Recurrent Bacterial Meningitis (RBM): An Interesting Presentation Due to a Motor Vehicle Accident (MVA) 10 Years Ago

1Hospital Medicine/Internal Medicine, MetroHealth Medical Center/Case Western Reserve University, Cleveland, OH
2Internal Medicine, MetroHealth Medical Center/Case Western Reserve University, Cleveland, OH
3Internal Medicine, MetroHealth Medical Center/Case Western Reserve University, Cleveland, OH

Meeting: Hospital Medicine 2008, April 3-5, San Diego, Calif.

Abstract number: 131

Case Presentation:

A 51‐year‐old diabetic and hypertensive woman was life‐flighted with complaints of fever, headache, mental status changes, and acute respiratory failure. She was found to be in diabetic ketoacidosis. Vancomycin, ceftriaxone, and an insulin drip were initiated. A year ago, the patient was treated for an episode of pneumococcal meningitis. Lumbar puncture with cerebrospinal fluid analysis was performed. CSF protein was 275 mg/dL and glucose 93 mg/dL (blood glucose 386 mg/dL), and a WBC count of 9064 with 77% neutrophils was noted. CSF culture and gram stain were negative. Blood culture grew Streptococcus pneumoniae. Other labs revealed a normal C1 esterase inhibitor and C4 complement, increased C2 and C3 complements, and a non reactive HIV. After an uneventful recovery, the patient was extubated and discharged with antibiotics and ENT/neurosurgery referrals. A CT scan of facial bones without contrast revealed irregular calcification in the right frontal sinus adjacent to the cribiform plate and thinning of the left posterior wall of the frontal sinus. The patient remembered being an unrestrained passenger in a motor vehicle accident 10 years ago, where she was launched into the windshield. Intermittent positional postnasal drip without anterior rhinorrhea or hearing loss was noted by the patient, but she never sought further investigation or treatment. CT cisternogram confirmed the presence of CSF leak via the defect in the right paramedian cribiform plate. She subsequently underwent lumbar drain and transnasal endoscopic CSF leak repair. Currently she is 5 months postrepair with no symptoms and a negative follow‐up cisternogram.

Discussion:

RBM in an immunocompetent host warrants evaluation to exclude transdural communication between subarachnoid space and the base of the skull. Trauma is the most common cause of CSF rhinorrhea. Presentation can range from within few weeks to years from the inciting event. Nontraumatic CSF rhinorrhea is rare and is a result of congenital defects and an iatrogenic and immunocompromised state. Streptococcus pneumoniae is the most frequent culprit. Prophylactic antibiotics are not usually recommended. Prognosis of appropriately treated patients is good. Patients with persistent CSF rhinorrhea (more than 4‐6 weeks) along with an episode of meningitis need surgical repair. The visualization of a fracture or bony dehiscence is very difficult but critical for the repair. CT cisternogram, high‐definition CT, fluorescein nasal endoscopy, and MRI imaging are the available imaging options.

Conclusions:

A patient presenting with recurrent meningitis, CSF rhinorrhea, or pneumococcal meningitis needs to be thoroughly evaluated for dural communication and surgically repaired to prevent fatal RBM and their sequelae.

Author Disclosure:

A. S. Nemeth, none; S. M. Glagola, none; R. S. R. Sappati Biyyani, none.

To cite this abstract:

R. R, Biyyani S, Nemeth A, Glagola S. Recurrent Bacterial Meningitis (RBM): An Interesting Presentation Due to a Motor Vehicle Accident (MVA) 10 Years Ago. Abstract published at Hospital Medicine 2008, April 3-5, San Diego, Calif. Abstract 131. Journal of Hospital Medicine. 2008; 3 (suppl 1). https://www.shmabstracts.com/abstract/recurrent-bacterial-meningitis-rbm-an-interesting-presentation-due-to-a-motor-vehicle-accident-mva-10-years-ago/. Accessed May 26, 2019.

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