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Lesson Learned Through a Case of Pneumococcal Meningitis: Sometimes Doing Less Is More Harmful

Magnetic resonance imaging brain scan with contrast. (A) Axial view showing (arrow) transverse and sigmoid sinus venous thrombosis. (B) Axial view showing (arrow) left ophthalmic vein thrombosis. (C) Sagittal view showing (arrow) left ophthalmic vein thrombosis. (D) Axial view showing (arrow) focal perichiasmatic enhancement of the left optic nerve.

Pneumococcal meningitis is commonly associated with intracranial complications. We present a case of pneumococcal meningitis leading to partial loss of vision in the left eye secondary to vascular complications.

A 62-year-old African American female with a past medical history of breast cancer and hypothyroidism presented with complaints of altered mental status, neck pain, headache, and dysphasia. Vital signs showed a temperature of 98.1°F in degrees Celsius 36.7, heart rate of 75 beats per minute, blood pressure of 154/72 mm Hg, respiratory rate of 16 per minute, and saturation of 100% on room air. On physical examination, nuchal rigidity was positive, and pupils were equal and reactive to light. Computed tomography (CT) noncontrast brain scan showed no acute intracranial findings except partial opacification of right mastoid air cells. Lumbar puncture was done, and cerebrospinal fluid analysis showed cloudy character with a white blood cell count of 263/mm3 with 94% polymorphic cells, glucose <10 mg/dL, and total protein 368 mg/dL. Cerebrospinal fluid Phadebact was positive for Streptococcus pneumonia. The patient was started on vancomycin, ceftriaxone, and dexamethasone. Subsequently, blood cultures and cerebrospinal fluid culture were positive for S pneumonia with penicillin sensitivity. Antibiotics were downgraded to ceftriaxone only.

During the course of treatment, the patient complained of blurry vision in the left eye. An ophthalmology consultation was done. Ophthalmologic evaluation showed visual acuity of 20/100 in the right eye and 20/200 the left eye without glasses, extraocular movements were intact, intraocular pressure was 16 mm Hg, and a dilated eye examination with ophthalmoscope showed no abnormality. CT brain scan without contrast was repeated and showed no acute intracranial findings except right mastoid cell effusion. Dexamethasone was stopped after 4 days, and ceftriaxone was given for 7 days. The patient was discharged home on moxifloxacin 400 mg orally for the next 3 days. Two days after discharge, the patient was readmitted with complaints of nausea, dizziness, vertigo, and blurry vision in the left eye. Magnetic resonance imaging (MRI) brain scans with and without contrast were ordered and showed right-sided otomastoiditis, right-sided subdural empyema, a partially occlusive thrombus in the right transverse and sigmoid sinus (Figure,, A), a partially thrombosed left superior ophthalmic vein (axial view: Figure,, B; sagittal view: Figure,, C), multiple scattered areas of acute infarction in the bilateral frontal lobes, and focal perichiasmatic enhancement of the left optic nerve (Figure,, D). The patient was started on ceftriaxone for the infection and heparin for anticoagulation. Otomastoiditis was treated with grommet tube insertion. The patient was discharged home on intravenous ceftriaxone and oral warfarin. On outpatient follow-up, blurry vision in the left eye persisted.

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-Ashish Verma, MBBS, Muhammad Hassaan Shahid, MBBS, Laura Youngblood, MD

This article originally appeared in the October issue of The American Journal of Medicine.

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