A 30-year-old female with no relevant pathological history came to the emergency department due to seven days of fever and headache, with an intensity of 8/10 on the visual analogue scale (VAS) of pain, photophobia, and neck pain. Subsequently, this was accompanied by an acute confusional syndrome, with variations in her behavior having aggressiveness and prosopagnosia.
On physical examination, vital signs were normal: blood pressure: 107/58 mmHg, mean blood pressure: 71 mmHg, heart rate: 88 beats/minute, respiratory rate: 18 breaths/minute, oxygen saturation: 99%, temperature: 36.2 C, and glucometer: 110 mg/dl. She was in poor general condition, stuporous, with neck stiffness accompanied by a positive Kerning and Brudzinski sign, a positive jolt accentuation sign, and an 11/15 Glasgow coma scale (GCS). The presence of a periodontal abscess was striking. The rest of the physical examination was unremarkable.
At anamnesis, patient referred a persistent orodental pain which required a dental procedure fifteen days ago; she denied imaging realization and commented received an antibiotic (amoxicillin 500 mg every 8 hours) for 3 days ordered by a dentist. Blood tests reported the following: leukocytes: 4.87 x 103/mm3, neutrophils: 52.80%, lymphocytes: 41.7%, hemoglobin: 7.7gr/dL; hematocrit: 25.4%; platelets: 361 x 103/uL, glycemia 70 mg/dL, and initial chest X-ray was normal. A brain computed tomography (CT) was performed, reporting no space-occupying lesions, ischemic, hemorrhagic, and/or tomographic signs of intracranial hypertension.
With the described findings, central nervous system (CNS) infection was suspected, and due to disturbance of consciousness of fluctuating course, the patient was transferred to the intensive care unit for monitorization. Empirical therapy with broad-spectrum antibiotics (ceftriaxone 2 g every 12 hours) and corticosteroids (dexamethasone 10 mg every 6 hours) was started. Blood and urine cultures were taken.
A lumbar puncture was performed. The CSF cytochemical reported the following: glucose in liquid 58 mg/dl, proteins in liquid 70.80 mg/dl, colorless, appearance: transparent, pH: 8, density: 1000, leukocytes: 8.24 x 103/mm3, polymorphonuclear cells: 60%, and mononuclear cells: 40%. A nonreactive nontreponemal test (VDRL), negative-staining India ink, and negative CSF culture for M. tuberculosis were obtained. Also, blood and urine cultures were reported as negative without any bacterial growth.
CSF culture reported single isolation of multisensitive A. faecalis (Table 1).
Considering the rareness of the microorganism isolated in an adult without obvious risks for this infection leads to concern that the single CSF culture isolate may have been a contaminant. Thus, the culture was repeated, yielding the same result, confirming the diagnosis of meningitis due to A. faecalis. The patient was assessed by infectious diseases, who recommended giving antibiotic management for 14 days.
Given favorable evolution, improvement in the state of consciousness, and GCS, she was transferred to the hospitalization ward to continue treatment for the next seven days. After completing antimicrobial coverage, the patient was discharged without sequelae or neurological repercussions.