1775: a Rare Case of Pneumococcal Meningitis and Vertebral Osteomyelitis.

SEPTEMBER 2015 PRACTICAL NEUROLOGY 47 A 61-year-old male with a past medical history of hypertension initially presented in the emergency department with fever, chest pain, and tachycardia. He was found to have a left lower lobe infiltrate on admission chest x-ray. He also had left lower extremity edema. A CT angiogram of the thorax was negative for pulmonary embolism and a lower extremity Doppler study was negative for deep vein thrombosis. The patient was treated for sepsis secondary to community-acquired pneumonia. His blood cultures grew Streptococcus pneumoniae (S. pneumonia) susceptible to ceftriaxone. Symptoms improved with ceftriaxone and azithromycin. His repeat blood cultures were negative and he was discharged home on a course of cefpodoxime. The patient returned one month later with fever to 103.5°F, altered mental status, nuchal rigidity and back pain. He was found to have leukocytosis (WBC = 12,600/μL, 86% neutrophils). Physical exam was remarkable for tenderness of the lumbar spine. Lungs were clear to auscultation; heart sounds were of normal intensity without murmurs or gallops and he did not have any focal neurological deficits. CT of the head was unremarkable. A lumbar puncture revealed a white blood cell count of 2680 /μL (60% neutrophils, 20% lymphocytes). The patient was started empirically on ceftriaxone, vancomycin, and ampicillin for suspected meningitis. MRI of the cervical, thoracic and lumbar spine demonstrated spondylodiscitis at the C5-C6 and T5-T6 levels and fasciitis at the L4-L5 level with a posterior epidural phlegmon and an adjacent 2mm abscess. Neurosurgery did not recommend drainage of the minor abscess but IV antibiotics were continued. An MRI of the head with and without gadolinium demonstrated abnormal signal within the right frontal and parietal sulci with FLAIR hyperintensity of the cortex, suspicious for both meningitis and cerebritis (Figure 1). Diffusionweighted images demonstrated areas of diffusion hyperintensity within the dependent portions of the bilateral atria suspicious for proteinaceous material. Laboratory workup including HIV Ab, IgA/M/G and total complement were within normal limits. Blood cultures were positive for S. pneumoniae. CSF culture returned negative. He also had an elevated IgE to 1000 IU/mL and his maximum erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were 40 mm/hr and 6.68 mg/dL respectively. The patient returned to baseline mental status. His headache, neck pain, and back pain resolved. Repeat blood cultures were obtained and remained negative for five days. Infectious Disease Service was consulted and recommended eight weeks of intravenous ceftriaxone. The patient received a peripherally inserted central catheter and was discharged on ceftriaxone with close follow up by his primary care doctor, infectious disease, neurology, and spine surgery.