Abstract
BackgroundPersistent neutrophilic meningitis is an unusual form of chronic meningitis that is defined as clinical meningitis with a neutrophilic pleocytosis that persists for greater than 7 days despite empiric antimicrobial therapy. Although numerous disease processes can cause this syndrome, the majority of cases are due to opportunistic pathogens infecting immunocompromised hosts.Case PresentationA 47 year-old female presented after basilar skull fracture with persistent neutrophilic meningitis unresponsive to empiric broad-spectrum antibiotics. After more than weeks of intensive therapy, 4 hospitalizations and 3 relapses, Nocardia cyriacigeorgica was identified from cerebral spinal fluid. Induction therapy was begun with Ceftriaxone and trimethoprim-sulfamethoxazole (TMP-SMX) for 6 weeks followed by therapy with TMP-SMX and doxycycline for one year. The patient made a complete recovery without sequelae.ConclusionsDue to the difficulty in obtaining a microbiologic diagnosis, appropriate treatment in cases of persistent neutrophilic meningitis is often delayed leading to morbidity, This case highlights a number of the unique features of Nocardia meningitis and the importance of considering Nocardia infection as a cause of persistent neutrophilic meningitis even in immunocompetent patients.
Highlights
Persistent neutrophilic meningitis is an unusual form of chronic meningitis that is defined as clinical meningitis with a neutrophilic pleocytosis that persists for greater than 7 days despite empiric antimicrobial therapy
Due to the difficulty in obtaining a microbiologic diagnosis, appropriate treatment in cases of persistent neutrophilic meningitis is often delayed leading to morbidity, This case highlights a number of the unique features of Nocardia meningitis and the importance of considering Nocardia infection as a cause of persistent neutrophilic meningitis even in immunocompetent patients
We speculate that in our patient, a low inoculum of Nocardia entered the immune-privileged subdural space from the basilar skull fracture, resulting in prolonged infection with persistent neutrophilic inflammation without abscess formation. This case highlights a number of the unique features of Nocardia meningitis including the acute to chronic presentation with fevers, headache and meningismus with persistent neutrophilic pleocytosis, hypoglycorrhachia and elevated cerebrospinal fluid (CSF) protein levels
Summary
This unique case demonstrates the importance of considering Nocardia infection as a cause of persistent neutrophilic meningitis even in immunocompetent patients. Microbiologic diagnosis can be difficult to obtain due to the organism’s slow rate of growth and sensitivity to numerous antibiotics which are generally started early and empirically. Our patient did clinically respond to treatment with meropenem, which was enough to sterilize the CSF but insufficient to fully treat the infection (as demonstrated by relapse even after a 6 + week course of therapy). Our patient eventually made a full recovery after completing 6 weeks of ceftriaxone and TMP-SMX followed by one year of therapy with TMP-SMX and doxycycline
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