I read with interest the recent article by Udani V, et al.(1). Based on a well-conducted retrospective study on infants presenting with hydrocephalus, they conclude that neonatal meningitis/ventriculitis remains undiagnosed in about a third of newborns with this condition. However, I would like to make certain observations.

Hydrocephalus is but one of the several sequelae of neonatal meningitis (NM). Other common sequelae include mental retarda-tion, seizures, and sensorineural hearing loss(2). Therefore, studying cases of hydro-cephalus alone may not reflect a true picture of unrecognized NM and figures thus obtained may under-estimate the proportion of missed cases. In fact, in the present series too, 4/13 infants presenting with hydro-cephalus had seizures also. Further studies are required to determine the proportion of cases of infantile seizures where unrecog-nized NM could be a contributing factor.

There could be various factors that lead to a missed diagnosis of NM. Authors highlight the problem of inadequate antibiotic administration (less than three weeks) for suspected "sepsis", resulting in only partial treatment of meningitis. Other reason could be the absence of classical symptoms and signs of meningitis. It was observed that dyspnea was the commonest clinical manifestation among newborns presenting with meningitis before seven days of age, whereas fever and diarrhea were the commonest manifestation among those presenting after seven days(3). In the current series too, about 60% of infants did not have usual symptoms of infection.

Lumbar puncture (LP) is not routinely performed in evaluation of early neonatal sepsis due to several factors such as that it is an invasive procedure, it may compromise respiratory function, and interpretation of cerebrospinal fluid analysis may not always be straightforward(4). However, omitting LP could result in delayed or missed diagnosis of NM in about 40% of cases(5). Therefore, LP should be included in evaluation of all high-risk newborns presenting with sepsis.

Authors report a poor outcome in majority of their cases of NM with hydrocephalus. Seven of 11 (63%) patients for whom follow up data was available had a severe disability. Delayed diagnosis and inadequate treat-ment, according to the authors, is responsible for this. However, due to a "retrospective hospital-based" nature of this study, it is likely that patients with favorable outcomes did not return to the hospital. Small sample size is a further limitation to this conclusion.

In conclusion, the current study has convincingly highlighted that NM is commonly undiagnosed or diagnosed late. This could be a significant factor leading to a higher morbidity and mortality in this group of newborns. LP should be performed in all high-risk cases with neonatal sepsis to avoid missing NM.

Kumar S.,
Neurology Unit,
Department of Neurological Sciences,
Christian Medical College Hospital,
Vellore, Tamilnadu-632004,India.
E-mail: [email protected]

1. Udani V, Udani S, Merani R, Bavdekar M. Unrecognized meningitis / ventriculitis presenting as hydrocephalus in infancy. Indian Pediatr 2003; 40: 870-873.

2. Stevens JP, Eames M, Kent A, Halket S, Holt D, Harvey D. Long term outcome of neonatal meningitis. Arch Dis Child Fetal Neonatal Ed. 2003; 88: F179-184.

3. Chang Chien HY, Chiu NC, Li WC, Huang FY. Characteristics of neonatal bacterial meningitis in a teaching hospital in Taiwan from 1984-1997. J Microbiol Immunol Infect. 2000; 33: 100-104.

4. McIntyre P, Isaacs D. Lumbar puncture in suspected neonatal sepsis. J Paediatr Child Health. 1995; 31: 1-2.

5. Wiswell TE, Baumgart S, Gannon CM, Spitzer AR. No lumbar puncture in the evaluation for early neonatal sepsis: will meningitis be missed? Pediatrics. 1995; 95: 803-806.