We report the case of a 16-year-old girl who presented initially to her local hospital emergency department with headache, vomiting, and hallucinations associated with photophobia and neck stiffness. She underwent an urgent head CT, which was normal. She was commenced on acyclovir and ceftriaxone on the day of admission, and she made a clinical improvement. A lumbar puncture performed 24 h after antimicrobial therapy was commenced, which revealed CSF cell count of 226 (200 lymphocytes, 6 polymorphs), raised protein 1.2 g/L, negative Gram stain and culture, negative viral polymerase chain reaction (PCR). CSF glucose was not sent. In light of a predominantly lymphocytic CSF and presumed viral meningitis with clinical improvement, antibiotics were stopped 4 days after treatment. Three days later, she had acute deterioration in the neurological status with no clear evidence of seizures with a drop in the Glasgow Coma Scale score from 15 to 7 (E1V1M5) requiring intubation. Antimicrobial treatment was recommenced with additional cover for listeria and tuberculosis bacterium (TB). An urgent MRI brain demonstrated evidence of tonsillar herniation and coning which was not present on her previous cranial imaging (Fig. 1).
In light of significant clinical and radiological deterioration, she was transferred to our unit for further treatment. On arrival, she had equal and bilaterally reactive pupils to light. She underwent emergency insertion of an external ventricular drain (EVD) and foramen magnum decompression and C1 arch laminectomy. Postoperative MRI demonstrated satisfactory decompression of the foramen magnum (Fig. 2).
She was extubated on day 2 with removal of the EVD on day 11 postoperatively. Repeat CSF sampling from the EVD remained culture negative, as well as negative for 16S ribosomal protein, TB PCR, and an extensive viral PCR screen. TB treatment was discontinued following negative TB PCR results. She made a full recovery with no neurological deficit. She was discharged following completion of a full course of intravenous antibiotics.