A 48-year-old Indian male with no chronic medical illness in the past admitted to emergency department with history of fever, headache, dry cough, and generalized body pain for 4 days and vomiting for one day. No abdominal pain, SOB, chest pain, joint pain, skin rash, recent travel, or exposure to sick person and no significant family history were reported. Patient denied alcohol consumption or tobacco smoking. On physical examination, the patient was well built and nourished; he was icteric, conscious, and oriented to time, place, and person. Vitals were as follows: temperature: afebrile, 35.9 C; heart rate: 94/minute; respiratory rate: 20/minute; blood pressure: 121/81 mmHg; and SpO2: 98% in room air.
Systemic examination showed normal neurological findings except meningeal signs. Other systems were unremarkable. Initial investigations showed hemoglobin and platelets were normal. White blood cell (WBC) count was 12.6 x 103/microliter (normal: 4 x 103/microliter-10 x 103/microliter) with 92% neutrophils. Serum creatinine was 146 micromol per liter (normal: 64 to 110 micromol per liter), urea was 11 mmol per liter (normal: 3.2 mmol per liter to 7.4 mmol per liter), and serum electrolytes were normal. Alanine aminotransferase (ALT) was 56 units per liter (normal: 0 units per liter to 30 units per liter), aspartate aminotransferase (AST) was 38 units per liter (normal: 0 units per liter to 31 units per liter), alkaline phosphatase (ALP) was 96 units per liter (normal: 40 units per liter to 150 units per liter), albumin was 33 g per liter (normal: 35 g/L to 50 g/L), total bilirubin was 68 micromol per liter (normal: 3.4 to 20.5 micromol per liter), direct bilirubin was 34 micromol per liter (normal: 0 to 8.6 micromol per liter), C-reactive protein (CRP) was 495 mg per liter (normal: 0 to 5 mg/L), procalcitonin (PCTN) was 11 ng per milliliter (normal: 0 to 2 ng/mL), and chest X-ray was normal. His conscious level deteriorated soon after hospital admission, and the Glasgow Coma Scale (GCS) dropped from 15/15 to 12/15. Meningitis is suspected, and antibiotics were started after lumbar puncture (LP) and computerized tomography (CT) head. Initial empirical intravenous (IV) antibiotics were started: ceftriaxone, vancomycin, and acyclovir along with dexamethasone. CT head was normal, and cerebrospinal fluid (CSF) analysis showed WBC 145 per microliter (normal: 0 to 5/microL) with 96% neutrophils, protein 4.55 grams per liter (normal: 0.15 to 0.45 g/L), and Glu <0.3 mmol per liter; CSF viral panel showed Epstein-Barr virus (EBV) PCR was 326 International Units per mL, acid-fast bacilli staining was negative, and tuberculosis PCR was negative. Both CSF and blood culture showed Streptococcus pneumonia which was sensitive to ceftriaxone. So acyclovir and vancomycin were stopped, dexamethasone was given for a total of 3 days, and IV ceftriaxone 2 g every 12 hours was continued; later, the patient's condition improved and oriented to person but not oriented to time and place. There was no focal neurological deficit. However, he developed hard of hearing and though fever pattern has improved, having fever spike on and off. Repeat blood cultures were negative, CRP improved from >500 mg/L to 93 mg/L, PCTN decreased from 11 ng/mL to 0.41 ng/mL, and serum creatinine level normalized. However, liver enzymes persisted to rise (both transaminases and alkaline phosphatase), and white blood cell persisted to be in the range of 13-15. Due to presence of persistence of symptoms, magnetic resonance image (MRI) brain and repeat LP were done to rule out any complication of the disease. MRI brain (Figures 1 and 2) showed meningoencephalitis, vasculitis, and extradural fluid collection. There was right-sided fluid in the mastoid cavity without bone destruction. ENT was consulted and advised for medical management. As the patient is confused, hearing assessment could not be done properly. Repeat LP showed CSF WBC 11/microL, neutrophils 70%, lymphocytes 29%, protein 1.11 g/L, EBV PCR was negative, and CSF culture was negative. Dexamethasone was restarted with continuation of IV ceftriaxone for a total of 6 weeks as Streptococcus pneumoniae meningitis is complicated by infective vasculitis, mastoiditis, and subdural collection. Repeat MRI brain (Figure 3) showed significant improvement in leptomeningeal enhancement and resolution of epidural collection; however, there was a new communicating hydrocephalus. After completion of his IV ceftriaxone, the patient was repatriated to his home country. Although his condition improved on above treatment, he was discharged with mild disorientation to time and person.