Letter to the Editor
“Sweet tears”: Streptococcus salivarius meningitis secondary to ethmoidal mucocele
«Lágrimas dulces»: meningitis bacteriana por Streptococcus salivarius secundario a mucocele etmoidal
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Resonancia magnética craneal que confirma los hallazgos previos, y descarta la presencia de mielomeningocele, cortes coronal (C) y sagital (D).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "C.M. Oblitas, A. Sánchez-Soblechero, M.D. Pulfer" "autores" => array:3 [ 0 => array:2 [ "nombre" => "C.M." "apellidos" => "Oblitas" ] 1 => array:2 [ "nombre" => "A." 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A propósito de un caso" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1227 "Ancho" => 2167 "Tamanyo" => 211275 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Axial T2-weighted FLAIR brain MRI scan obtained in a 3T scanner at the time of diagnosis, before treatment onset. A) The image shows numerous hyperintense punctiform foci measuring < 3<span class="elsevierStyleHsp" style=""></span>mm in diameter (“salt and pepper sign”), predominantly in the infratentorial region (particularly affecting the middle cerebellar peduncles and pons), with no perilesional mass effect. B) Homogeneous gadolinium enhancement in all punctiform foci.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "I. Esparragosa Vázquez, R. Valentí-Azcárate, J. Gállego Pérez-Larraya, M. Riverol Fernández" "autores" => array:4 [ 0 => array:2 [ "nombre" => "I." "apellidos" => "Esparragosa Vázquez" ] 1 => array:2 [ "nombre" => "R." "apellidos" => "Valentí-Azcárate" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Gállego Pérez-Larraya" ] 3 => array:2 [ "nombre" => "M." 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"tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "684" "paginaFinal" => "687" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Trastorno psicótico <span class="elsevierStyleItalic">de novo</span> inducido por levetiracetam: ¿existe un perfil de paciente epiléptico neuroestructural y/o biológicamente más vulnerable a desarrollarlo?" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1394 "Ancho" => 1250 "Tamanyo" => 197597 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Neuroimaging studies performed in our 3 patients. A) Brain MRI scan (axial plane, FLAIR sequence) showing multiple patchy areas of corticosubcortical hyperintensity bilaterally, including the hippocampus (particularly the left; purple arrow) and the pons (orange arrows). B) Brain MRI scan (axial plane, non-contrast T1-weighted sequence) showing a hypointense region in the left hippocampus (suggestive of chronic progression; light blue arrow) and signal hyperintensity in the ipsilateral occipital region (suggestive of subacute lesion; green arrow). C) Non-contrast head CT scan (axial plane) revealing a hyperdense area in the right temporal lobe, with no intraventricular extension, and surrounding vasogenic oedema (red arrow). D) CT angiography of the supra-aortic trunks and circle of Willis confirming the presence of an arteriovenous malformation in the right temporal region (dark blue arrow), mainly supplied by the right middle cerebral artery, as well as by the right posterior cerebral artery through the lateral posterior choroidal arteries, and with venous drainage through the right transverse and sigmoid sinuses.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. León Ruiz, M.L. Rodríguez Sarasa, L. Sanjuán Rodríguez, J. Benito-León, O. Álvarez de Toledo, M.T. Pérez Nieves, S. Arce Arce" "autores" => array:7 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "León Ruiz" ] 1 => array:2 [ "nombre" => "M.L." "apellidos" => "Rodríguez Sarasa" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Sanjuán Rodríguez" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Benito-León" ] 4 => array:2 [ "nombre" => "O." "apellidos" => "Álvarez de Toledo" ] 5 => array:2 [ "nombre" => "M.T." 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Oblitas, A. Sánchez-Soblechero, M.D. Pulfer" "autores" => array:3 [ 0 => array:4 [ "nombre" => "C.M." "apellidos" => "Oblitas" "email" => array:1 [ 0 => "crhistian.cao@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Sánchez-Soblechero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "M.D." "apellidos" => "Pulfer" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "«Lágrimas dulces»: meningitis bacteriana por <span class="elsevierStyleItalic">Streptococcus salivarius</span> secundario a mucocele etmoidal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1141 "Ancho" => 1250 "Tamanyo" => 145843 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Coronal (A) and sagittal (B) face CT scans revealing a hypodense mass in the right anterior ethmoidal air cells and a defect in the ipsilateral cribriform plate. Coronal (C) and sagittal (D) brain MRI sequences confirming these findings and ruling out myelomeningocele.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Bacterial meningitis is associated with high morbidity and mortality rates. Some of the main pathogens that can cause the disease include <span class="elsevierStyleItalic">Streptococcus pneumoniae</span>, <span class="elsevierStyleItalic">Neisseria meningitidis</span>, and <span class="elsevierStyleItalic">Haemophilus influenzae</span> in the general population; and <span class="elsevierStyleItalic">Streptococcus agalactiae</span> and <span class="elsevierStyleItalic">Listeria monocytogenes</span> in neonates and immunosuppressed individuals, respectively. The recommended empirical treatment for community-acquired bacterial meningitis is a combination of cephalosporins and vancomycin, which may also be combined with another beta-lactam antibiotic.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a><span class="elsevierStyleItalic">Streptococcus salivarius</span> meningitis is infrequent in our setting, and is mainly associated with spinal procedures.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 54-year-old woman with no relevant medical or surgical history who visited the emergency department due to sudden-onset holocranial headache of 6 hours' progression, fever (38.5 °C), nausea, and vomiting. She also reported a 4-month history of “sweet tears” associated with right rhinorrhoea triggered by anterior flexion of the neck in both seated and standing positions; this may be attributable to decreased venous return and the transient increase in intracranial pressure. The physical examination revealed general discomfort, blood pressure of 158/89 mm Hg, heart rate of 106 bpm, room-air oxygen saturation of 95%, and rhythmic breathing with normal breath sounds. The neurological examination revealed somnolence (Glasgow Coma Scale: motor 6, verbal 4, eye 3). A head CT scan revealed no abnormal findings. Lumbar puncture revealed purulent CSF; opening pressure could not be measured. A CSF analysis showed 5360 leukocytes/µL (normal range: <5), 74% polymorphonuclear; a protein level of 173 mg/dL (normal range: <30); and a glucose level of 60 mg/dL (normal range: 40-70). A blood analysis revealed a serum glucose level of 154 mg/dL. The patient was diagnosed with bacterial meningitis.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We started intravenous empirical treatment with ceftriaxone 2 g every 12 hours, vancomycin 1 g every 12 hours, ampicillin 2 g every 4 hours, and a single dose of dexamethasone 4 mg. Polymerase chain reaction (PCR) amplification of 16S rRNA genes in CSF yielded negative results for <span class="elsevierStyleItalic">S. pneumoniae</span>, <span class="elsevierStyleItalic">L. monocytogenes</span>, and <span class="elsevierStyleItalic">N. meningitidis</span> and positive results for <span class="elsevierStyleItalic">S. salivarius</span>, which is susceptible to cephalosporins. Blood culture findings (1:3) 48 h later were positive for <span class="elsevierStyleItalic">S. salivarius</span>.</p><p id="par0020" class="elsevierStylePara elsevierViewall">A biochemical study of nasal discharge revealed a glucose level of 51 mg/dL, 17 leukocytes/µL, and a protein level of 89 mg/dL.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Face CT (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B) and brain MRI scans (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C and D) revealed mucocele in the right ethmoidal air cells measuring 2 cm axially, and a 4-mm defect in the ipsilateral cribriform plate, related with the dural fistula, with MRI detecting no signs of myelomeningocele. The patient continued on ceftriaxone 2 g every 24 hours for 14 days, remaining asymptomatic at discharge. Two months later, the patient underwent surgical excision of the mucocele and endoscopic repair of the CSF fistula on an outpatient basis. After 2 years of follow-up, the patient remains asymptomatic and has presented no further episodes.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">S. salivarius</span>, which belongs to the viridans group of streptococci, is a commensal bacterium found in the orogastrointestinal and upper respiratory tracts. Despite its low virulence, it has been associated with bacteraemia, sinusitis, meningitis (approximately 0.3%-2.4% of cases), and endocarditis. Factors potentially favouring the development of <span class="elsevierStyleItalic">S. salivarius</span> meningitis include presence of CSF fistulas, sinusitis, brain abscesses, head trauma, and neoplasia.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Diagnosis is made by isolating the pathogen in CSF cultures or by PCR. Cross-reaction with other <span class="elsevierStyleItalic">Streptococcus</span> species (<span class="elsevierStyleItalic">S. pneumoniae</span>) has been reported, which may result in aetiological misdiagnosis and underdiagnosis of the condition.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The genus <span class="elsevierStyleItalic">Streptococcus</span> presents adequate sensitivity to beta-lactams.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Although bacterial meningitis is a rare complication of spinal procedures (eg, lumbar puncture), it may have a fatal outcome.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In recent years, several cases have been reported of bacterial meningitis following spinal procedures. The most frequently identified pathogens were oral commensals (viridans group streptococci), which suggests the possibility of direct transmission by physicians through droplets if masks are not used during the procedure.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–10</span></a> The literature includes only one case of <span class="elsevierStyleItalic">S. salivarius</span> meningitis secondary to sphenoid sinus mucocele,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> resembling our own. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> compares the clinical characteristics of previous cases of <span class="elsevierStyleItalic">S. salivarius</span> meningitis to the case presented here.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion, mucocele or CSF fistula should be suspected in patients with <span class="elsevierStyleItalic">S. salivarius</span> meningitis and no history of spinal procedures; neuroimaging studies should be performed in these patients. As spinal procedures constitute the main risk factor for <span class="elsevierStyleItalic">S. salivarius</span> meningitis, we should stress the need for systematic use of face masks during these procedures.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0050" class="elsevierStylePara elsevierViewall">No funding was received for this study.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "xack602788" "titulo" => "Acknowledgements" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:1 [ "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as: Oblitas CM, Sánchez-Soblechero A, Pulfer MD. «Lágrimas dulces»: meningitis bacteriana por <span class="elsevierStyleItalic">Streptococcus salivarius</span> secundario a mucocele etmoidal. Neurología. 2020;35:687–690.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1141 "Ancho" => 1250 "Tamanyo" => 145843 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Coronal (A) and sagittal (B) face CT scans revealing a hypodense mass in the right anterior ethmoidal air cells and a defect in the ipsilateral cribriform plate. Coronal (C) and sagittal (D) brain MRI sequences confirming these findings and ruling out myelomeningocele.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">CSF: cerebrospinal fluid; GCS: Glasgow Coma Scale.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">+: present; −: absent.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Source: taken from Wilson et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Previous cases (n = 65) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Our patient \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Male/female ratio</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24/46:22/46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Woman \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Age at diagnosis</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">44.5 (mean)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">54 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Signs/symptoms</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Abnormal GCS score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30/53 (57%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Headache \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40/53 (75%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fever \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">44/53 (83%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Nausea/vomiting \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27/53 (51%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Meningeal signs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37–39/53 (70%-74%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">− \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Positive CSF culture</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23/42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Positive blood culture</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13/46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1:3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Initial treatment</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cephalosporins \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31/49 (63%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Vancomycin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18/49 (37%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ampicillin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4/49 (8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dexamethasone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3/49 (6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Risk factors</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Iatrogenesis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39/58 (67%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">− \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>CSF fistula \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12/58 (21%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">− \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mucocele \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1/58 (2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Other \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13/65 (20%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">− \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Survival \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">55/57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2905181.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Age at diagnosis was not reported in 10 cases.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Clinical characteristics of previously reported cases of <span class="elsevierStyleItalic">Streptococcus salivarius</span> meningitis and of our own.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Update on community-acquired bacterial meningitis: guidance and challenges" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C.N. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 1 | 10 |
| 2024 October | 39 | 2 | 41 |
| 2024 September | 45 | 12 | 57 |
| 2024 August | 41 | 12 | 53 |
| 2024 July | 43 | 2 | 45 |
| 2024 June | 70 | 6 | 76 |
| 2024 May | 65 | 2 | 67 |
| 2024 April | 42 | 3 | 45 |
| 2024 March | 38 | 7 | 45 |
| 2024 February | 36 | 8 | 44 |
| 2024 January | 69 | 7 | 76 |
| 2023 December | 61 | 10 | 71 |
| 2023 November | 55 | 6 | 61 |
| 2023 October | 53 | 10 | 63 |
| 2023 September | 31 | 4 | 35 |
| 2023 August | 17 | 2 | 19 |
| 2023 July | 35 | 6 | 41 |
| 2023 June | 30 | 3 | 33 |
| 2023 May | 52 | 4 | 56 |
| 2023 April | 35 | 3 | 38 |
| 2023 March | 37 | 3 | 40 |
| 2023 February | 44 | 3 | 47 |
| 2023 January | 26 | 9 | 35 |
| 2022 December | 29 | 6 | 35 |
| 2022 November | 39 | 9 | 48 |
| 2022 October | 23 | 7 | 30 |
| 2022 September | 24 | 10 | 34 |
| 2022 August | 32 | 6 | 38 |
| 2022 July | 31 | 13 | 44 |
| 2022 June | 33 | 6 | 39 |
| 2022 May | 34 | 7 | 41 |
| 2022 April | 36 | 9 | 45 |
| 2022 March | 39 | 14 | 53 |
| 2022 February | 43 | 9 | 52 |
| 2022 January | 48 | 8 | 56 |
| 2021 December | 31 | 8 | 39 |
| 2021 November | 49 | 9 | 58 |
| 2021 October | 57 | 15 | 72 |
| 2021 September | 49 | 12 | 61 |
| 2021 August | 36 | 7 | 43 |
| 2021 July | 20 | 12 | 32 |
| 2021 June | 26 | 8 | 34 |
| 2021 May | 50 | 8 | 58 |
| 2021 April | 72 | 20 | 92 |
| 2021 March | 28 | 10 | 38 |
| 2021 February | 16 | 11 | 27 |
| 2021 January | 19 | 11 | 30 |
| 2020 December | 11 | 4 | 15 |
| 2020 November | 0 | 9 | 9 |
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