bacterial meningitis is frequently accompanied by intracranial and systemic complications , such as septic shock , adult respiratory distress syndrome , or disseminated intravascular coagulation in children .
however , spinal cord involvement is an extremely rare complication of bacterial meningitis in adults5 ) .
recurrent bacterial meningitis is defined as repeated episodes of acute infection followed by periods during which signs and symptoms are absent and cerebrospinal fluid ( csf ) is normal , and is usually a complication of a cranial anatomical defect or the result of impaired humoral immunity , notably , a complement system defects or agammaglobulinemia2 ) .
recurrent bacterial meningitis can present a diverse range of symptoms in children , but no previous report has been issued of recurrent meningitis accompanied by a spinal intramedullary abscess in an adult2 ) . in this article ,
we report a rare and interesting case of recurrent bacterial meningitis in an adult presenting as a spinal intramedullary abscess .
a 63-year - old man was admitted to the emergency department complaining about severe suboccipital headache , fever , and neck pain lasting for 5 days . on physical examination , he was alert and fully oriented , but febrile ( 38.3 ) and had apparent nuchal stiffness with positive kernig and brudzinski signs .
his pupils were midsize and reactive to the light , and bilateral papilledema was not detected in the fundoscopic examination .
a laboratory examination revealed a white blood cell count of 13,100/mm and an erythrocyte sedimentation rate ( esr ) of 78 mm / hour .
for the diagnosis of bacterial meningitis , lumbar puncture ( lp ) was performed after emergent brain computed tomography ( ct ) scan , which ruled out any space - occupying lesion within brain parenchyma .
csf contained 792 cells/l ( 94% polymorphonuclear cells ) , protein level was 6.3g / dl , and his csf glucose level was less than 15% of the serum glucose level . from the csf gram - positive cocci were found , and staphylococcus aureus ( s. aureus ) was isolated .
hence , ceftriaxone ( hanmi pharmaceuticals , korea ) and vancomycin ( cj pharmaceuticals , korea ) , which had been initiated empirically before confirmation of staphylococcus , were continued for 14 days .
an obvious clinical improvement occurred after lp and antibiotic therapy , and he was discharged after a second lp that revealed infection was resolved by culture ( 42 white blood cells and normal glucose and protein in csf ) . however , 6 days after discharge , he was readmitted due to the reappearance of fever and severe headache .
he was also complaing about decreased sensation on the lower extremities , but his motor power remained intact .
laboratory data showed leukocytosis ( 12300/mm with 89% neutrophils ) and elevated esr at 60 mm / hour .
g / l , and a glucose level of 29 mg/100 ml , but the second csf culture was negative for s. aureus .
magnetic resonance imaging ( mri ) of the thoracolumbar spine revealed a homogeneously enhanced solid lesion in gadolinium enhanced t1 weighted images ( fig .
1 ) . a 6-week course of high - dose , broad - spectrum antibiotics ( ceftriaxone , vancomycin ) was administered again and a series of magnetic resonance images were taken every 3 week .
no surgical removal was performed , due to rapid improvement of his clinical symptoms and radiological findings .
this rarity is attributed to the absence of sinuses in the spinal cord , the width of filtering epidural space , which filters , and the centripetal pattern of blood flow as compared with the centrifugal pattern of blood flow in the brain4,7 ) .
most of these lesions are either secondary to hematogenous spread from a cardiopulmonary source or originate in mediastinal , peritoneal , or retroperitoneal spaces6 ) .
acute bacterial meningitis is a potentially life - threatening infection of the cranial and spinal leptomeninges , and although recurrent episodes of meningitis are rarely seen in children , if they occur , an extensive investigation has to be made to identify the etiologic factors . congenital or acquired anatomical defects are the most common entities that accompanied by recurrent meningitis in children .
however , in this case , which developed in an adult , we could not identify the primary source of responsible for the spinal cord abscess , and no congenital defects , such as , a dermoid sinus , were evident .
the csf cultures in our patient were negative at discharge and readmission , which might have been a result of antibiotic therapy .
however , given his laboratory csf findings , a negative csf culture did not rule out recurrent meningitis .
the clinical presentations of acute spinal cord abscess are depend on the location of an abscess and are consistent with fever , back pain , an increased wbc and esr , and partial or total transverse myelitic features1 ) .
mri visualizes the extent and the location of an abscess better than ct or myelography .
in addition , mri also can be used to determine the extent of disease , to distinguish solid lesions , and it may suggest the nature of the lesion3 ) . after the diagnosis has been made ,
prompt decompressive laminectomy , myelotomy , and surgical drainage along with appropriate antibiotics , which are the mainstay of the treatment .
due to the eloquent location of the lesion in our patient and the lack of symptoms at diagnosis , 6 weeks of broad - spectrum antibiotic therapy was considered with close clinical and imaging follow up ( mri was performed 3 weekly to monitor the size of the lesion ) .
first , a spinal intramedllary abscess combined with a recurrent bacterial meningitis is uncommon in adults .
although it is not clear whether the spinal intramedullary abscess was the source of the meningeal infection in this case , it seems that this is the first case to suggest such a relationship between these two entities in an adult .
we report a rare case of recurrent bacterial meningitis who recovered from the disease by antibiotic therapy to treat a spinal intramedullary abscess in an adult .
although rare , the relationship between spinal intramedullary abscess and recurrent meningeal infection should be borne in mind .
 bacterial meningitis is rarely complicated by an intradural spinal abscess , and recurrent meningitis is an uncommon presentation of a spinal intramedullary abscess . here , we report a 63-year - old patient with recurrent meningitis as the first manifestation of an underlying spinal intramedullary abscess . to the best of our knowledge , 
 no previous report has been issued on recurrent meningitis accompanied by a spinal intramedullary abscess in an adult . in this article , the pathophysiological mechanism of this uncommon entity is discussed and the relevant literature reviewed . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION