying. The severe spasm-like symptoms include whole body rapid bending forward, hand shaking violently, and crying hysterically with a loud voice. The most serious one appeared on January 16, 2016.

So far, following examinations have been done on the baby: blood test, the optic nerve check, trace elements, hearing tests, abdominal ultrasound, EEG, and brain CT/MR.

Currently, no hospitals in China would treat the infant. My friend asked me if I can find someone to help her baby. Doc please help her. I really appreciate your generous help. – Changge

The Expert, Ren Chats Answers

Thank you for your confidence in the website and me.

Meningitis is a frequent complication of Group B streptococcus (GBS) septicaemia. It primarily affects term infants with an unremarkable maternal history, birth history, and early neonatal course, the period before 7 days of age.

Prevalence

Almost 1 in 3 healthy pregnant women harbour GBS in vaginal and rectal flora. Half of the babies born to these mothers acquire GBS colonization, of which 2% develop GBS disease. The chances of developing early (less than 7 days of age) or late (more than 7 days of age) onset disease are fifty-fifty.

Prevention

Screening of all expectant mothers at 35--37 weeks of gestation for GBS colonization, and prophylactic administration of antibiotics during labour has significantly reduced the incidence of early-onset GBS disease among newborns. But the incidence of the late-onset disease remains unchanged.

Risk factors

The risk factors for late-onset invasive GBS disease are not well defined. Though vertical transmission from the mother is believed to be the commonest source of infection, neonates’ grossly immature immune system makes them particularly vulnerable to GBS in their new environment.

Disease presentation is misleading

The classic signs like bulging fontanelle and nuchal rigidity are more common in neonates with late-onset than early-onset meningitis, but initially it typically manifests only with fever and lethargy. The absence of seizures in the early stages delay the initiation of aggressive antibiotic therapy needed to stop the progressive inflammatory damage. About a week’s delay is noted in your case as well.

Prognosis

Nevertheless, the outcome of neonatal bacterial meningitis remains unsatisfactory even on early management with the latest available highly potent antibiotics. It commonly leaves behind devastating neurological sequelae, of which seizures and other abnormal movements are the commonest.

About 10 to 15% cases suffer from prolonged intractable seizures, attributed to neuron damage due to infection related vascular events, such as intracranial bleeds, arterial strokes or venous sinus thrombosis and ischemic strokes, which are usually demonstrable on neuroimaging and MR venography studies. Affected infants frequently suffer delay in development of milestones, language, and intelligence, which lead to gross behaviour issues and learning disabilities.

Treatment for post meningitis seizure disorder

Seizures secondary to meningitis are difficult to control. Hence they are commonly termed as “refractory,” or “drug resistant.” Moreover, the focal abnormal electrical activity in the brain often spreads rapidly in to generalized tonic, clonic, or tonic and clonic activity with eye and head deviation to the opposite side of the brain lesion. Most such seizures last 1-2 min. Tongue biting, urinary and stool incontinence, vomiting with risk of aspiration, and cyanosis are common. Fractures of the vertebrae or upper limb bones are rare complications. The long-term therapy needed in such cases should therefore be in conjunction with the treating paediatrician and a neurologist.

Infants who do not respond to usual antiepileptic medications, can be considered for guarded therapeutic trial with intravenous vitamin B6 under continuous EEG monitoring to rule out pyridoxine-responsive seizures. Full metabolic work-up, including amino acids, organic acids, biotinidase, and CSF studies, may also be asked for.

In hope to offer cure or reduction of seizures, surgical treatment is sometimes advised to drug resistant cases, but the chances of improvement need to be carefully weighed against the potential side-effects of the procedure. However, around one third of the cases neither respond to medical nor to surgical treatment.

Infants with post meningitis seizure require comprehensive care to improve their quality of life, and to deal with associated complications and disorders. Their parents need to be educated and given emotional support to handle the seizures. They can find help and more information at http://www.epilepsy.com/helpline

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