Ureaplasma Parvum Meningitis in a Full-term Newborn (2010)

To the Editors: We read with great interest the review of Ureaplasma neonatal meningitis.1 We would like to report a case that raises some clinical and biologic features highlighting the difficulty of diagnosis. An infant born at 39 weeks of gestation (birth weight, 3500 g) after uneventful gestation was admitted to hospital on day 10 with sudden fever (39°C) associated with rhinitis and bilateral conjunctivitis. Laboratory findings revealed a normal white blood cell count, C-reactive protein, and procalcitonin. The cerebrospinal fluid (CSF) cell count was 289 leukocytes/mL (90% lymphocytes). CSF protein and glucose were 0.68 g/L and 1.68 mmol/L, respectively. Treatment was started with intravenous cefotaxime (200 mg/kg/d), amoxicillin (200 mg/kg/d), gentamicin (4 mg/kg/d), and acyclovir (60 mg/kg/d). CSF, blood, urine, and ocular secretion cultures on standard medium were sterile as was PCR for enteroviruses and herpes simplex virus. Fever and conjunctivitis persisted despite antibiotic therapy, and on day 17, the infant developed focal seizure activity. A cranial ultrasound revealed dilated ventricles associated with signs of CSF resorption. CSF, obtained before ventriculoperitoneal shunt on day 18, showed changes consistent with bacterial meningitis: 1610 leukocytes/mL (86% polymorphonuclear cells); protein 5.2 g/L, glucose 0.1 mmol/L. C-reactive protein and procalcitonin values remained normal. Therapy was changed to cefotaxime and ciprofloxacin (30 mg/kg/d) pending culture results. Broad range (16S rDNA) bacterial PCR on CSF sample indicated the presence of Ureaplasma which was confirmed by cultural examination of CSF and tracheal aspirates on A8 agar. The French National Expert Center (Pr Bébéar, Bordeaux, France) confirmed the presence of U. parvum in CSF and determined as previously described,2 the following are minimal inhibitory concentration (MIC) values: ciprofloxacin, 4 μg/mL; moxifloxacin, 0.5 μg/mL; and chloramphenicol, 2 μg/mL. The patient completed 7 weeks of treatment with ciprofloxacin and 3 weeks with thiophenicol. The CSF cultures were sterile on days 28 and 42. By the age of 8 and 14 months, he was developing appropriately. Our case clearly illustrates that U. parvum can cause late onset meningitis in a full-term newborn even though U. parvum meningitis is mainly described in preterm newborns.3 The diagnosis can be delayed not only because of specific culture medium or molecular tools requirement but also by the atypical biologic presentation, notably the initial predominance of lymphocytes in CSF and the normal C-reactive protein and white blood cell values suggesting viral meningitis, and particularly enterovirus infection. Because of their good CSF penetration, the MICs of ciprofloxacin and chloramphenicol were determined. The high MIC of ciprofloxacin compared with its CSF concentration and the potential blood side effects of thiophenicol encourage finding a new treatment. Moxifloxacin that has a low MIC could represent an alternative4; however, its efficacy and safety in neonates remain to be determined.5,6 We encourage clinicians and microbiologists to search for Ureaplasma and Mycoplasma species as a cause of abnormal CSF with no immediate evident etiology in preterm as well as full-term neonates. Valerie Biran, MD, PhD Service de Réanimation et Pédiatrie Néonatales Assistance Publique-Hôpitaux de Paris Hôpital Robert Debré 48 Université Paris Diderot Equipe AVENIR R05230HS Inserm U676 PremUP Fondation [email protected] Andrea Madalina Dumitrescu, MD Service de Réanimation et Pédiatrie Néonatales Catherine Doit, MD Service de Microbiologie Assistance Publique-Hôpitaux de Paris Hôpital Robert Debré 48 Aurelie Gaudin, MD Service de Réanimation et Pédiatrie Néonatales Cecile Bébéar, MD, PhD Laboratoire de Bactériologie Pr C Bébéar Université Victor Segalen Bordeaux 2 et CHU de Bordeaux Bordeaux Cedex, France Henri Boutignon, MD Service de Pédiatrie Hôpital de Compiègne Compiègne, France Edouard Bingen, MD, PhD Service de Microbiologie Assistance Publique-Hôpitaux de Paris Hôpital Robert Debré 48 Olivier Baud, MD, PhD Service de Réanimation et Pédiatrie Néonatales Assistance Publique-Hôpitaux de Paris Hôpital Robert Debré 48 Equipe AVENIR R05230HS Inserm U676 Paris, France PremUP Fondation Paris, France Stephane Bonacorsi, MD, PhD Service de Microbiologie Assistance Publique-Hôpitaux de Paris Hôpital Robert Debré 48 Yannick Aujard, MD, PhD Service de Réanimation et Pédiatrie Néonatales Assistance Publique-Hôpitaux de Paris Hôpital Robert Debré 48 Sérurier, Paris, France