18 August 2024: Articles
Uncommon Meningitis Leading to Pulmonary Abscess and Brainstem Infarct in an Immunocompetent Patient
Rare disease
Richard M. Bresler1ABCDEF*, Thomas Rabadi1EF, Joseph Kordsmeier1CDF, Bilal Abaid1BE, Jacob Whelan1AEDOI: 10.12659/AJCR.944667
Am J Case Rep 2024; 25:e944667
Abstract
BACKGROUND: Except for neonates, streptococci other than Streptococcus pneumoniae are a rare cause of acute bacterial meningitis. Streptococcus constellatus is a member of the Streptococcus anginosus group of gram-positive streptococci. It is a commensal microbe of the mucosae of the oral cavity, gastrointestinal tract, and urogenital tract. Rarely, it becomes pathogenic and causes contiguous or distant infections after mucosal damage. This report describes a 19-year-old immunocompetent man who developed bacterial meningitis, lung abscess, and brainstem infarct secondary to Streptococcus constellatus.
CASE REPORT: A 19-year-old immunocompetent man presented to the Emergency Department with a 4-week history of headache and neck pain. He was febrile on arrival. Physical examination revealed ataxia, upper-limb discoordination, and a positive Brudzinski sign. Cerebrospinal fluid and blood cultures were positive for Streptococcus constellatus, identified by matrix-assisted laser desorption ionization – time of flight mass spectrometry. Computed tomography of the chest demonstrated a lung abscess measuring 7×3.5×3 cm. A magnetic resonance imaging scan of the head revealed a 1.8×0.7 cm acute infarct in the right pons. The patient was treated initially with intravenous ceftriaxone and vancomycin before culture and sensitivity results, in addition to intravenous dexamethasone. After culture and sensitivities resulted, antibiotics were transitioned to a 4-week course of intravenous penicillin. The patient survived with no neurological consequences upon discharge.
CONCLUSIONS: Streptococcus constellatus should be suspected as an etiological agent for bacterial meningitis and other rare complications such as brainstem infarction and lung abscess, even in immunocompetent patients.
Keywords: ischemic stroke, lung abscess, Streptococcus anginosus, Streptococcus constellatus
Introduction
There is no criterion standard for the identification of
This report describes a 19-year-old immunocompetent man who developed
Case Report
A 19-year-old man with no significant past medical history presented to the Emergency Department (ED) with a 4-week history of headaches and neck pain. The pain was accompanied by fever, body aches, nausea, and vomiting. He had a few intermittent episodes of double vision, which had resolved prior to presentation to the hospital. The patient had no recent surgeries or dental manipulations. On arrival to the ED, he was febrile to 39.4°C and had a Glasgow Coma Scale of 15. He was slightly dysarthric. He had ataxia, upper-limb discoordination, and a positive Brudzinski sign. Cranial nerve examination revealed 4-mm pupils that were equal, symmetric, and reactive to light. There was evidence of horizontal and vertical nystagmus. Corneal reflex and vestibulo-ocular reflex were intact bilaterally. Upper and lower extremities were hypertonic. Toes were bilaterally extensor. No obvious dental caries were found on oral examination.
Initial laboratory investigations revealed a leukocyte count of 19.5 K/uL (normal 5.0–10.0 K/uL), hemoglobin of 11.4 g/dL (normal 14.0–18.0 g/dL), platelet count of 552 K/uL (normal 150–500 K/uL), sodium of 128 mmol/L (normal 135–145 mmol/L), international normalized ratio of 1.05 (normal 0.8–1.4), and activated partial thromboplastin time of 34 seconds (normal 23–37 seconds). Computed tomography (CT) scan of the head showed complete opacification of the right maxillary sinus, characteristic of right maxillary sinusitis (Figure 1).
A lumbar puncture was performed in the ED given concern for acute bacterial meningitis. Cerebrospinal fluid (CSF) analysis revealed glucose of 3 mg/dL (normal 40–80 mg/dL) and protein 103 mg/dL (normal 15–45 mg/dL). Total nucleated cells were 3613/cu mm (normal 0–5/cu mm), of which 78% were neutrophils (normal 0–6%), 15% were lymphocytes (normal 40–100%), and 7% were monocytes (normal 15–45%). The CSF red blood cell count was 31/cu mm (normal 0/cu mm).
A chest X-ray (CXR) showed a thick-walled cavitary lesion in the right lower lobe (Figure 2). CT chest demonstrated a right lower-lobe cavitary lesion measuring 7×3.5×3 cm (Figure 3). CT abdomen/pelvis was unrevealing.
A magnetic resonance imaging (MRI) scan of the head performed on day 1 of admission revealed a 1.8×0.7 cm area of increased T2 signal in the right pons, consistent with an acute infarct (Figure 4). There were normal findings on transthoracic echocardiography (TTE), with no patent foramen ovale. CT angiography of the head and neck was normal.
CSF and blood cultures became positive for S
Lab investigations into common bacterial, fungal, and viral pathogens associated with meningitis and lung abscess, including 3 samples of acid-fast bacilli, QuantiFERON, histoplasma, and fungitell assays were largely negative. Immunodeficiency work-up, including human immunodeficiency virus (HIV), was negative.
The patient was treated initially with intravenous ceftriaxone 2 g every 12 hours and vancomycin 1250 mg every 8 hours before culture and sensitivity results, in addition to intravenous dexamethasone 8 mg every 6 hours for 5 days. After culture and sensitivity results were available, antibiotics were transitioned to a 4-week course of intravenous crystalline penicillin 4 MU every 4 hours.
The patient improved clinically over his hospital course. His nystagmus resolved, with improvement in his dysarthria and co-ordination. He was then discharged to our in-patient rehabilitation unit without any clinical sequalae.
Discussion
The patient was immunocompetent. Few cases of acute meningitis caused by
There is no criterion standard for the identification of
Lung abscesses are a known complication of
Brainstem stroke in the setting of acute bacterial meningitis secondary to
Our patient was initially treated with broad-spectrum antibiotics given the high suspicion for bacterial meningitis. When culture sensitivities resulted, 4 weeks of intravenous penicillin was initiated. Generally, all isolates of
Conclusions
This report presents a case of
Figures
Figure 1.. Computed tomography (CT) scan of the head revealed complete opacification of the right maxillary sinus characteristic of right maxillary sinusitis (red arrow). Figure 2.. Chest X-ray (CXR) revealed a thick-walled cavitary lesion in the right lower lobe of the lung (red arrow). Figure 3.. Axial (A) and coronal (B) computed tomography (CT) scans of the chest revealed a 7×3.5×3 cm cavitating lesion in the right lower lobe of the lung (red arrows). Figure 4.. Magnetic resonance imaging (MRI) scan of the brain demonstrated a 1.8×0.7 cm area of increased T2 signal in the right pons, consistent with an acute infarct (red arrow).References:
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