A 24-year-old pregnant female (G1P0) presented to the maternity ward of the local hospital, 12 weeks pregnant with a 14-day history of a mild headache and high fever for 2 days. After two generalized tonic-clonic seizure episodes, the female was transferred to our hospital. She had a 4-year history of hypothyroidism with irregular medication. The patient had no history of nasosinusitis, head trauma, or surgery. On admission, her vital signs revealed a temperature of 39.4 C, a blood pressure of 89/55 mmHg, a pulse of 120 beats/min, and a respiratory rate of 22 breaths/min. Physical examination revealed a lethargic patient with a Glasgow coma scale (GCS) score of 15/15. She had a normal physical examination except for nuchal rigidity and a positive Kernig's sign. Blood tests showed that her leukocyte count was 22.7 x 109/L (neutrophil 85.4%), sedimentation rate (ESR) 105 mm/H, C-reactive protein (CRP) 99.1 mg/L, and procalcitonin (PCT) 0.5 ng/ml. Lumbar puncture showed that her cerebrospinal fluid (CSF) pressure was 330 mmH2O, leukocyte count 540 x 106/L (neutrophil 80.0%), protein 1.57 g/L, glucose 1.16 mmol/L, and chloride 117.1 mmol/L ( Figure 1 ). The patient was diagnosed with bacterial meningitis, and treated immediately with empirical antibiotic therapy with meropenem (2.0 q8h intravenous drip) and vancomycin (1.0 q8h intravenous drip). Levetiracetam (1.0) was administered twice daily for antiepileptic treatment. Brain magnetic resonance imaging (MRI) revealed diffuse hyperintensities on fluid attenuated inversion recovery (FLAIR) imaging, accompanying by meningeal enhancement on a T1 contrast image ( Figure 2A ). Brain magnetic resonance angiography (MRA) imaging exhibited normal findings. Head CT and MRI showed no bone destructions and fistulas. Later, blood and CSF culture indicated staphylococcus aureus, which was sensitive to vancomycin and linezolid. The results were consistent with the analysis of metagenomics next-generation sequencing (mNGS). Thereafter, temperature was gradually decreased. There was no recurrence of seizures. Repeated blood and CSF results were significantly improved. Serum and CSF antibodies were negative for all antibodies against nerve cell-surface antigens and intracellular antigens. Autoantibodies and mycoplasma pneumoniae antibody were also negative. The T-SPOT.TB test was normal. There were no cardiac valve destructions and vegetations on the echocardiography exam. A Doppler ultrasound suggested fetal growth restriction.
The patient selected to abort the pregnancy because the fetus had growth restriction and had undergone medical interventions, including medications and imaging examinations, that had the potential to result in the teratogenic effect for the fetus. After 20 days of antibiotic therapy, the patient underwent a successful medication abortion. However, she developed weakness of the right limb, and fever again. She deteriorated with a fluctuating mental condition (GCS ranging from 10 to 12 of 15). Although brain MRA imaging were still normal, brain MRI revealed lesions were enlarged and meningeal enhancement was even more obvious ( Figure 2B ). Repeated multiple blood and CSF culture were negative for any bacteria. Linezolid (0.6 g bid intravenous drip) was used to as a substitute to vancomycin.
Unfortunately, the patient continued to deteriorate. She lapsed into a coma with a GCS 8 of 15. The repeated MRI was confirmed the progressive condition ( Figure 2C ). Antibodies related to autoimmune encephalitis were still negative in the serum and CSF. Therefore, CNS-IRIS was considered. The patient received high-dose intravenous methylprednisolone (20 mg/d/kg body weight, 5 days) followed by oral corticosteroids.
The neurologic abnormalities gradually improved, and follow-up MRI showed marked improvement ( Figure 2D ). She was discharged from hospital three months after her admission. Although weakness of the right limb continued, she was able to walk unaided.