(757) When a Stroke Is Something More: Meningitis Causing Infectious Vasculopathy

Introduction: Streptococcus anginosus bacteria is a common colonizer of the oropharynx and gastrointestinal tract. It is known to cause invasive, pyogenic infections with a tendency towards abscess formation. Infrequently, S. anginosus is associated with meningitis. Stroke, particularly in the brainstem, is an uncommon sequelae of streptococcal meningitis.

Description: A 59 year-old female with a remote history of left parotid carcinoma and mastoidectomy presented to the hospital after being found unresponsive at home. On initial examination, the patient had asymmetric, reactive pupils and no gag reflex. Other cranial nerve reflexes were intact and she was noted to be moving her left arm and leg spontaneously. CT Head revealed a hypodensity in the left pons concerning for acute infarct and bilateral intraventricular hemorrhage with associated obstructive hydrocephalus. She was intubated for airway protection and admitted for further stroke workup. Shortly after admission, all cranial nerve reflexes were lost and acute hypotension developed. Mannitol was administered given concern for brain herniation. MRI Brain revealed diffusion restriction in the bilateral pons and purulent material in the ventricles, previously thought to be blood, concerning for bacterial meningitis complicated by hydrocephalus. Neurosurgery was consulted and an external ventricular drain was placed. CSF cultures grew Streptococcus anginosus. Appropriate antibiotic therapy was initiated. Repeat MRI was negative for CNS abscess, but did reveal new areas of diffusion restriction in the bilateral frontal cortices and basal ganglia, consistent with progression of an underlying infectious vasculopathy. It was suspected that extension of the infection into the CNS originated from her previous mastoidectomy. Despite appropriate treatment, the patient did not improve and family opted to withdraw care.

Discussion: Streptococcus anginosus is considered a rare cause of bacterial meningitis, particularly in immunocompetent patients without underlying abscess. Vascular complications resulting from streptococcal meningitis are thought to be due to vasculopathy from the underlying infectious process. Our case highlights that clinical signs of ischemia may be the presenting feature of S. anginosus meningitis.