STREPTOCOCCUS PYOGENES: A DEVASTATING CAUSE OF MENINGITIS IN A YOUNG ADULT

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SESSION TITLE: Critical Care 1 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Streptococcus pyogenes is a rare but aggressive cause of bacterial meningitis. CASE PRESENTATION: A 27-year-old healthy gentleman presented to the emergency department with a 3 day history of headache. His symptoms began with an upper respiratory infection and fever which had resolved. Vital signs were normal, but he appeared in mild distress. His neurologic exam was non-focal without nuchal rigidity. There was tenderness to palpation over the right maxillary sinus. A CT head showed paranasal mucosal thickening and air-fluid levels in the right maxillary sinus. He was treated with intravenous fluids, acetaminophen, and promethazine with improvement in his headache. He was discharged home with a diagnosis of sinusitis. Within 24 hours, he returned to the emergency room after he developed confusion and suddenly collapsed. On presentation, he was hypotensive and febrile. His mental status was obtunded. Laboratory studies were notable for a leukocytosis with 55% bands, lactic acidosis, and acute renal failure. A lumbar puncture was performed with an opening pressure of 57 cm of water and had 11,000 white blood cells with 98% neutrophils. He was given dexamethasone, vancomycin, and ceftriaxone. Gram stain of the cerebral spinal fluid revealed gram positive cocci in chains and later grew Streptococcus pyogenes. A repeat CT head showed progression of sinusitis and effacement of the sulci concerning for cerebral edema. In the intensive care unit, he had multiple episodes of cardiac arrest, septic shock requiring vasopressors, and acute respiratory distress syndrome with refractory hypoxemia. On exam, brainstem reflexes were absent and he passed away 34 hours after admission. DISCUSSION: Streptococcus pyogenes, or Group A Streptococcus (GAS), is a rare cause of bacterial meningitis in the United States. In 1985, the incidence of bacterial meningitis due to GAS was 0.2% (1). A review of the literature showed a prospective study in the Netherlands where GAS was the cause of 2% of cases of bacterial meningitis. Of the patients with GAS meningitis, 92% initially presented with otitis media or sinusitis, 52% of patients developed neurologic sequelae, and 19% of the patients died. The most common neurologic complications were subdural empyema and hearing loss, while the most common systemic complications were respiratory failure and septic shock (2). Of note, this patient had preceding upper respiratory symptoms and presented during influenza season. There are reports of increased invasive GAS co-infection with influenza in healthy patients, some of which resulted in death (3). CONCLUSIONS: Although GAS is a rare cause of meningitis, this invasive organism may present with benign features of otitis media or sinusitis, and develop aggressively to meningitis associated with high rates of morbidity and mortality. It is important to consider GAS infection especially during influenza season. Reference #1: Schleck, W. et al. “Bacterial Meningitis in the United States, 1978-1981.” JAMA. 1985; 253(12): 1749-1754. Reference #2: Marjolein, L. et al. “Group A Streptococcal meningitis in adults.” Journal of Infection. 2015; 71(1): 37-72. Reference #3: Jean, C. et al. “Invasive Group A Streptococcal Infection Concurrent with 2009 H1N1 Influenza.” Clinical Infectious Disease. 2010; 50(10): e59-e62. DISCLOSURES: No relevant relationships by Chloe Castro, source=Web Response No relevant relationships by Edward Warren, source=Web Response