Pneumococcal Meningovasculitis: A Deadly Foe

Abstract

Meningitis is an inflammation of the protective membranes surrounding the brain and spinal cord, typically caused by viral or bacterial infections. Bacterial meningitis is a medical emergency requiring prompt diagnosis and treatment, which is associated with a significant mortality rate, even with optimal care. We report the case of a previously healthy 57-year-old man who presented to the emergency department with a three-week history of fever, dry cough, myalgia, fatigue, weakness, anorexia, and excessive sweating. Physical examination revealed a tympanic temperature of 38.9ºC, leukocytosis with neutrophilia, and elevated C-reactive protein levels. A computed tomography (CT) scan of the chest, abdomen, and pelvis showed consolidations in the left lung with air bronchograms and ground-glass opacities. His condition rapidly deteriorated with progressively higher fever, neck stiffness, positive Kernig and Brudzinski signs, profuse sweating, and altered mental status with a Glasgow Coma Scale (GCS) of 8, requiring non-invasive ventilation. He was thus admitted to the intensive care unit (ICU) on the second day of hospitalization. Lumbar puncture confirmed Streptococcus pneumoniae in the cerebrospinal fluid culture, supporting the diagnosis of pneumococcal meningitis. Electroencephalogram (EEG) findings were consistent with severe encephalopathy, while a follow-up CT scan revealed bilateral temporal hypodensities extending into the brainstem, suggestive of ischemic lesions of a vasculitic nature. Magnetic resonance imaging (MRI) confirmed multiple acute ischemic lesions throughout the brain and brainstem, along with signs of leptomeningitis and purulent collections in the lateral ventricles. Despite receiving 14 days of antibiotic therapy and intensive medical efforts, the patient showed no clinical improvement and ultimately succumbed to the infection. This case highlights the critical importance of early recognition and diagnosis of meningitis, as delayed treatment can lead to devastating outcomes. Continuous monitoring and a low threshold of suspicion are key elements for preventing fulminant central nervous system infections.

Keywords: encephalopathy; fulminant infection; meningovascular involvement; neurocritical patient; pneumococcal meningitis.

Figure 1. Brain CT scan

A-C: In the follow-up CT scan, new areas of hypodensity were seen in the temporal lobes bilaterally (circles in A and B) and in the brainstem (arrows in C).

Figure 2. Brain MRI scan

A-D: diffusion-weighted images (DWI) on the axial plane showing multiple bright areas scattered throughout the fronto-temporal lobes and on the pons bilaterally that are compatible with acute infarcts, as well as pus inside the ventricles (green arrows); E-G: post-contrast T2-FLAIR images on the axial plane, besides the parenchymal lesions, there’s also leptomeningeal (orange arrows) and ependymal (white arrows) enhancement in keeping with meningitis and ventriculitis, respectively; H: 3D time-of-flight (TOF) angiography with areas of vasoconstriction on both carotid tips and middle cerebral arteries, suggestive of vasculitis (blue arrows). FLAIR: fluid attenuated inversion recovery