During the period July 1, 1954 till July 1, 1958 a number of 28 patients suffering from purulent meningitis were admitted in the Bethesda children’s ward and in the University’s children’s ward in Jogjakarta. Purulent meningitis is less frequent than tuberculous meningitis. In this same period 50 patients suffering from tuberculous meningitis were admitted in these children’s wards. It is improbable that cases of purulent meningitis were overlooked, because the indication for a lumbar puncture was often present. Of every child admitted with convulsion or other cerebral symptoms the cerebrospinal fluid was examined. In difficult cases and of every child that died without a clear diagnosis the cerebrospinal fluid was also examined to exclude the diagnosis purulent meningitis. So the number of 28 patients is rather exact.
The age of these patients was as follow:
number of admissions died
first three months of life : 8 5
second three months of life : 8 7
second half year of life : 8 5
second year of life : 2 1
third year of life : 1 1
seventh year of life : 1 -
Most of these patients were infants. The patients who died were classified according to cause of death into the section: all other causes of death. See chapter VII.
In 20 out of these 28 patients it was possible to find the causative agent. Twelve times the micro-organism was isolated with a culture of the cerebrospinal fluid and 8 times it was only possible to find the suspected micro-organism through microscopical examination. The cultures were carried out in the laboratory of the Civil Health Service in Jogjakarta.
The frequency of the different micro-organisms are shown in table VIII – 9.
The rule that the patients were only taken to the hospital after a waiting period of several days after the first symptoms became manifest was also operative for these patients. Convulsions were in 19 patients the reason that the parents brought their child to hospital for admission, mostly after the treatment of the dukun remained with out success. This is the cause that a great number of them were admitted in a rather serious condition after this delay. Out of the 19 patients who died by purulent meningitis 12 died within 24 hours after admission. Three patients who died of meningitis caused by a salmonella shall be mentioned more detailed in the section about Salmonellosis, in chapter IX.
Table VIII – 9.
The causative microorganisms in 28 cases of purulent meningitis at Jogjakarta.
The treatment of these patients was watersoluble penicillin 800,000 units and streptomycine 50 mgr per kg bodyweight daily intramuscular as long as the causative agent was unknown. When it appeared that C.Pneumoniae was the causative agent the streptomycine was not given any longer. When Haemophilus influenzae was the causative agent the penicilin was replaced by chloromycetin 150 mg per kg bodyweight, as long as was necessary till the number of cells in the cerebrospinal fluid was below 30 per mm3. The cerebrospinal fluid was controlled once in two days and later on twice a week. The patients were not treated intrthecally. In many other places of the world also D.Pneumoniae and H.influenzae are the most important causative agents of purulent meningitis (Senecal 1957, Smith 1954).
In 1941 a detailed report about cerebral disorders in Djakarta children was published by Verhaart. In this report the cerebral disorders leading to death in childhood were analysed and it comprised 1,405 infants and children in Djakarta. Among these 1,405 children with cerebral disorders were found 168 children aged less than 10 and suffering from a non-tuberculous meningitis.
All these patients were admitted in the University’s children’s ward during the period 1932-1940. The group of 168 patients suffering from non-tuberculous meningitis comprised 129 infants, 31 toddlers and 8 school-children (5-9 years of age).
In 35% of the cases D.Pneumoniae was the causative agent, in 25% Haemophilus influenzae, in 7% N.Meningitis and in 15% there were other causative agents, while in 16% the causative agent was not known. Seven out of these 168 patients suffered from meningitis ans a complication of typhoid fever. Escheria coli as a cause of purulent meningitis is neither mentioned in the report of Verhaart nor in the other literature about purulent meningitis in Indonesia. Therefore a short case history of a patient suffering from meningitis caused by E.coli is mentioned below.
SURATINAH: A Javanese girl, 50 days old, was admitted because she suffered from diarrhoea, fever and congenital syphilis. The diarrhoea had started two days before, but during examination it appeared that she also had a rhinitis (“snuffles”), liver and spleen, and skinalterations in handpalms and feet. The infants also suffered from jaundice. The diagnosis Congenital syphilis could be confirmed by the X-ray examination and the serological test of mother and child. The patient was treated with penicillin. On the 7th day after admission the child was worse than during admission and was also dozy. To be sure a lumbar puncture was done and to my astonishment a purulent spinal fluid dropped from the needle. It appeared that in the spinal fluid: Nonne test++; Pandy test++; cells 28,600 per mm3; sugar 18 mg per 100ml.; protein 908 mg per 100 ml.; chlorides 579 mg per 100 ml.
Besides with penicillin the infant was also treated with streptomycin. She died two days after the diagnosis purulent meningitis was made. From the cerebrospinal fluid a strain of Esch.paracoli(?) was isolated. This strain was send to the Statens Serum Institutat copenhagen. The result of the examination at copenhagen was as follows:
“The strain is an Escheria coli, which ferments lactose after 7 days. It belongs to 0- group 4. This 0-group is one of the 0-groups which were found rather frequently in different pathological conditions by Kauffmann and Vahlne. It does not belong to any of the established types of infantile diarrhoea.”
Postmortem a little bit of the liver was examined by the pathologist. In the I livertissue many and extended fooi of necrosis with out sighns of inflammation were found. In the Levadittiocoupes no spirochetes were observed.
We made the diagnosis : Enteritis
Congenital syphilis
Purulent meningitis by E.coli
(as a symptom of septicemia?).
In his thesis about child-mortality on the east coast of Sumatera Straub (1927) described a frequent coincidence of purulent meningitis and pneumonia. He described a number of 75 children ages less than 2 with pneumonia. In 29 out of these 75 children also purulent meningitis was found. The causative organisms were 20 times Heamophilus in fluenza, 5 times D.Pneumoniae, one time streptococcus while in three cases no causative agent was found. In 9 cases a postmortem examination was also performed and from the lungtissue were isolated: 7 times H.Influenzae and 6 times D.Pneumoniae, mostly both micro-organisms in the same lung. The coincidence of purulent meningitis and pneumonia was in Jogjakarta rather rare. In only 3 out of 28 patients suffering from purulent meningitis an pneumonia was found at the same time.