Abstract
IntroductionUnvaccinated patients with history of splenectomy are prone to fulminant courses of Streptococcus pneumoniae-associated bacterial meningitis. Besides direct brain damage those patients may additionally suffer from parainfectious syndromes, notably vasculitis and acute disseminated encephalomyelitis (ADEM). Differentiation and treatment of these immunological reactions is challenging.MethodsCase report.ResultsA 61 year-old woman with history of splenectomy without vaccination for S. pneumoniae presented with progressive headache and meningism. CSF-analysis revealed pleocytosis with microbiological evidence for pneumococcal meningitis. After unsuspicious initial cranial CT imaging and initiation of appropriate antibiotic therapy, MRI two days later showed widespread FLAIR- and T2-hyperintense white matter lesions that further progressed upon follow-up MRI and that fulfilled imaging criteria of ADEM. Meanwhile the patient deteriorated and required mechanical ventilation. Cranial angiography showed no signs of vasculitis or vasospasms. Screening for autoimmune diseases remained negative, however oligoclonal bands turned positive. Brain biopsy mainly revealed perivascular CD4+ T-cells and demyelinated areas. Despite ongoing acute meningitis, a 10-day corticosteroid-pulse was initiated followed by steroid-tapering. Within 4 weeks, clinical and MRI findings ameliorated. In an one-year follow-up visit, the patient significantly recovered, MRI lesions were markedly reduced and no further relapses occurred.ConclusionAcute pneumococcal meningitis in unvaccinated splenectomized patients may be complicated by a monophasic course of parainfectious ADEM that can be controlled with high-dose corticosteroids. Parainfectious vasculitis or cerebritis are important differential diagnoses and exact differentiation of these entities is important to initiate early appropriate immunotherapy.
Highlights
Unvaccinated patients with history of splenectomy are prone to fulminant courses of Streptococcus pneumoniae-associated bacterial meningitis
Besides direct brain damage due to cerebral infection, there is some evidence that patients with bacterial meningitis may suffer from parainfectious inflammatory syndromes such as vasculitis or acute disseminated encephalomyelitis (ADEM) (Ohnishi et al 2007), (Beleza et al 2008; Okada and Yoshioka 2010) which is usually more common in younger patients (Tenembaum et al 2007)
Here we report on a fulminant parainfectious ADEM related to acute pneumococcal meningitis in an unvaccinated splenectomized patient
Summary
Unvaccinated patients with history of splenectomy are prone to fulminant courses of Streptococcus pneumoniae-associated bacterial meningitis. Besides direct brain damage those patients may suffer from parainfectious syndromes, notably vasculitis and acute disseminated encephalomyelitis (ADEM). Differentiation and treatment of these immunological reactions is challenging. Bacterial meningitis in adults is most commonly caused by Streptococcus pneumoniae and often shows a fulminant clinical course (Weisfelt et al 2006). Besides direct brain damage due to cerebral infection, there is some evidence that patients with bacterial meningitis may suffer from parainfectious inflammatory syndromes such as vasculitis or acute disseminated encephalomyelitis (ADEM) (Ohnishi et al 2007), (Beleza et al 2008; Okada and Yoshioka 2010) which is usually more common in younger patients (Tenembaum et al 2007). After microbiological confirmation of Streptococcus pneumonia in CSF and blood cultures antibiotic treatment was switched to penicillin G according to resistance screening
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