Group A Streptococcal meningitis in adults

•In 2013, we notified a doubling in cases with GAS meningitis in the Netherlands.•A new finding is the high rate of subdural empyema associated with GAS meningitis.•The development of subdural empyema was associated with bacterial genotype.

SummaryObjectivesWe report on the incidence, clinical characteristics, and bacterial genotype of group A streptococcal (GAS) meningitis in the Netherlands.MethodsWe assessed the incidence, clinical characteristics, and outcome of patients with GAS meningitis from a nationwide cohort study of adults with community-acquired bacterial meningitis in the Netherlands from 2006 to 2013.ResultsGAS was identified in 26 of 1322 patients with community-acquired bacterial meningitis (2%); 9 cases (35%) occurred in the first four months of 2013. GAS meningitis was often preceded by otitis or sinusitis (24 of 26 [92%]) and a high proportion of patients developed complications during clinical course (19 of 26 [73%]). Subdural empyema occurred in 8 of 26 patients (35%). Nine patients underwent mastoidectomy and in 5 patients neurosurgical evacuation of the subdural empyema was performed. Five of 26 patients (19%) died and 11 of 21 surviving patient had neurologic sequelae (52%). Infection with the emm1 and cc28 GAS genotype was associated with subdural empyema (both 4 of 6 [67%] vs. 2 of 14 [14%]; P = 0.037).ConclusionsGAS meningitis is an uncommon but severe disease. Patients are at risk for empyema, which is associated with infection with the emm1 and cc28 genotype.