Cervicomedullary injury after pneumococcal meningitis with brain edema.

OBJECTIVES To demonstrate a rare but potential mechanism of quadriplegia in a patient with fulminant pneumococcal meningitis complicated by severe intracranial hypertension. DESIGN Case report. SETTING Intensive care unit. PATIENT A 21-year-old man who presented with 3 days of headache, combativeness, and fever. INTERVENTION Antibiotics and steroids were initiated after lumbar puncture yielded purulent cerebrospinal fluid and streptococcus pneumoniae. RESULTS The patient's course was complicated by severe cerebral edema necessitating intracranial pressure monitoring and intracranial pressure-targeted therapy. Within 5 days he developed quadriplegia and areflexia. Brain and cervical spine magnetic resonance imaging revealed patchy areas of T2 signal hyperintensity with associated gadolinium enhancement in the superior cervical spinal cord, cerebellar tonsils, and medulla. CONCLUSIONS Quadriplegia secondary to tonsillar herniation in fulminant meningitis is rare but should be considered in patients with acute quadriparesis after treatment of increased intracranial pressure. Magnetic resonance imaging signal changes and gadolinium enhancement may be demonstrated. Significant improvement of cord symptoms can be expected.