A 30-year-old previously healthy male presented to the Emergency Department with a 5-day history of productive cough, fever, shortness of breath, and severe pleuritic chest pain. The fever was associated with chills and decreased appetite and was responding partially to over the counter antipyretics. The patient had traveled to India within 4 weeks prior to the presentation. Upon presentation, the patient appeared acutely ill. Vital signs included tachycardia of 112 beats per minute, respiratory rate of 26 breaths per minute, with an oxygen saturation of 94 % on room air. Laboratory investigations showed leukocytosis of 32,800/mu/L with neutrophilia, high procalcitonin of 16.5 ng/mL, and CRP of >300 mg/L.
A chest x-ray revealed a right upper lobe patchy consolidation, with no cavitation, associated with prominent perihilar and infrahilar markings. There was no pleural effusion or pneumothorax (Fig. 1).
The patient was initially admitted as a case of community-acquired pneumonia (CAP). Sputum and blood cultures were collected. Since his illness was during the COVID-19 pandemic, nasopharyngeal swabs were taken to rule out COVID-19 infection. The patient was started on piperacillin-tazobactam and Azithromycin as per local empiric antibacterial guidelines for CAP. Within a day of incubation, the blood culture grew gram-negative diplococci in the aerobic bottles. The final culture results identified Neisseria meningitidis which was sensitive to benzylpenicillin, ceftriaxone, ciprofloxacin, and meropenem, but resistant to trimethoprim- sulfamethoxazole. The antibacterials were initially changed to ceftriaxone 2 g every 12 h to cover possible meningitis. However, due to the absence of any risks for meningococcemia and its complications, the antimicrobial dose was decreased to 1 g of ceftriaxone every 12 h. The patient denied any headache or neurologic symptoms and was free of any meningeal signs on multiple physical examinations. The patient had no other end-organ complications. Routine liver and renal function laboratory tests were normal and an abdominal ultrasound was unremarkable.
HIV testing was negative. Active pulmonary tuberculosis was ruled out with 3 negative samples of sputum acid-fast bacillus (AFB) smears, negative Mycobacterium tuberculosis PCR, and negative Quantiferon test. Sputum culture isolated light growth of normal upper respiratory flora. COVID-19 PCR was negative.
Repeat blood cultures were drawn 48 h after the initial culture and showed no growth. The patient was afebrile within 72 h of admission and remained hemodynamically stable throughout the hospital stay with no complications. The patient completed a 10-day course of ceftriaxone and was discharged home safely and in good health. Adequate infection control precautions were maintained throughout his hospitalization.