Nasal lymphatics as a novel invasion and dissemination route of bacterial meningitis.

Bacterial meningitis constitutes an infectious disease with high morbidity and mortality, characterized by complex pathophysiology. Neisseria meningitis, Streptococcus pneumoniae, Haemophilus influenzae type b and other pathogens are capable of invading the CNS and infecting the meninges due to the incorporation of virulence factors. The pathophysiologic theories concerning the route of infection in bacterial meningitis consider a general cascade of events involving nasopharyngeal or middle ear colonization, pathogen bloodstream dissemination, blood-brain and blood-cerebrospinal fluid barriers crossing, and finally entrance of the implicated pathogen into the subarachnoid space, survival and subsequent infection. However, these theories cannot adequately explain the high percentage of negative blood cultures especially in cases of neonatal meningitis. Also, they cannot address with certainty the pathogens' entry site in to the cerebrospinal fluid, since the presence of barriers could act against bacterial infection of the meninges. In addition, experimental models of S. pneumoniae meningitis indicate that the route of infection may be independent of bacteraemia. The documented direct communication between the nasal lymphatics and the subarachnoid space could provide a hypothesis explaining the pathophysiologic mechanisms of meningeal infection and overcoming all the limitations of the current theories. It could also explain the presence of negative blood cultures while meningeal inflammation is present. Furthermore, it could also interpret the occasional fulminating evolution of bacterial meningitis since intense host defenses and central nervous system barriers could be bypassed. In our current communication we examine the role of the nasal lymphatic pathway in the development of meningitis. It is apparent that better understanding of the infection and dissemination route for bacterial meningitis can provide the opportunity for a more effective treatment.