The 31-year-old previously healthy man with no previous medical illness presented to emergency department at a tertiary hospital in Malaysia in May 2012 with complaints of fever and headache for 3 weeks. He had history of loss of appetite and weight loss for 2 months. His condition progressively became worse during the last three weeks as he became more lethargic and was speaking irrelevantly. One day prior to admission, the patient had change in his behaviour. He went to see the general practitioners twice over the course of 3 weeks, but the administration of antibiotics was unknown.
The patient was initially sent to a private hospital on 25 May 2012. Glasgow Coma Scale (GCS) was 10/15 (E4V1M5). The power was 3+/5 in both upper and lower limbs. Plantar response was upgoing on the right side. Computed tomography (CT) of the brain (contrasted) done at the private hospital showed widespread meningeal enhancement in the brain with cerebral oedema and hydrocephalus (Fig. 1a-f). The patient was diagnosed with meningoencephalitis and transferred to the University Malaya Medical Centre.
On examination, his GCS was E4V2M5 (11/15). He was not responding to questions and was not obeying commands. Neck stiffness was present. Pupils were 4 mm in size bilaterally and were reacting sluggishly. Blood pressure (BP) was 146/88 mm Hg. He was afebrile. The tone was normal in upper and lower limbs bilaterally. The power was at least 3/5 at upper and lower limbs bilaterally. Reflexes were normal in all the limbs. Plantar response was downgoing bilaterally. Lung examination was normal.
Lumbar puncture was done. Cerebrospinal fluid (CSF) opening pressure was more than 50 cm H2O. CSF result showed presence of raised white blood cells (WBCs) 210/muL (neutrophils 78%, lymphocytes 12%), glucose 3.1 mmol/L, and raised protein 2.47 g/L, which was consistent with meningitis. He was given intravenous ceftriaxone and acyclovir. He was given anti-tuberculous medication to cover tuberculous meningitis. Chest X-ray was normal.
Repeat plain CT brain done after lumbar puncture showed unchanged degree of hydrocephalus and cerebral oedema. Full blood count showed Hb 191 g/L, WBC 9.0 x 109/L (neutrophils 89%, lymphocytes 5%), and platelet count of 251 x 109/L. Renal function and electrolytes were normal. Immunoglobulin titres were not checked.
The following day in the morning, he was opening his eyes to call and was able to lift his right upper limb on command. GCS was 9/15 (E3V1M5). At night on the same day, the patient's GCS dropped to 7/15. His pupils were unequal. Right pupil was 4 mm and left pupil was 6 mm.
He was intubated and ventilated. Repeat plain CT brain showed increased degree of cerebral oedema and unchanged degree of hydrocephalus (Fig. 2a-e). He was planned for extraventricular drainage (EVD) by neurosurgical team on the following day. But, the patient passed away in the morning the following day.
CSF culture grew S. paucimobilis sensitive to ceftriaxone, ceftazidime, ciprofloxacin, and piperacillin/tazobactam (Tazosin). CSF acid-fast bacillus (AFB) smear was negative. CSF AFB C&S was negative. CSF tuberculous (TB) polymerase chain reaction (PCR) was negative. Blood culture showed no growth. A diagnosis of meningitis secondary to S. paucimobilis was made. Permission for autopsy was not obtained. Unfortunately a microphotographic picture has not been kept in stock.