Bacterial meningitis complicating the course of liver cirrhosis

Meningitis is rarely reported in studies investigating bacterial infections in patients affected by liver cirrhosis. We investigated the findings of bacterial meningitis in patients affected by liver cirrhosis referred to our department in a 16-year period.

Patients with cirrhosis and bacterial meningitis were enrolled. Cirrhosis was defined by liver histology or clinical, laboratory, and ultrasonographic and endoscopic findings. Bacterial meningitis was defined by cerebro-spinal fluid pleocytosis (>10/mcl) and characteristic clinical presentation. Fisher exact test and Wilcoxon rank-sum test were employed as appropriate for statistical analysis.

Forty-four patients with bacterial meningitis and cirrhosis were enrolled in the study. Sex ratio (male:female) was 1.4:1 and median (IQR) age was 64 (55–72) years. Cirrhosis was viral in 40 patients. At admission, median (IQR) MELD score was 12 (9–14), and median (IQR) Child-Pugh score was 8 (6–10). Other conditions associated with immunodepression were present in 22 (50%) cases. Streptococcus pneumoniae and Listeria monocytogenes were the agents more frequently identified. An extra-meningeal focus of infection was identified in 17 (39%) cases. Main symptoms at admission were fever, nuchal rigidity, and an obtunded or comatose status, and at least 2 of these were reported in 37 (84%) episodes. Cerebro-spinal fluid showed high cells, low CSF/serum glucose ratio, and elevated protein. Seventeen patients (39%) died and 8 (18%) reported sequelae. High MELD and Child-Pugh scores were related to the mortality risk (p < 0.001). The findings of blood and cerebro-spinal fluid analysis were not predictive of outcome.

Bacterial meningitis should be considered in cirrhotics presenting with fever and altered conscience status. MELD and Child-Pugh scores predicted prognosis.