When Usual Turns Unusual: Pneumococcal Meningitis With Resistant Features and Rare Complications

Introduction: Streptococcus pneumoniae remains the leading cause of adult bacterial meningitis worldwide. Although early diagnosis and antibiotics are cornerstones of management, treatment can be complicated by delays in cerebrospinal fluid sampling and antibiotic resistance. We present a case of severe pneumococcal meningitis in an anticoagulated patient with delayed lumbar puncture and disease progression through appropriate antimicrobial coverage.


Description: A 39-year-old male on apixaban for recent pulmonary embolism presented with fever, lethargy, and bidirectional nystagmus. Initial vital signs revealed heart rate of 118 bpm and fever to 104°F. Labs were notable for a leukocytosis of 21,060 cells/mL with 90.7% neutrophils and lactate of 5.02 mmol/L. Computed tomography head showed sinus disease and opacification of the right mastoid air cells without bony erosion. Empiric antibiotics were initiated with ceftriaxone and vancomycin. LP was deferred for 24 hours due to anticoagulation, showing WBC of 137 cells/μL with neutrophilia, glucose of 68 mg/dL, protein of 274 mg/dL, opening pressure of 31cm H2O, and PCR positive for S. pneumoniae. CSF culture showed no growth. The patient initially improved clinically, but on hospital day 5 developed progressive lethargy and fevers. MRI and MRV demonstrated an acute right-frontal infarct, subdural empyema, and frontal cortical vein thrombosis. Repeat LP revealed WBC of 131 cells/μL with persistently positive S. pneumoniae PCR. Levofloxacin and rifampin were added to patient’s antimicrobial therapy and the patient’s encephalopathy improved, and fevers resolved. Repeat MRI displayed resolution of the empyema.


Discussion: This case highlights the potential for deterioration in bacterial meningitis despite timely and appropriate empiric coverage. Emerging resistance patterns in Streptococcus pneumoniae including reduced susceptibility to beta-lactam agents present growing challenges in treatment. Culture based sensitivities may not be possible with delayed LPs on antibiotics, so antimicrobial modification should be considered with lack of improvement. Furthermore, pneumococcal meningitis is associated with serious complications such as infarction, venous thrombosis, and, rarely, subdural empyema as seen in this case.