Associate Program Director Thomas Jefferson University, United States
Introduction: Bacterial meningitis is a fatal disease whose incidence has been declining. Its clinical relevance comes from the associated morbidity and mortality. The most common etiology worldwide is Streptococcus pneumoniae. Even with vaccination, the mortality of pneumococcal meningitis today remains 30%. Clinicians must also be vigilant because the presentation of bacterial meningitis is heterogeneous. Recent data shows that few patients present with the classic triad of fever, nuchal rigidity, and altered mental status. Focal deficits such as hemiparesis or cranial nerve palsies have been reported, but aphasia is uncommon. Here we present a patient with pneumococcal meningitis who presented with aphasia.
Description: A neurologically intact 65-year-old female presented to the ER with fevers, confusion, nausea, vomiting, and low back pain. Admission labs showed leukocytosis, lactic acidosis, and acute kidney injury. CT abdomen had findings of cystitis and pyelonephritis. She was started on broad-spectrum antibiotics and admitted to ICU for septic shock. On hospital day 1, she acutely developed aphasia, for which stroke workup was negative. Blood cultures grew S. pneumoniae. MRI was negative for epidural abscess, so lumbar puncture was performed. Spinal fluid was purulent and cultures grew S. pneumoniae, confirming a diagnosis of bacterial meningitis. The patient’s family later revealed that she is asplenic. By hospital day 3, her mentation had returned to baseline and she was transferred out of ICU on hospital day 4.
Discussion: This is a case of pneumococcal meningitis that spread hematogenously in an asplenic patient. Older patients account for 27% of the incidence of invasive pneumococcal disease, and 80% of these cases develop pneumonia rather than meningitis. Furthermore, the route of entry is more often hematogenous spread in asplenic patients such as ours, rather than sinusitis or otitis. Lastly, meningitis tends to produce long-term neurologic sequelae, ranging from subtle cognitive slowing to executive dysfunction. Our patient returned to her neurologic baseline prior to leaving the ICU. This case highlights the importance of maintaining a high index of suspicion for bacterial meningitis, as prompt recognition and treatment can reduce morbidity.
