Avaliação neurológica e do líquido cefalorraqueano em crianças com meningite meningocócica do sorogrupo A

Bresolin, A. U.

doi:10.1590/S0004-282X1983000400004

Resumos

Este trabalho aborda o estudo clínico e a análise do LCR, em 255 crianças de zero a 12 anos de idade, com meningite por meningococo do sorogrupo A. Por ocasião da admissão hospitalar verificamos que 27 pacientes (10,59%) apresentavam intercorrências neurológicas, sendo que a intercorrência mais freqüente foi a manifestação epiléptica, com predomínio nos pacientes menores de 13 meses de idade. O óbito foi registrado em 11 pacientes (4,31%). No momento da alta hospitalar, 14 pacientes (5,49%) apresentavam anormalidades neurológicas, com prevalência para a surdez e a ataxia, com exceção dos pacientes menores de 13 meses de idade, nos quais predominou a involução neuropsicomotora. Em pacientes com meningite meningocócica, não há necessidade de exame do LCR, para que a antibioticoterapia seja interrompida.

Our aim is to present the results obtained from the evaluation of the neurological examination as well as chemical and cytologic data from the CSF obtained at the admission and discharge of 255 children aged between zero and 12 years with a diagnosis of serogroup A meningococcal meningitis made at the Hospital Emilio Ribas in São Paulo, Brasil, in the years of 1976 and 1977. By the time of their admission, 27 patients (10,59%) showed positive neurologic findings besides meningeal signs. Seizures were the most common ones, with higher incidence in children under 13 months; ataxia, deafness, motor deficits, neuro-psychmotor involution, subdural effusions and disturbed behavior followed in that order. Subdural effusions were found only in those under 13 months. A fatal outcome was registered in eleven (4,31%) patients, of which nine died in the first 24 hours after admission. By the time of hospital discharge 14 patients (5,49%) had neurological abnormalities, deafness and ataxia being the most common ones, in the older patients. Under 13 months, developmental involution predominated. There is no need of CSF evaluation for antibiotic therapy interruption in patients with meningococcal meningitis.

Avaliação neurológica e do líquido cefalorraqueano em crianças com meningite meningocócica do sorogrupo A

Neurologic and CSF evaluation in children with serogroup A meningococcal meningitis

A. U. Bresolin

Médico Chefe da Seção de Diagnóstico e Terapêutica do Serviço de Neurologia do Hospital do Servidor Público de São Paulo e Neuropediatra do Hospital Emilio Ribas

RESUMO

Este trabalho aborda o estudo clínico e a análise do LCR, em 255 crianças de zero a 12 anos de idade, com meningite por meningococo do sorogrupo A. Por ocasião da admissão hospitalar verificamos que 27 pacientes (10,59%) apresentavam intercorrências neurológicas, sendo que a intercorrência mais freqüente foi a manifestação epiléptica, com predomínio nos pacientes menores de 13 meses de idade. O óbito foi registrado em 11 pacientes (4,31%). No momento da alta hospitalar, 14 pacientes (5,49%) apresentavam anormalidades neurológicas, com prevalência para a surdez e a ataxia, com exceção dos pacientes menores de 13 meses de idade, nos quais predominou a involução neuropsicomotora. Em pacientes com meningite meningocócica, não há necessidade de exame do LCR, para que a antibioticoterapia seja interrompida.

SUMMARY

Our aim is to present the results obtained from the evaluation of the neurological examination as well as chemical and cytologic data from the CSF obtained at the admission and discharge of 255 children aged between zero and 12 years with a diagnosis of serogroup A meningococcal meningitis made at the Hospital Emilio Ribas in São Paulo, Brasil, in the years of 1976 and 1977. By the time of their admission, 27 patients (10,59%) showed positive neurologic findings besides meningeal signs. Seizures were the most common ones, with higher incidence in children under 13 months; ataxia, deafness, motor deficits, neuro-psychmotor involution, subdural effusions and disturbed behavior followed in that order. Subdural effusions were found only in those under 13 months. A fatal outcome was registered in eleven (4,31%) patients, of which nine died in the first 24 hours after admission. By the time of hospital discharge 14 patients (5,49%) had neurological abnormalities, deafness and ataxia being the most common ones, in the older patients. Under 13 months, developmental involution predominated. There is no need of CSF evaluation for antibiotic therapy interruption in patients with meningococcal meningitis.

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Resumo da Dissertação para Mestrado, Área de Neurologia do Curso de Pós Graduação da Faculdade de Medicina da Universidade de São Paulo.

Hospital Emilio Ribas - Av. Dr. Arnaldo - São Paulo, SP - Brasil.

1. ALEXANDER, W. S. - Influence of chemotherapy in the pathology of purulent leptomeningitis. Arch. Neurol. Psychiat. 63:73, 1949.
2. BANKS, H. S. - Meningococcosis. Lancet 2:635, 1948.
3. BANKS, H. S. - Meningococcosis. Lancet 2:677, 1948.
4. BANKS, H. S. & McCARTNEY, J. E. - Meningococcal encephalitis. Lancet 1:219, 1942.
5. BEENSON, P. B. & WESTERMAN, E. - Cerebrospinal fever. Analysis of 3,575 case reports with special reference to sulphonamide therapy. Brit. med. J. 1:497, 1943.
6. BELL, W. E. & McCORMICK, W. F. - Neurologic Infection in Children. W. B. Saunders C, Philadelphia, 1975, cap 4.
7. BUCHAN, G. C. & ALVORD, E. C. Jr. - Diffuse necrosis of subcortical white matter associated with bacterial meningitis. Neurology (Minneapolis) 19:1, 1969.
8. BUCHTHAL, F. & LENNOX-BUCHTHAL, M. A. - Diphenylhydantoin: relation of anticonvulsant effect to concentration in serum. In WOODBURY, D. M.; PEN-RY, J. K. & SCHMIDT, R. P. (eds.): Antiepiletic Drugs. Raven Press, New York, 1972, pg. 193.
9. BUCHTHAL., F. & LENNOX-BUCHTHAL, M. A. - Phenobarbital: relation of serum concentration to control of seizure. In WOODBURY, D. M.; PENRY, J. K. & SCHMIDT, R. P. (eds.): Antiepileptic Drugs. Raven Press, New York, 1972, pg. 335.
10. BUTLER, I. J. & JOHNSON, R. T. - Central nervous system infections. Pediat. Clin. N. Am. 21:649, 1974.
11. CARPENTER, R. R. & PETERSDORF, R. G. - The clinical spectrum of bacterial meningitis. Amer. J. Med. 33:262, 1962.
12. DESMIT, E.. M. - A Follow-up study of 110 patients treated for purulent meningitis. Arch. Dis. Child. 30:415, 1955.
13. DIAMENT, A.J. - Evolução neurológica do lactente normal. EDART, São Paulo, 1975.
14. DODGE, P. R. & SWARTZ, M. N. - Bacterial meningitis: a review of selected aspects. II. Special neurologic problems, postmeningitic complications and clinicopathological correlation. New Engl. J. Med. 272:954, 1965.
15. DODGE, P. R. &. SWARTZ, M. N. - Bacterial meningitis: a review of selected aspects. New Engl. J. Med. 272:1003, 1965.
16. EINHORN, A. H. - Bacterial meningitis. In BARNETT, H. L. (ed.): Pediatric (15Ş ed.). Meredith Corps., New York, 1972, pg. 698.
17. FARMER, T. W. - Neurologic complications during meningococcic meningitis treated with sulfonamide drugs. Arch. int. Med. 76:201, 1945.
18. FARMER, T. W. & WISE, G. R. - Subdural empyema in infants, children and adults. Neurology (Minneapolis) 23:254, 1973.
19. FEIGIN, R. D. & DODGE, P. R. - Bacterial meningitis: new concepts of pathophysiology and neurologic sequelae. Ped. Clin. N. Am. 23:541, 1976.
20. GOODMAN, J. M. & MEALEY, J. Jr. - Postmeningitic subdural effusions. The syndrome and its management. J. Neurosurg. 30:658, 1969.
21. HOSFIELD, W. B. - Management and complications of acute bacterial meningitis. Postgrad. Med. 50:100, 1971.
22. HOYNE, A. L. & BROWN, R. H. - 727 meningococcic cases: Ann. int. Med. 28;241, 1948.
23. JONSSON, M. & ALVIN, A. - A 12 year review of acute bacterial meningitis in Stockholm. Scand. J. infect. Dis. 3:141, 1971.
24. KAUFMAN, B.; LEVY, H.; ZALEZNAK, B. D. & UTVAK, A. M. - Statistical analysis of 242 cases of meningococcus meningitis. J. Pediat. 38:705, 1951.
25. KRUGMAN, S.; WARD, R. & KATZ, S. L. - Acute bacterial meningitis. Infectious Diseases of Children (6Ş ed.). C. V. Mosby Co. Saint Louis, 1977, cap. 13.
26. LEFÈVRE, A. B. - Exame neurológico da criança. In TOLOSA, A. P. M. & CANELAS, H. M. (eds.): Propedêutica Neurológica (2Şed.). Procienx, São Paulo, 1971, cap. 25.
27. LEFÈVRE, A. B.; ALMEIDA, I. J. M.; SANTOS, I.; ELKIS, L. C.; PAZINATO, M. Jr.; PAREDES, M. A. N.; PINTO, M. C. B.; VALENTE, M. 1.; GUIMARÃES, M. L. O.; GROSSMAN, R. M.; DEL PORTO, R.; GAZAL, S.; CYPEL, S. & GOES, S. L. - Estudo clinico de 78 casos de meningite em crianças. Neuroped. latino-amer. 11:217, 1977.
28. LIEBMAN, E. P.; RONIS, M. L.; LOVRINIC. J. H. & KATINSKY, S. E. - Hearing improvement following meningitis deafness. Arch. Otolaryng. 90:470, 1969.
29. MATSON, D. D. - Neurosurgery of Infancy and Childhood (¾ ed.). Charles C. Thomas Publ., Springfiels. Illinois, 1969, cap. 45.
30. MOURA-RIBEIRO, M. V. L. - Meningencefalites purulentas em crianças no primeiro ano de vida: evolução clinica e eletrencefalográfica. Tese de Livre Docência. Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Brasil, 1978.
31. MURRAY, J. D.; FLEMING, P.; WEBER, J.; HSUEN, J.; BANNATYNE, R. & ANGLIN, C. - The continuing problem of purulent meningitis in infants and children. Pediat. Clin. N. Am. 21:967, 1974.
32. DUNSTED, C. - Significance of convulsions in children with purulent meningitis. Lancet 1:1246, 1951.
33. PAI, M. N. - Personality defects and psychiatric symptons after cerebrospinal fever in childhood - meningococcal encephalopaty. J. ment. Sc. 92:369, 1946.
34. PLUM, F. & POSNER, J. P. - Diagnosis of Stupor and Coma. (2Ş. ed.). F. A. Davis Co., Philadelphia, 1975, pg. 204.
35. POLLARD, R. B. - Early bilateral eighth nerve involvement in meningococcal meningitis. South, med. J. 69:343, 1976.
36. PORTILLO, J. M.; SANTOS, F.; BANCUICERAS, R. L.; FERRARI, M. A.; RIOS, E.; BA2ZINO, I. R.; QUIAN, J.; FREITAS, T.; GARRIDO, M.; PELUFFO, L.; CACERES, M. P.; LOY, A. A.; FOLLE. A. U.; TARLOWSKY, M.; MENDONZA, M. P. & THEVENET, M. C. - Meningitis supuradas, Neuroped. latinoamer. 11:181, 1977.
37. RABE, E. F.; FLYNN, R. E. & DODGE, P. R. - Study of subdural effusions in infants with particular to the mechanism of their persistence. Neurology (Minneapolis) 12:79, 1962.
38. RAIMONDI, A. J. & DIROCCO, C. - The physiopathogenetic basis for angiographic diagnosis of bacterial infections of the brain and its covering in children. I. Leptomeningitis. Child's Brain 5:1, 1979.
39. RORKE, L. B. & PITTS, F. W. - Meningitis purulent: pathologic basis of clinical manifestations. Clin. Pediat. 2:64, 1963.
40. ROSS, A. T. - Meningococcic meningitis: incidence of residua following serum, sulfonamide and sulfonamide-penicillin therapy. Arch. Neurol. Psychiat. 67:89, 1952.
41. SAHS, A. L. & JOYNT, R. J. - Meningitis. In BAKER A. B. & BAKER L. H. (eds.). Clinical Neurology (2Ş ed.). Harper & Row Publ., 1974, vol. 2, cap. 15.
42. SCHWARTZ, J. F. - Ataxia in bacterial meningitis. Neurology (Minneapolis) 22:1071, 1972.
43. SEIBEL, R. G. - Meningitis meningocócica. In PUG T.F. (coord.): Meningitis en la Infancia. Ed. Médica Panamericana, Buenos Aires, 1976, pg. 155.
44. SESHIA, S. S.; SESHIA, M. M. K. & SCHDEVA, R. K. - Coma in childhood. Develop. Med. Child. Neurol. 19:614, 1977.
45. SILLANPAA. M.; PELTONEN, T. & NURMIKKO, T. - Social and medical prognosis of child with acute nontuberculous purulent meningitis. Acta paediat. scand., suppl. 265, 1977.
46. SLESINGER, H. A. - Complications and sequelae of meningococcic meningitis during infancy and childhood. Pennsylvania med. J., pg. 327, 1933.
47. SMITH, D. H.; INGRAM, D. D.; SMITH, A. L.; GILLES, F. & BRESNAN, M. J. - Bacterial meningitis. Pediatrics 52:586, 1973.
48. SPINA-FRANÇA, A. - Líquido cefalorraqueano na infância. In: MARCONDES, E. (coord.): Pediatria Básica. Sarvier, São Paulo, 1975, vol. 1, pg. 287.
49. SWARTZ, M. N, & DODGE, P. R. - Bacterial meningitis. A review of selected aspects. New Engl. J. Med. 272:725, 1965.
50. SWARTZ, M. N. & DODGE, P. R. - Bacterial meningitis. A review of selected aspects. New Engl. J. Med. 272:779, 1965.
51. TENG, Y. C; LIU, J. H. & HSU, Y. H. - Meningitis and deafness: report of 337 cases of deafness due to cerebrospinal meningitis. Chinese med. J. 81:127, 1962.
52. UNDERMAN, A. E.; OVERTURF, G. D. & LEEDOM, J. M. - Bacterial meningitis. Disease-a-Month. Year Book Medical Publ., Chicago, vol. XXIV, february 1978.
53. WEHRLE, P. F.; MATHIES, A. W. & LEEDOM, J. M. - The critically ill child: management of acute bacterial meningitis. Pediatrics 44:991, 1969.
54. WEHRLE, P. F.; MATHIES, A. W. & LEEDOM, J. M. - Acute bacterial meningitis. In CLEMENT, A. S. (ed.): The Critically 111 Child. W. B. Saunders Co.. Philadelphia, 1977, pg. 91.
55. ZIMMERMAN, R. A.: PATEL, S. & BILANIUK, L. - Demonstration of purulent bacterial intracranial infections by computed tomography. Am. J. Roentgenol. 127:155, 1975.

Datas de Publicação

Publicação nesta coleção
14 Ago 2012
Data do Fascículo
Dez 1983

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. ALEXANDER, W. S. - Influence of chemotherapy in the pathology of purulent leptomeningitis. Arch. Neurol. Psychiat. 63:73, 1949.

[2] 2. BANKS, H. S. - Meningococcosis. Lancet 2:635, 1948.

[3] 3. BANKS, H. S. - Meningococcosis. Lancet 2:677, 1948.

[4] 4. BANKS, H. S. & McCARTNEY, J. E. - Meningococcal encephalitis. Lancet 1:219, 1942.

[5] 5. BEENSON, P. B. & WESTERMAN, E. - Cerebrospinal fever. Analysis of 3,575 case reports with special reference to sulphonamide therapy. Brit. med. J. 1:497, 1943.

[6] 6. BELL, W. E. & McCORMICK, W. F. - Neurologic Infection in Children. W. B. Saunders C, Philadelphia, 1975, cap 4.

[7] 7. BUCHAN, G. C. & ALVORD, E. C. Jr. - Diffuse necrosis of subcortical white matter associated with bacterial meningitis. Neurology (Minneapolis) 19:1, 1969.

[8] 8. BUCHTHAL, F. & LENNOX-BUCHTHAL, M. A. - Diphenylhydantoin: relation of anticonvulsant effect to concentration in serum. In WOODBURY, D. M.; PEN-RY, J. K. & SCHMIDT, R. P. (eds.): Antiepiletic Drugs. Raven Press, New York, 1972, pg. 193.

[9] 9. BUCHTHAL., F. & LENNOX-BUCHTHAL, M. A. - Phenobarbital: relation of serum concentration to control of seizure. In WOODBURY, D. M.; PENRY, J. K. & SCHMIDT, R. P. (eds.): Antiepileptic Drugs. Raven Press, New York, 1972, pg. 335.

[10] 10. BUTLER, I. J. & JOHNSON, R. T. - Central nervous system infections. Pediat. Clin. N. Am. 21:649, 1974.

[11] 11. CARPENTER, R. R. & PETERSDORF, R. G. - The clinical spectrum of bacterial meningitis. Amer. J. Med. 33:262, 1962.

[12] 12. DESMIT, E.. M. - A Follow-up study of 110 patients treated for purulent meningitis. Arch. Dis. Child. 30:415, 1955.

[13] 13. DIAMENT, A.J. - Evolução neurológica do lactente normal. EDART, São Paulo, 1975.

[14] 14. DODGE, P. R. & SWARTZ, M. N. - Bacterial meningitis: a review of selected aspects. II. Special neurologic problems, postmeningitic complications and clinicopathological correlation. New Engl. J. Med. 272:954, 1965.

[15] 15. DODGE, P. R. &. SWARTZ, M. N. - Bacterial meningitis: a review of selected aspects. New Engl. J. Med. 272:1003, 1965.

[16] 16. EINHORN, A. H. - Bacterial meningitis. In BARNETT, H. L. (ed.): Pediatric (15Ş ed.). Meredith Corps., New York, 1972, pg. 698.

[17] 17. FARMER, T. W. - Neurologic complications during meningococcic meningitis treated with sulfonamide drugs. Arch. int. Med. 76:201, 1945.

[18] 18. FARMER, T. W. & WISE, G. R. - Subdural empyema in infants, children and adults. Neurology (Minneapolis) 23:254, 1973.

[19] 19. FEIGIN, R. D. & DODGE, P. R. - Bacterial meningitis: new concepts of pathophysiology and neurologic sequelae. Ped. Clin. N. Am. 23:541, 1976.

[20] 20. GOODMAN, J. M. & MEALEY, J. Jr. - Postmeningitic subdural effusions. The syndrome and its management. J. Neurosurg. 30:658, 1969.

[21] 21. HOSFIELD, W. B. - Management and complications of acute bacterial meningitis. Postgrad. Med. 50:100, 1971.

[22] 22. HOYNE, A. L. & BROWN, R. H. - 727 meningococcic cases: Ann. int. Med. 28;241, 1948.

[23] 23. JONSSON, M. & ALVIN, A. - A 12 year review of acute bacterial meningitis in Stockholm. Scand. J. infect. Dis. 3:141, 1971.

[24] 24. KAUFMAN, B.; LEVY, H.; ZALEZNAK, B. D. & UTVAK, A. M. - Statistical analysis of 242 cases of meningococcus meningitis. J. Pediat. 38:705, 1951.

[25] 25. KRUGMAN, S.; WARD, R. & KATZ, S. L. - Acute bacterial meningitis. Infectious Diseases of Children (6Ş ed.). C. V. Mosby Co. Saint Louis, 1977, cap. 13.

[26] 26. LEFÈVRE, A. B. - Exame neurológico da criança. In TOLOSA, A. P. M. & CANELAS, H. M. (eds.): Propedêutica Neurológica (2Şed.). Procienx, São Paulo, 1971, cap. 25.

[27] 27. LEFÈVRE, A. B.; ALMEIDA, I. J. M.; SANTOS, I.; ELKIS, L. C.; PAZINATO, M. Jr.; PAREDES, M. A. N.; PINTO, M. C. B.; VALENTE, M. 1.; GUIMARÃES, M. L. O.; GROSSMAN, R. M.; DEL PORTO, R.; GAZAL, S.; CYPEL, S. & GOES, S. L. - Estudo clinico de 78 casos de meningite em crianças. Neuroped. latino-amer. 11:217, 1977.

[28] 28. LIEBMAN, E. P.; RONIS, M. L.; LOVRINIC. J. H. & KATINSKY, S. E. - Hearing improvement following meningitis deafness. Arch. Otolaryng. 90:470, 1969.

[29] 29. MATSON, D. D. - Neurosurgery of Infancy and Childhood (¾ ed.). Charles C. Thomas Publ., Springfiels. Illinois, 1969, cap. 45.

[30] 30. MOURA-RIBEIRO, M. V. L. - Meningencefalites purulentas em crianças no primeiro ano de vida: evolução clinica e eletrencefalográfica. Tese de Livre Docência. Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Brasil, 1978.

[31] 31. MURRAY, J. D.; FLEMING, P.; WEBER, J.; HSUEN, J.; BANNATYNE, R. & ANGLIN, C. - The continuing problem of purulent meningitis in infants and children. Pediat. Clin. N. Am. 21:967, 1974.

[32] 32. DUNSTED, C. - Significance of convulsions in children with purulent meningitis. Lancet 1:1246, 1951.

[33] 33. PAI, M. N. - Personality defects and psychiatric symptons after cerebrospinal fever in childhood - meningococcal encephalopaty. J. ment. Sc. 92:369, 1946.

[34] 34. PLUM, F. & POSNER, J. P. - Diagnosis of Stupor and Coma. (2Ş. ed.). F. A. Davis Co., Philadelphia, 1975, pg. 204.

[35] 35. POLLARD, R. B. - Early bilateral eighth nerve involvement in meningococcal meningitis. South, med. J. 69:343, 1976.

[36] 36. PORTILLO, J. M.; SANTOS, F.; BANCUICERAS, R. L.; FERRARI, M. A.; RIOS, E.; BA2ZINO, I. R.; QUIAN, J.; FREITAS, T.; GARRIDO, M.; PELUFFO, L.; CACERES, M. P.; LOY, A. A.; FOLLE. A. U.; TARLOWSKY, M.; MENDONZA, M. P. & THEVENET, M. C. - Meningitis supuradas, Neuroped. latinoamer. 11:181, 1977.

[37] 37. RABE, E. F.; FLYNN, R. E. & DODGE, P. R. - Study of subdural effusions in infants with particular to the mechanism of their persistence. Neurology (Minneapolis) 12:79, 1962.

[38] 38. RAIMONDI, A. J. & DIROCCO, C. - The physiopathogenetic basis for angiographic diagnosis of bacterial infections of the brain and its covering in children. I. Leptomeningitis. Child's Brain 5:1, 1979.

[39] 39. RORKE, L. B. & PITTS, F. W. - Meningitis purulent: pathologic basis of clinical manifestations. Clin. Pediat. 2:64, 1963.

[40] 40. ROSS, A. T. - Meningococcic meningitis: incidence of residua following serum, sulfonamide and sulfonamide-penicillin therapy. Arch. Neurol. Psychiat. 67:89, 1952.

[41] 41. SAHS, A. L. & JOYNT, R. J. - Meningitis. In BAKER A. B. & BAKER L. H. (eds.). Clinical Neurology (2Ş ed.). Harper & Row Publ., 1974, vol. 2, cap. 15.

[42] 42. SCHWARTZ, J. F. - Ataxia in bacterial meningitis. Neurology (Minneapolis) 22:1071, 1972.

[43] 43. SEIBEL, R. G. - Meningitis meningocócica. In PUG T.F. (coord.): Meningitis en la Infancia. Ed. Médica Panamericana, Buenos Aires, 1976, pg. 155.

[44] 44. SESHIA, S. S.; SESHIA, M. M. K. & SCHDEVA, R. K. - Coma in childhood. Develop. Med. Child. Neurol. 19:614, 1977.

[45] 45. SILLANPAA. M.; PELTONEN, T. & NURMIKKO, T. - Social and medical prognosis of child with acute nontuberculous purulent meningitis. Acta paediat. scand., suppl. 265, 1977.

[46] 46. SLESINGER, H. A. - Complications and sequelae of meningococcic meningitis during infancy and childhood. Pennsylvania med. J., pg. 327, 1933.

[47] 47. SMITH, D. H.; INGRAM, D. D.; SMITH, A. L.; GILLES, F. & BRESNAN, M. J. - Bacterial meningitis. Pediatrics 52:586, 1973.

[48] 48. SPINA-FRANÇA, A. - Líquido cefalorraqueano na infância. In: MARCONDES, E. (coord.): Pediatria Básica. Sarvier, São Paulo, 1975, vol. 1, pg. 287.

[49] 49. SWARTZ, M. N, & DODGE, P. R. - Bacterial meningitis. A review of selected aspects. New Engl. J. Med. 272:725, 1965.

[50] 50. SWARTZ, M. N. & DODGE, P. R. - Bacterial meningitis. A review of selected aspects. New Engl. J. Med. 272:779, 1965.

[51] 51. TENG, Y. C; LIU, J. H. & HSU, Y. H. - Meningitis and deafness: report of 337 cases of deafness due to cerebrospinal meningitis. Chinese med. J. 81:127, 1962.

[52] 52. UNDERMAN, A. E.; OVERTURF, G. D. & LEEDOM, J. M. - Bacterial meningitis. Disease-a-Month. Year Book Medical Publ., Chicago, vol. XXIV, february 1978.

[53] 53. WEHRLE, P. F.; MATHIES, A. W. & LEEDOM, J. M. - The critically ill child: management of acute bacterial meningitis. Pediatrics 44:991, 1969.

[54] 54. WEHRLE, P. F.; MATHIES, A. W. & LEEDOM, J. M. - Acute bacterial meningitis. In CLEMENT, A. S. (ed.): The Critically 111 Child. W. B. Saunders Co.. Philadelphia, 1977, pg. 91.

[55] 55. ZIMMERMAN, R. A.: PATEL, S. & BILANIUK, L. - Demonstration of purulent bacterial intracranial infections by computed tomography. Am. J. Roentgenol. 127:155, 1975.