Pneumococcal Meningitis Presenting With Normocellular CSF
A 34-year-old Japanese woman presented to our hospital one morning because of nausea, headache, and loss of hearing in her right ear, all of which had developed a few hours before visiting our hospital. She also stated that she had a fever of 39.7°C, which had suddenly developed after suffering chills two nights previously. She had a history of splenectomy as a result of a traffic accident, but had not received a pneumococcal vaccine. She had received oral cephalosporin (cefditoren pivoxil) and an antipyretic analgesic (loxoprofen sodium hydrate), which were prescribed at a nearby clinic, for the fever on the day before her hospital visit.
On initial physical examination, she was afebrile (36.6°C), but in a hypotensive state (88/55mmHg) with tachycardia (120 beats/minute). There was no obvious deficiency in her mental status nor was neck stiffness detected at initial presentation, but she became progressively disoriented (Glasgow coma scale rating of E3V4M6) during out-patient management. She was admitted to the intensive care unit and treated with fluid replacement and a vasopressor. Blood tests showed an elevated leukocyte count (27,400/μL) with a left shift, elevated C-reactive protein level (27.3mg/dL), and low platelet count (89,000/μL). Examination of a CSF sample obtained 90 minutes after presenting to the hospital demonstrated a normal cell count (2/μL) without red blood cells. The CSF was clear, and the concentrations of glucose and total protein in the CSF were 56mg/dL (blood glucose level: 92mg/dL) and 40mg/dL, respectively (Table 1). Gram staining of the CSF showed Gram-positive cocci that were subsequently identified in culture as Streptococcus pneumoniae. Penicillin G was initially administered in the emergency department, and combination therapy with cefotaxime and vancomycin was started after admission. CSF examination on day 2 of hospitalization showed marked pleocytosis (mononuclear cells: 2448/μL, polymorphonuclear cells: 1638/μL), an increased total protein level (270mg/dL), and a decreased glucose level (13mg/dL). Two blood samples for culture were obtained simultaneously with the start of intravenous antimicrobial therapy in the emergency department, but no bacteria were cultivated. The drug susceptibilities of S. pneumoniae grown in the CSF cultures were determined by the disk dilution method and showed susceptibility to penicillin (≥20mm), erythromycin (≥21mm), and levofloxacin (≥17mm). She recovered after a 3-week treatment with these antimicrobial agents and was discharged on day 23. Her hearing loss remained.
A 62-year-old Japanese man with a history of treatment for laryngeal cancer 7 years previously was transferred to the emergency department after an acute onset of delirium. He had developed a fever the previous day. He did not receive antimicrobial therapy before being transferred. Neither neck stiffness nor paralysis was apparent on physical examination. Blood tests revealed a low leukocyte count (2480/μL), elevated C-reactive protein level (33.0mg/dL), and low platelet count (38,000/μL). CSF examination demonstrated a normal cell count (1/μL) without red blood cells. A low CSF glucose level of 8mg/dL (blood glucose level: 69mg/dL) and a high total protein level of 125mg/dL were present. Gram staining of the CSF showed numerous Gram-positive cocci that were proven to be S. pneumoniae by CSF culture. Blood cultures were not obtained. A chest X-ray showed an infiltrate in his left lower lung field. Within 1 hour of arrival, he developed hypotension followed by cardiopulmonary arrest, and resuscitation was unsuccessful. The drug susceptibilities of S. pneumoniae were determined by the microdilution method with MicroScan WalkAway® (Siemens Healthcare) and showed susceptibility to ampicillin (≤0.5μg/mL), cefotaxime (≤0.5μg/mL), and meropenem (≤1μg/mL), but resistance to penicillin (0.12μg/mL) and erythromycin (≥2μg/mL).
Case Presentation
Case 1
A 34-year-old Japanese woman presented to our hospital one morning because of nausea, headache, and loss of hearing in her right ear, all of which had developed a few hours before visiting our hospital. She also stated that she had a fever of 39.7°C, which had suddenly developed after suffering chills two nights previously. She had a history of splenectomy as a result of a traffic accident, but had not received a pneumococcal vaccine. She had received oral cephalosporin (cefditoren pivoxil) and an antipyretic analgesic (loxoprofen sodium hydrate), which were prescribed at a nearby clinic, for the fever on the day before her hospital visit.
On initial physical examination, she was afebrile (36.6°C), but in a hypotensive state (88/55mmHg) with tachycardia (120 beats/minute). There was no obvious deficiency in her mental status nor was neck stiffness detected at initial presentation, but she became progressively disoriented (Glasgow coma scale rating of E3V4M6) during out-patient management. She was admitted to the intensive care unit and treated with fluid replacement and a vasopressor. Blood tests showed an elevated leukocyte count (27,400/μL) with a left shift, elevated C-reactive protein level (27.3mg/dL), and low platelet count (89,000/μL). Examination of a CSF sample obtained 90 minutes after presenting to the hospital demonstrated a normal cell count (2/μL) without red blood cells. The CSF was clear, and the concentrations of glucose and total protein in the CSF were 56mg/dL (blood glucose level: 92mg/dL) and 40mg/dL, respectively (Table 1). Gram staining of the CSF showed Gram-positive cocci that were subsequently identified in culture as Streptococcus pneumoniae. Penicillin G was initially administered in the emergency department, and combination therapy with cefotaxime and vancomycin was started after admission. CSF examination on day 2 of hospitalization showed marked pleocytosis (mononuclear cells: 2448/μL, polymorphonuclear cells: 1638/μL), an increased total protein level (270mg/dL), and a decreased glucose level (13mg/dL). Two blood samples for culture were obtained simultaneously with the start of intravenous antimicrobial therapy in the emergency department, but no bacteria were cultivated. The drug susceptibilities of S. pneumoniae grown in the CSF cultures were determined by the disk dilution method and showed susceptibility to penicillin (≥20mm), erythromycin (≥21mm), and levofloxacin (≥17mm). She recovered after a 3-week treatment with these antimicrobial agents and was discharged on day 23. Her hearing loss remained.
Case 2
A 62-year-old Japanese man with a history of treatment for laryngeal cancer 7 years previously was transferred to the emergency department after an acute onset of delirium. He had developed a fever the previous day. He did not receive antimicrobial therapy before being transferred. Neither neck stiffness nor paralysis was apparent on physical examination. Blood tests revealed a low leukocyte count (2480/μL), elevated C-reactive protein level (33.0mg/dL), and low platelet count (38,000/μL). CSF examination demonstrated a normal cell count (1/μL) without red blood cells. A low CSF glucose level of 8mg/dL (blood glucose level: 69mg/dL) and a high total protein level of 125mg/dL were present. Gram staining of the CSF showed numerous Gram-positive cocci that were proven to be S. pneumoniae by CSF culture. Blood cultures were not obtained. A chest X-ray showed an infiltrate in his left lower lung field. Within 1 hour of arrival, he developed hypotension followed by cardiopulmonary arrest, and resuscitation was unsuccessful. The drug susceptibilities of S. pneumoniae were determined by the microdilution method with MicroScan WalkAway® (Siemens Healthcare) and showed susceptibility to ampicillin (≤0.5μg/mL), cefotaxime (≤0.5μg/mL), and meropenem (≤1μg/mL), but resistance to penicillin (0.12μg/mL) and erythromycin (≥2μg/mL).
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