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Emergency Medicine

Training Level

Resident PGY 3


Henry Ford Macomb


This is a case of streptococcus pneumoniae meningitis in an immunocompromised patient.This case discusses the presentation, management, and complications of a 57-year-old female with past medical history significant for Hodgkin's lymphoma in remission and rheumatoid arthritis on immunosuppressive therapy who presented to the emergency department with altered mental status.In the emergency department patient was found to have a fever of39.5 ° C, tachycardia 140s , and hypotensive at 73/40. Laboratory studies were significant for leukocytosis of 24 with a lactic acid of 4. Chest x-ray was negative for pneumonia.CT head was negative for acute intracranial abnormality. Patient was empirically started on antibiotic coverage for possible meningitis that included vancomycin, ceftriaxone, ampicillin, and acyclovir. Lumbar puncture was performed and spinal fluid was positive for 879 white blood cells, protein 591, lactic acid 16.2, and glucose <10. Cerebral spinal fluid grew gram positive cocci in pairs within the hour. By the next day both blood cultures and cerebral spinal fluid grew streptococcus pneumoniae.While patient remained intubated in the intensive care unit, she continued to be treated with vancomycin, ceftriaxone, and dexamethasone for 72 hours. Neurologically, Pt would open her eyes, not follow commands, but withdraw to pain with her left upper and lower extremities. EEG was indicative of moderate to severe degree of cerebral dysfunction. 2 days after presentation, patient had an MRI that showed a devastating acute infarct of left insular cortex and left parietal lobe with findings of ventriculitis. Patient was ultimately extubated day 6, but remains severely aphasic with complete hemiparesis of her right upper and lower extremity. Streptococcus pneumoniae is the most frequent cause of bacterial meningitis in the United States. Unfortunately this patient never had the streptococcal pneumoniae vaccine which is indicated for patients undergoing immunosuppressive therapy. There is no way to know for sure if this infection may have been prevented. Meningitis should always be considered in the differential in a patient with fever and altered mental status. As physicians, it is vital to act early by initiating empirical antibiotics and performing a lumbar puncture to identify this disease process.

Presentation Date


A Case of Streptococcus Pneumoniae Meningitis