Successful Management of Acute Streptococcal Meningoencephalitis Complicated by Bilateral Third-Nerve Palsies, Wall-Eyed Bilateral Internuclear Ophthalmoplegia, Blindness, and Deafness: Case Report

Abstract

Introduction: Streptococcal meningoencephalitis (SME) is a rare, and frequently lethal, acute infection, and inflammation of the central nervous system parenchyma, with associated meningeal involvement. Bacterial meningoencephalitis is generally associated with high rates of morbidity and mortality, despite available antimicrobial and corticosteroid treatments. While Streptococcus pneumoniae is well recognised to cause bacterial meningitis, direct extension into the central nervous system parenchyma is rare.

Case presentation: A previously well 49-year-old man presented with sudden onset severe headache, fevers, neck stiffness, and reduced consciousness. The manifestations of SME in this patient were bilateral pupil-involving third-nerve palsies, wall-eyed bilateral internuclear ophthalmoplegia (WEBINO), bilateral blindness, bilateral deafness, a right lower motor neuron facial palsy, and upper motor neuron signs in his limbs. Initially, a partial response to high dose intravenous antibiotics occurred, but with administration of intravenous corticosteroids, further substantial resolution of the patient's neurological and neuro-ophthalmological deficits occurred.

Conclusion: This case highlights the benefit of multidisciplinary diagnostic and therapeutic interventions in a case of SME complicated by bilateral pupil-involving third-nerve palsies, WEBINO, bilateral blindness, bilateral deafness, a right lower motor neuron facial palsy, and upper motor neuron signs. It appears to be the first reported case of SME with this rare collection of neuro-ophthalmological abnormalities.

Keywords: Antibiotics; Corticosteroids; Cranial nerve palsies; Streptococcal meningoencephalitis; Wall-eyed bilateral internuclear ophthalmoplegia.

Fig. 1.

a Axial MRI brain diffusion-weighted imaging sequence demonstrating multiple foci of restricted diffusion in the hypothalamus at the walls of the third ventricle bilaterally (white arrows), insular cortex bilaterally (red arrows), and pus in the occipital horns of both lateral ventricles (yellow arrows). b Axial MRI brain post contrast T2 FLAIR sequence demonstrating leptomeningeal enhancement at the brainstem (yellow arrows). c Axial MRI brain post contrast T1 fat-saturated sequence demonstrating abnormal enhancement of both oculomotor nerves in the interpeduncular cistern (yellow arrows).

Fig. 2.

Bilaterally abducted eyes consistent with both bilateral third-nerve palsies as well as WEBINO. The fixed dilated pupils are consistent with bilateral third-nerve palsies.

Fig. 3.

a Humphrey visual field (30-2) at 24 weeks demonstrating bilateral tunnel vision. b Macular cube ganglion cell analysis on optical coherence tomography (OCT) demonstrating reduced ganglion cell layer thickness. c OCT nerve fibre layer analysis demonstrating bilateral reduced retinal nerve fibre layer thickness.