Streptococcus pneumoniae meningitis in an adult with normal cerebrospinal fluid.

CMAJ 2011. DOI:10.1503 /cmaj.090310 A60-year-old woman presented to our emergency department with a one-day history of fever and headache. Her medical history included an appendectomy and a hysterectomy. She was not taking any medications, and she had not recently taken any antibiotics. She had not she received a vaccination against pneumococcus. The night before her visit to the hospital, the patient had a fever of 38.7°C, a frontal headache and neck pain. She had no pain in her throat or ears. None of her family members or intimate contacts had a similar illness. When she presented to the emergency department, she was afebrile and her vital signs were stable. On examination, the patient had neck stiffness with no focal neurologic signs. She had a score of 15 on the Glasgow Coma Scale. Laboratory investigations showed an elevated serum leukocyte count of 16.6 (normal 4–10) × 10/L. Her serum electrolyte and blood glucose levels were normal, as were her levels of liver enzymes. A blood culture and a lumbar puncture were done. The patient’s cerebrospinal fluid was clear and colourless, and analysis showed a protein level of 0.39 g/L, a glucose level of 3.9 mmol/L (the serum glucose level was 6.1 mmol/L) and a leukocyte count of less than 1 × 10/L. A Gram stain of the patient’s cerebrospinal fluid showed no organisms (Table 1). Because of the normal results of the lumbar puncture, the patient was sent home. Three days later, the patient was contacted by a physician from the emergency department because the initial blood culture was positive for Streptococcus pneumoniae. The patient returned to the hospital. She complained of neck stiffness and occasional shivering. On examination, she had persistent neck stiffness and no focal neurologic signs. Again, she had a score of 15 on the Glasgow Coma Scale. A second lumbar puncture showed clear, colourless cerebrospinal fluid with a protein level of 0.74 g/L, a glucose level of 3.8 mmol/L (the serum glucose level was 5.3 mmol/L) and a leukocyte count of 63 × 10/L. Again, no organisms were seen in a Gram stain of the cerebrospinal fluid (Table 1). A second blood culture was positive for S. pneu moniae. The first sample of cerebrospinal fluid had remained sterile, but S. pneumoniae was found in the sample obtained during the patient’s second visit. Bacterial meningitis was diagnosed with a four-day delay as of the initial clinical symptoms. The patient responded favourably to treatment with intravenous ceftriaxone.