Meningitis Secondary to a Sphenoid Defect

1Carilion Clinic Virginia Tech Carilion Internal Medicine Residency Program, Roanoke, VA

Meeting: Hospital Medicine 2011, May 10-13, Dallas, Texas.

Abstract number: 315

Case Presentation:

A 45‐year‐old woman with a history of chronic migraines and diabetes was brought to the emergency room for decreased responsiveness with hypoxic respiratory failure. She had been treated for migraines at an outside facility the day prior and had not recovered from sedative medications. Other medications prior to admission included amitriptyline, and butalbital‐acetaminophen‐caffeine. She had no history of facial trauma or head and neck surgery. On admission, the patient was febrile (38.1°C), unresponsive, and intubated. Lumbar puncture confirmed meningitis with neutrophil‐predominate pleocytosis (9479 cells/mm3, 91% neutrophils) and hypogly‐corrhachia (<10 mg/dL; normal, 40–70 mg/dL). Bacterial antigens were positive for Streptococcus pneumoniae, which also grew in blood cultures. Although maintained on mechanical ventilation and appropriate antibiotic treatment, the patient developed profuse clear to blood‐tinged rhinorrhea (up to 600 mL/day) that had an undetectable glucose concentration on spot testing sticks. Because of a suspicion of cerebrospinal fluid (CSF) leak, otolaryngology recommended testing the fluid for beta‐2 transferrin, which was positive. Computed tomography (CT) of the sinuses revealed fluid in the left sphenoid sinus with a defect in the posterior sphenoid bone. The defect was corrected via endoscopic transnasal, transsphenoid ablation, where the sphenoid fossa was packed with abdominal fat and sealed with grafted nasal cartilage. Rhinorrhea and migraines resolved completely and have not recurred.

Discussion:

Basal skull defects are congenital, and symptoms include (recurrent) meningitis and/or CSF rhinorrhea. This exceedingly rare cause of meningitis can present in adulthood with the above symptoms. Although sphenoid encephaloceles and meningoencephaloceles have been associated with meningitis and CSF rhinorrhea, there is little literature regarding nontraumatic sphenoid sinus defects as a cause of these complications. Diagnosis can be confirmed by high‐resolution CT or magnetic resonance imaging. In our case, the CSF leak likely developed spontaneously from inflammation of the meninges in the setting of the sphenoid defect. Moreover, the area directly posterior to the defect showed the most significant meningeal inflammation on magnetic resonance imaging, consistent with this area as the source of infection.

Conclusions:

Various primary etiologies exist for pneumococcal meningitis, but often the cause is not elucidated. However, there are certain cases in which a source should be entertained. One such situation is a patient with meningitis and rhinorrhea, as they could represent a basal skull defect.

Disclosures:

K. Khosa ‐ none; S. Penland Ismatov ‐ none; C. Demott ‐ none

To cite this abstract:

Khosa K, Penland‐Ismatov S, Demott C. Meningitis Secondary to a Sphenoid Defect. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 315. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/meningitis-secondary-to-a-sphenoid-defect/. Accessed May 24, 2019.

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