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30-day period of life It poses a number of special problems Infants, of course, cannot complain of headache, stiff neck may be absent, and one has only the nonspeci c signs of a systemic illness fever, irritability, drowsiness, vomiting, convulsions and a bulging fontanel to suggest the presence of meningeal infection Signs of meningeal irritation do occur, but only late in the course of the illness A high index of suspicion and liberal use of the lumbar puncture needle are the keys to early diagnosis Lumbar puncture is ideally performed before any antibiotics are administered for other neonatal infections An antibiotic regimen suf cient to control a septicemia may allow a meningeal infection to smolder and to are up after antibiotic therapy for the systemic infection has been discontinued A number of other facts about the natural history of neonatal meningitis are noteworthy It is more common in males than in females, in a ratio of about 3:1 Obstetric abnormalities in the third trimester (premature birth, prolonged labor, premature rupture of fetal membranes) occur frequently in mothers of infants who develop meningitis in the rst weeks of life The most signi cant factor in the pathogenesis of the meningitis is maternal infection (usually a urinary tract infection or puerperal fever of unknown cause) The infection in both mother and infant is most often due to gram-negative enterobacteria, particularly E coli, and group B streptococci and less often to Pseudomonas, Listeria, Staph aureus or epidermidis (formerly albus), and group A streptococci Analysis of postmortem material indicates that in most cases infection occurs at or near the time of birth, although clinical signs of meningitis may not become evident until several days or a week later In infants with meningitis, one should be prepared to nd a unilateral or bilateral sympathetic subdural effusion regardless of bacterial type Young age, rapid evolution of the illness, low polymorphonuclear cell count, and markedly elevated protein in the CSF correlate to some extent with the formation of effusions, according to Snedeker and coworkers Also, these attributes greatly increase the likelihood of the meningitis being associated with neurologic signs Transillumination of the skull is the simplest method of demonstrating the presence of an effusion, but computed tomography (CT) and magnetic resonance imaging (MRI) are the de nitive diagnostic tests When aspirated, most of the effusions prove to be sterile If recovery is delayed and neurologic signs persist, a succession of aspirations is required In our experience and that of others, patients in whom meningitis is complicated by subdural effusions are no more likely to have residual neurologic signs and seizures than are those without effusions.

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of myelitis, including autopsy proven ones, in which the disease develops without an apparent antecedent infection There is understandable uncertainty in such cases as to whether the illness is the opening phase of MS of the type described below under Demyelinative Myelitis In the numerous cases of transverse myelitis under our care, fewer than half have shown other signs of MS after 10 to 20 years (this is a far lower incidence than following a bout of optic neuritis) Also, there is an isolated form of relapsing myelitis, sometimes but not always triggered by an infection that does not manifest lesions elsewhere in the neuraxis and therefore has an ambiguous relationship to MS Further discussion of acute transverse myelitis in relation to other demyelinating diseases can be found below and on pages 778 and 791 The pathologic changes take the form of numerous subpial and perivenular zones of demyelination, with perivascular and meningeal in ltrations of lymphocytes and other mononuclear cells, and para-adventitial pleomorphic histiocytes and microglia (page 772) Taken in isolation, these changes cannot be clearly distinguished from those of MS Treatment Once symptoms begin, it is doubtful if any treatment is of consistent value One s rst impulse, assuming the mechanism to be an autoimmune, is to administer high doses of corticosteroids a practice we have followed but without conviction Perhaps it is advisable to do so, but there is as yet no evidence that this alters the course of the illness We have also used plasma exchange or intravenous immune globulin in several patients, with uncertain results, although this approach was seemingly helpful in a few patients who had an explosive clinical onset In general, the prognosis is better than the initial symptoms might suggest Invariably, the myelitic disease improves, sometimes to a surprising degree, but there are examples in which the sequelae have been severe and permanent Pain in the midthoracic region or an abrupt, severe onset usually indicates a poor prognosis (Ropper and Poskanzer) The authors have several times given a good prognosis for long-term recovery and assurance that no relapse will occur, only to witness a recrudescence of other symptoms at a later date, indicating that the original illness was MS Demyelinative Myelitis (Acute Multiple Sclerosis) The lesions of acute MS presenting as a myelitis share many of the features of the postinfectious type except that the clinical manifestations of the former tend to evolve more slowly, over a period of 1 to 3 weeks or even longer Also, their relation to antecedent infections is less certain, and in most recorded examples such provocative events were lacking Only the occurrence of subsequent attacks or additional lesions revealed by MRI or evoked potentials indicates that the basic illness is one of chronic recurrent demyelination, indistinguishable from the usual type of MS The most typical mode of clinical expression of demyelinative myelitis is with numbness that spreads over one or both sides of the body from the sacral segments to the feet, anterior thighs, and up over the trunk, with coincident but variable and usually asymmetric weakness and then paralysis of the legs As this process becomes complete, the bladder is also affected The sensorimotor disturbance may extend to involve the arms, and a sensory level can be demonstrated on the upper parts of the trunk The CSF usually shows a mild lymphocytosis, as in the postinfectious variety, but it is as often normal Oligoclonal bands may be absent with the rst attack Bakshi and colleagues have suggested that in myelitis due to MS, the changes seen on MRI occupy only a few adjacent spinal segments in comparison to the postinfectious le-.

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