Case Presentation:

3yo male, with a history of presumed bacterial meningitis, was admitted with concern for recurrent meningitis. He was brought to the emergency department due to fever, headache, and vomiting for one day. He had sensorineural deafness due to previous meningitis. On exam he was febrile and mildly ill-appearing but non-toxic. He had nuchal rigidity and was consolable. Cerebrospinal fluid (CSF) indices included glucose of <1 mg/dL, protein 262 mg/dL, and 10,752 WBC/mcL. There was minimal bifrontal leptomeningeal enhancement on MRI. He was started on broad spectrum antibiotics. He had a positive blood culture with Streptococcus pneumoniae, and CSF culture was negative. Due to recurrent meningitis, he had an immunology workup completed. On further history, he had persistent nasal discharge which was mostly right sided and clear. There was concern for anatomic abnormality with CSF leak, and facial CT was consistent with cribriform plate deformity. The injury was thought to be secondary to a fall down stairs at age 2, although congenital defect could not be ruled out. He required craniotomy to repair the defect due to his age and size as per neurosurgery and otolaryngology.  

Discussion:

Recurrent bacterial meningitis is rare and should prompt further workup. In the pediatric population, this frequently is an indication for an immunology work up. Anatomic abnormalities, including defects of the cribriform plate as in our patient, may be less common than immunologic defects. The true percentage of pediatric patients with basilar skull fracture or CSF leak who develop meningitis is unclear. Studies have reported up to a 26% rate of meningitis in temporal and basilar skull fractures in children. However, lower rates have also been observed; one study reported meningitis in 1% of cases of basilar fracture. 

In children, the most common cause of CSF rhinorrhea is a defect in the cribriform plate. These defects can be caused by trauma (either accidental or iatrogenic), congenital defects, tumors, or meningoencephaloceles. The rate of congenital CSF leak with encephalocele is thought to be one in 5000 live births. Diagnosis is commonly due to meningitis, CSF rhinorrhea, facial deformity, or nasal obstruction. CSF rhinorrhea may be more difficult to diagnose in pediatric patients due to the inability of young patients to describe symptoms. 

CSF rhinorrhea has been managed conservatively in some patients as the leak may spontaneously resolve. However, these patients may be at risk for recurrent leak and sequelae including meningitis. Endoscopic transnasal surgical repair has been studied in the pediatric population and has been successful, although not done in this case. 

Conclusions:

Recurrent meningitis requires immunologic workup, and anatomic abnormalities causing CSF fistula should also be included in the differential diagnosis of underlying cause. The diagnosis of CSF rhinorrhea may be more difficult to make in the pediatric population.