2025 Proffered Presentations
S299: PNEUMOCOCCAL VACCINATION DOES NOT FULLY PROTECT AGAINST OTOGENIC MENINGITIS IN PATIENTS WITH TEGMEN DEFECTS
Ava Karam, BS1; Isaac Erbele, MD2; Julio Figueroa, MD1; Rahul Mehta, MD1; Moises A Arriaga, MD, MBA1; 1LSUHSC; 2Brooke Army Medical Center San Antonio
Introduction: This study assesses the claim that pneumococcal vaccination prevents otogenic meningitis in the setting of asymptomatic tegmen defects or encephaloceles. It additionally further characterizes clinical features of meningitis in the setting of tegmen defects or encephaloceles.
Methods: This retrospective review identified patients who had the diagnosis of meningitis and otitis media and encephalocele (or tegmen defect) between January 2015 and April 2024. Data collected included demographics, temporal bone CT findings, treatment details, hospitalization outcomes, meningitis pathogens, pneumococcal vaccination type and date of administration.
Results: In the total cohort of 2,570 cases of meningitis, 30 episodes of otogenic meningitis occurred in 29 patients with tegmen defects; ten were previously vaccinated for pneumococcus. The average age was 60.7 years (range 15-80). Nine cases were in males. Two patients had concomitant CSF leaks. The overall series had 15 with S. pneumoniae. The other identified pathogens were H. influenzae (5), S. pyogenes (1), S. agalactiae (2). Seven cases with no growth or unidentifiable cause. Meningitis pathogens were identified using cerebrospinal fluid cultures and/or meningitis/encephalitis PCR panels. Of the 15 patients with pneumococcal meningitis, nine additionally had pneumococcal bacteremia. Ten cases of otogenic meningitis occurred in patients with a prior S. pneumoniae vaccine; 5 of which experienced S. pneumoniae meningitis. Of these five cases, one received PPV only, one PCV 13 only, one PCV 7 and PCV13, and two PPV and PCV 13. Medical management included antibiotic use in 26 patients, antiepileptic drug use in 6 patients, corticosteroid use in 9 patients. Notably, 5 patients were intubated during their hospitalization. The average hospital length of stay was 12.8 days, and 19 patients required care in an intensive care unit. Six patients were required to be discharged to an inpatient rehabilitation center or a skilled nursing facility. During the review time, the senior author performed 423 middle fossa tegmen repairs with no cases of otogenic meningitis in this group.
Conclusions:
- Tegmen defects and otitis media create a two-hit mechanism for otogenic meningitis - the pathogens mirrored the bacteriology of otitis media.
- Pneumococcal vaccination in patients with tegmen defects may be insufficient to prevent otogenic meningitis.
- Since S. pneumoniae was the leading cause of meningitis in this group, we recommend enhancing the vaccine regimen in patients with tegmen defects if observation is selected, along with education on the warning signs of meningitis to facilitate timely treatment.
- Surgical repair should be considered in patients with tegmen defects.