Beta-2 Transferrin Research Articles

Determination of cerebrospinal fluid leakage by selective deletion of transferrin glycoform using an immunochromatographic assay.

Cerebrospinal fluid (CSF) leakage can lead to brain and spine pathologies and there is an urgent need for a rapid diagnostic method for determining CSF leakage. Beta-2 transferrin (β2TF), asialotransferrin, is a specific CSF glycoprotein biomarker used to determine CSF leakage when distinguished from serum sialotransferrin (sTF).Methods: We detected β2TF using an immunochromatographic assay (ICA), which can be potentially developed as a point-of-care (POC) testing platform. Sialic acid-specific lectin selectively captures sTF in multiple deletion lines within an ICA test strip, enabling the detection of β2TF. A sample pre-treatment process efficiently captures excess sTF increasing sensitivity for CSF leakage detection.Results: An optimal cut-off value for determining the presence of CSF in test samples was obtained from receiver operating characteristic (ROC) analysis of the ratio of the test signal intensity and the deletion lines. On 47 clinical samples, ICA test strips discriminated CSF positive from negative samples with statistically significant (positive versus negative t-test; P =0.00027). Additional artificial positive samples, prepared by mixing CSF positive and negative clinical samples, were used as a further challenge. These positive samples were clearly discriminated from the negative samples (mixture versus negative t-test; P =0.00103) and CSF leakage was determined with 97.1% specificity and 96.2% sensitivity.Conclusions: ICA represents a promising approach for POC diagnosis of CSF leakage. While requiring 70 min assay time inconvenient for POC testing, our method was significantly shorter than conventional electrophoresis-based detection methods for β2TF.

Endoscopic transnasal repair of two cases of spontaneous cerebrospinal fluid fistula in the foramen rotundum

We report two female patients aged 16 and 33 who presented with spontaneous cerebrospinal fluid (CSF) rhinorrhoea. Beta-2 transferrin was positive in both cases. Initial high-resolution CT showed fluid in the maxillary sinus but no obvious bony defect. MR imaging revealed maxillary sinus cysts with high signal on T2 sequences. Endoscopic transnasal surgery with intrathecal fluorescein was undertaken and in both cases a leak was identified from foramen rotundum and repaired. Both patients are symptom free at 6 months. These cases highlight the rare occurrence of spontaneous CSF leak from the foramen rotundum, and how they can be effectively repaired using the endoscopic transnasal approach.

DRIP DROP FROM THE NOSE, IT IS NOT RHINITIS, IT WILL NOT STOP

Introduction Cerebrospinal fluid (CSF) rhinorrhea occurs due to an abnormal communication between the subarachnoid space and the nasal cavity. Spontaneous CSF (sCSF) leaks are those not explained by traumatic injury, previous surgery, or secondary causes. We present a case of sCSF leak misdiagnosed as allergic rhinitis. Case Description A 64-year-old Hispanic woman with past medical history of hypertension, renal cell carcinoma, hypothyroidism and no prior surgery presented with a one-year history of continuous clear rhinorrhea from her left nostril. The patient had persistent cough and postnasal drip despite multiple courses of antibiotics, intranasal steroids, and oral antihistamines. Rhinoscopy and CT of the temporal bones were negative, but sample of the nasal fluid tested positive for beta-2 transferrin. A brain MRI revealed bilateral cribriform meningocele as a most likely site of CSF leak (Figure 1). There were also meningoceles of Meckel cave and jugular foramina along with increased optic nerve sheath diameter suggesting elevated intracranial pressure. Endoscopic sinus surgery with intrathecal fluorescein showed an active CSF leak on the left side and meningocele on the right. The leak was repaired with a nasal septal flap. On clinical follow-up 3 months after surgery, the patient reported no rhinorrhea or post-nasal drip. Discussion sCSF leaks are responsible for 6-23% cases of CSF rhinorrhea. The clinical diagnosis can be challenging because of their resemblance to chronic rhinitis. Failed response to medical management should raise suspicion. sCSF should be repaired to prevent meningitis and intracerebral infection, therefore early identification with β-2 transferrin testing is crucial. Figure. A. Right cribriform meningocele (red arrow), however, the leak can be seen as a linear fluid signal in the nasal roof on the left side from a cribriform plate defect (white arrow). B. Dilated optic nerve sheath diameter (8.4 mm, normal C. Dural diverticula arising from Meckel's cave (arrows)

Unilateral rhinorrhoea associated with cerebrospinal fluid leak

A 56-year-old postmenopausal obese woman presented with a 6-month history of right-sided rhinorrhoea. There was no history of head trauma or surgery. On clinical examination drops of clear fluid were...

The Use of Methylene Blue Staining Test in Determining the CSF Leaks Location of the Anterior Skull Base

Cerebrospinal fluid rhinorrhea represents drainage of cerebrospinal fluid into the nasal cavity. The first steps in diagnosing CSF rhinorrhea are a thorough history and physical examination of the patient. Other diagnostic procedures are the double ring sign, glucose content of the nasal fluid, Beta-trace protein test or beta 2-transferrin. To establish the exact location of the defect imagistic examinations are necessary. However, the gold standard CSF leakage diagnostic method is an intrathecal injection of fluorescein with the endoscopic identification of the defect. In this paper we analyze a staining test, using Methylene Blue solution, to identify the CSF leak�s location.

P.013 Convulsive status epilepticus due to intracranial hypotension

Background: Intracranial hypotension (IH) is typically characterized by an orthostatic headache. There have been limited case reports describing iatrogenic IH presenting with seizures. Methods: Case report. Results: A 71-year-old woman with chronic back pain developed convulsive status epilepticus (SE), characterized by generalized clonic seizures, immediately following scoliosis surgery. She had no history of seizures or seizure risk factors. Despite treatment with Midazolam, Phenytoin and Lacosamide, seizures recurred five times over three hours. Thus, Propofol and Midazolam infusions were initiated. An electroencephalogram revealed burst suppression and bilateral hemispheric epileptiform discharges. MRI brain was consistent with IH without cortical vein thrombosis. Fluid from the surgical drains was positive for Beta-2 transferrin, indicating cerebral spinal fluid. Her intracranial hypotension was likely due to an -intraoperative dural tear causing SE. Over two weeks, she remained on bedrest, sedation was weaned, and Phenytoin and Lacosamide were tapered and discontinued. She had no further seizures. Conclusions: IH is an under recognized cause of seizure following spinal or cranial surgery, lumbar puncture, or spinal anaesthesia. Proposed mechanisms include traction on cortical structures, increased cerebral blood flow and cortical irritation secondary to subdural hygromas.

Beta-2 transferrin is detectable for 14 days whether refrigerated or stored at room temperature.

The effect of time and temperature on beta-2 transferrin stability in cerebrospinal fluid (CSF) is not well established. After collecting nasal CSF for testing, beta-2 transferrin has been found to be stable and detectable for 1 week, whether being refrigerated or stored at room temperature. The purpose of this study was to determine if beta-2 transferrin remained detectable longer than 1 week and whether refrigeration improved its detectability. In patients undergoing therapeutic CSF diversion, 2-mL CSF samples were collected from 18 patients. The samples were divided and stored either at room temperature, or at 4°C, and tested for beta-2 transferrin at 7 and 14 days. CSF was collected from external ventricular drains (EVDs) (n = 15), lumbar drains (n = 2), and subdural drains (n = 1). Of the 18 CSF samples originally testing positive for beta-2 transferrin, none turned negative at 7 or 14 days, in both the refrigerated and room temperature groups (95% confidence interval [CI], 0% to 18.5%). Beta-2 transferrin remained detectable for 14 days in all CSF samples, regardless of being stored at 4°C or room temperature.

Pleural effusion from intrathoracic migration of a ventriculo-peritoneal shunt catheter: pediatric case report and review of the literature

BackgroundPleural effusion is a rare complication of ventriculo-peritoneal (VP) cerebrospinal fluid (CSF) shunting and its diagnosis is difficult in patients with neurological and consciousness impairment.Case reportHerein we report the case of a child affected by Pfeiffer syndrome and hydrocephalus, shunted at the age of 3 months, who developed acute respiratory failure due to a right-sided pleural effusion 2 years later. Plain chest radiographs and computed tomography (CT) showed the intrathoracic migration of the right VP shunt abdominal tip. Beta-2 transferrin, a marker for CSF, was found in the pleural fluid and the hypothesis of a CSF hydrothorax was confirmed. Effusion was treated with a thoracentesis. Seven days after, the right VP shunt was revised; a ventriculo-atrial (VA) shunt was also placed on the left side to serve as the main CSF shunt and to prevent the recurrence of hydrothorax. We review the pediatric cases of CSF hydrothorax reported in the literature and discuss the mechanisms underlying this complication together with the possible treatments.ConclusionPleural effusion due to VP shunt insertion is a rare and potentially life-threatening condition that should be suspected in any patient with a VP shunt and respiratory failure. Signs of hydrothorax may moreover represent the only clinical evidence of a shunt-related complication in case of neurologically severely compromised patients in which neurologic examination cannot help to make a diagnosis.

A modern approach to the diagnosis of nasal liquorrhea

The study purpose was to review and comparatively analyze all modern methods of diagnosing nasal liquorrhea as well as to substantiate the most effective and promising approaches and algorithms. The study included papers in English and Russian found in the Pubmed database and related to the diagnosis of basal liquorrhea of different etiology and localization. This review demonstrates that diagnostic tests vary widely in sensitivity, specificity, accuracy, invasiveness, and cost. Given all the criteria, detection of beta-2 transferrin or beta-trace protein is the best method for confirming nasal liquorrhea, and high-resolution computed tomography is the best technique for localization of the abnormality. Based on the review, we suggest a diagnostic algorithm for nasal liquorrhea. However, the evidence presented in this review is unfortunately not very reliable, which indicates the existing need for more accurate studies.

Análisis del líquido pleural: parámetros bioquímicos de uso infrecuente

Biochemical studies of the pleural fluid are often a key step in the diagnostic workup. Several parameters (pH, glucose, protein, lactate dehydrogenase, adenosine deaminase) add immediate relevant information, or they can help in the diagnosis of specific causes of pleural effusion (beta-2 transferrin, beta-trace-protein, creatinine, amylase, bilirubin, cholesterol, triglycerides, and C-reactive protein). However, parameters of questionable value may also be requested. The relationship between the attending physician and the clinical laboratory is critical in order to obtain higher diagnostic efficiency. An accurate selection of the biochemical tests to perform achieves the best approach to the study of a pleural effusion.

Endoscopic management of cerebrospinal fluid rhinorrhea.

Cerebrospinal fluid (CSF) rhinorrhea occurs due to communication between the intracranial subarachnoid space and the sinonasal mucosa. It could be due to trauma, raised intracranial pressure (ICP), tumors, erosive diseases, and congenital skull defects. Some leaks could be spontaneous without any specific etiology. The potential leak sites include the cribriform plate, ethmoid, sphenoid, and frontal sinus. Glucose estimation, although non-specific, is the most popular and readily available method of diagnosis. Glucose concentration of > 30 mg/dl without any blood contamination strongly suggests presence and the absence of glucose rules out CSF in the fluid. Beta-2 transferrin test confirms the diagnosis. High-resolution computed tomography and magnetic resonance cisternography are complementary to each other and are the investigation of choice. Surgical intervention is indicated, when conservative management fails to prevent risk of meningitis. Endoscopic closure has revolutionized the management of CSF rhinorrhea due to its less morbidity and better closure rate. It is usually best suited for small defects in cribriform plate, sphenoid, and ethmoid sinus. Large defects can be repaired when sufficient experience is acquired. Most frontal sinus leaks, although difficult, can be successfully closed by modified Lothrop procedure. Factors associated with increased recurrences are middle age, obese female, raised ICP, diabetes mellitus, lateral sphenoid leaks, superior and lateral extension in frontal sinus, multiple leaks, and extensive skull base defects. Appropriate treatment for raised ICP, in addition to proper repair, should be done to prevent recurrence. Long follow-up is required before leveling successful repair as recurrences may occur very late.

A modification of endoscopic endonasal approach for management of encephaloceles in sphenoid sinus lateral recess.

Spontaneous cerebrospinal fluid leak with meningoencephaloceles in sphenoid sinus lateral recess is challenging. Transnasal visualization of this area is difficult, especially when large pneumatization is present. External approaches to this region involve aggressive surgery and are often associated with significant morbidity. The aim of this study is to assess the real effectiveness of a modification of the endoscopic endonasal approach for their management. This is a prospective case series study and was conducted at Otolaryngology department, Ain Shams University Hospitals, Cairo, Egypt. Seven patients with spontaneous cerebrospinal fluid leak with meningoencephaloceles in the sphenoid sinus lateral recess were included. Diagnosis was confirmed by: analysis for beta-2 transferrin and imaging. They were managed with endoscopic endonasal retrograde trans-sphenoid approach described in this study with multilayered reconstruction of the defect. Mean age of our patients was 40.14±8.35years; mean BMI was 36.37±2.59kg/m2. Primary empty sella was present and osteodural defect was identified in superior wall of sphenoid sinus lateral recess with punched out and regular smooth edges. Mean intra-cranial pressure was (26.42±3.87 mmH2O) and size of defect was less than 10mm, mean 7.85±1.34. Mean-operative time was 169.28±21.87min. The mean hospital stay was 7.42±1.39days. No cerebrospinal fluid leak recurrences were observed during follow-up period that ranged from 37 to 48months. Endoscopic endonasal retrograde trans-sphenoid approach provides a wide, safe, and direct route to the management of sphenoid sinus lateral recess cerebrospinal fluid leak.

Diagnosis of cerebrospinal fluid rhinorrhea: an evidence-based review with recommendations.

Diagnostic strategies employed for cases of cerebrospinal fluid (CSF) rhinorrhea vary widely due to limited evidence-based guidance. A systematic review of the literature was performed using PubMed, EMBASE, and Cochrane databases from January 1990 through September 2014, to examine 9 diagnostic and localization modalities for CSF rhinorrhea. Benefit-harm assessments, value judgments and recommendations were made based on the available evidence. Study exclusion criteria were language other than English, pre-1990 studies, case reports, and nonrhinologic leak. All authors agreed on recommendations through an iterative process. We reviewed 68 studies examining 9 practices pertinent to the diagnosis of CSF rhinorrhea, with a highest aggregate grade of evidence of C. The literature does not support the use of the ring sign, glucose testing, radionuclide cisternography (RNC), or computed tomography cisternography (CTC) for identification of CSF leak. Beta-2 transferrin is the most reliable confirmatory test for CSF leak. High-resolution CT (HRCT) is then recommended as the first-line study for localization. Magnetic resonance cisternography (MRC) should be used for CSF leak identification as a second line for each of these if beta-2 transferrin is not available or if HRCT is ambiguous. Intrathecal fluorescein (IF) may also be of benefit in certain clinical scenarios. Despite relatively low levels of evidence, recommendations for the diagnosis and management of CSF rhinorrhea can be made based on the current literature. Higher-level studies are needed to better determine optimal diagnostic and clinical management approaches.

Magnetic resonance cisternogram with intrathecal gadolinium with delayed imaging for difficult to diagnose cerebrospinal fluid leaks of anterior skull base.

Workup of cerebrospinal fluid (CSF) leaks can be challenging. Patients with intermittent or infrequent clear rhinorrhea that cannot be collected, those with questionable or multiple skull-base (SB) defects on imaging, and those with previous SB surgery can present diagnostic dilemmas. In this patient population, radiologic studies that allow repeat imaging over hours to days can increase the diagnostic yield. We report our experience with magnetic resonance cisternogram with intrathecal gadolinium (MRCgGd) in this patient population. This study was a retrospective review of patients who underwent MRCgGd for workup of suspected CSF leaks at a tertiary care academic center. Over the past 3 years, 11 patients (10 females; mean age 50 years) underwent MRCgGd. Seven patients had suspected spontaneous CSF leaks from idiopathic intracranial hypertension and 2 had postsurgical defects. All patients had previous imaging that was indeterminate in localizing the site of the leak. Only 3 patients had positive beta-2 transferrin studies, all with multiple potential leak sites. MRCgGd confirmed the absence of leaks at 4 previously repaired SB defects, identified spinal canal leaks but no SB leaks in 2 patients (1 of whom had a nonleaking SB defect), and identified 5 patients with one or more SB leaks. Repeat imaging, from 30 minutes to 20 hours, was beneficial in identifying 4 leaks not confirmed in the immediate imaging, and ruling out leaks in 5 cases, therefore guiding further treatment. No complications occurred. MRCgGd is a useful diagnostic test in the workup of patients with difficult CSF leaks, with delayed imaging providing valuable diagnostic information.

CSF hydrothorax without intrathoracic catheter migration in children with ventriculoperitoneal shunt.

Background:Thoracic complications of ventriculoperitoneal (VP) shunts have been extensively reported in the literature. Cerebrospinal fluid (CSF) hydrothorax without catheter migration, however, has been rarely described and poorly understood.Case Description:We describe development of pleural effusion and respiratory distress in a 3-year-old boy with no evidence of VP shunt catheter displacement on plain radiograph and stable ventricle size on rapid sequence magnetic resonance imaging (MRI) brain. Chest X-ray revealed complete opacity of right hemithorax. Pleural effusion was consistent with transudate. Beta-2 transferrin returned positive. The patient underwent externalization of VP shunt, and upon resolution of effusion, re-internalization with new distal shunt catheter. A literature review of CSF hydrothorax in children without intrathoracic shunt migration was performed. Eleven cases were identified in the English literature. Age at VP shunt placement ranged from birth to 8 years of age. Interval from VP shunt placement to CSF hydrothorax ranged from 1.5 months to 5 years. History of shunt revision was reported in two cases. Presenting symptoms also included ascites and inguinal hernia or hydrocele. Reported diagnostic studies consist of CSF culture, radionuclide shuntogram, beta-2 transferrin, and beta-trace protein. Laterality of the VP shunt and development of pleural effusion were predominantly right sided. Definitive surgical treatment included VA shunt, repositioning of the peritoneal catheter, and endoscopic choroid plexus coagulation.Conclusion:CSF hydrothorax is a rare thoracic complication of VP shunt placement with no radiographic evidence of shunt migration or malfunction. Postulated mechanisms include limited peritoneal capacity to resorb CSF in children and microscopic communications present in congenital diaphragmatic hiatuses.

Unilateral massive transudative pleural effusion due to a duropleural fistula

Twenty three-year-old man had thoracal spinal cord surgery for gunshot injury three months ago. He had right hemiplegia and paraplegia for the past two months. He was admitted with poor performance status and progressive, severe dyspnea. Chest X-ray showed massive pleural effusion on the right side. Thoracentesis showed transudative pleural fluid. Duropleural fistula was considered due to the history of spinal injury and surgery. The presence of cerebrospinal fluid in the pleural fluid was demonstrated by beta-2 transferrin test. After the demonstration of the presence of duropleural fistula on intrathecal contrast-enhanced computed tomography scan surgical management of the duropleural fistula was successfully repaired by duroplasty. This case was presented as a complication of spinal cord injury and neurosurgery duropleural fistula is a very rare reason of massive transudative pleural effusions and the use of the cerebrospinal fluid by beta-2 transferrin in pleural effusion is reported very rare in the literature.

Cerebrospinal Fluid Leak Presenting as Oculorrhea After Blunt Orbitocranial Trauma

Cerebrospinal fluid (CSF) leak is an uncommon but well-documented occurrence after blunt head trauma, typically manifesting as otorrhea or rhinorrhea. Blunt cranio-orbital trauma also may cause CSF leak into the orbit, manifesting as orbitocele, blepharocele, chemosis, or tearing ("oculorrhea"). We report a patient who developed oculorrhea after blunt head trauma, and neuroimaging disclosed comminuted fractures of the left frontal, greater sphenoid wing, nasal, and maxillary bones. Because he also displayed chemosis and markedly reduced ocular ductions and periocular pain, carotid-cavernous fistula was suspected but appropriate vascular imaging was negative. Aspiration of subconjunctival fluid was positive for beta-2 transferrin, a specific marker for CSF. Chemosis lessened and the oculorrhea ceased spontaneously within 6 days of the trauma. This manifestation of CSF leak must not be overlooked because of the threat of meningitis.

Significance of ubiquitin carboxy-terminal hydrolase L1 elevations in athletes after sub-concussive head hits.

The impact of sub-concussive head hits (sub-CHIs) has been recently investigated in American football players, a population at risk for varying degrees of post-traumatic sequelae. Results show how sub-CHIs in athletes translate in serum as the appearance of reporters of blood-brain barrier disruption (BBBD), how the number and severity of sub-CHIs correlate with elevations of putative markers of brain injury is unknown. Serum brain injury markers such as UCH-L1 depend on BBBD. We investigated the effects of sub-CHIs in collegiate football players on markers of BBBD, markers of cerebrospinal fluid leakage (serum beta 2-transferrin) and markers of brain damage. Emergency room patients admitted for a clinically-diagnosed mild traumatic brain injury (mTBI) were used as positive controls. Healthy volunteers were used as negative controls. Specifically this study was designed to determine the use of UCH-L1 as an aid in the diagnosis of sub-concussive head injury in athletes. The extent and intensity of head impacts and serum values of S100B, UCH-L1, and beta-2 transferrin were measured pre- and post-game from 15 college football players who did not experience a concussion after a game. S100B was elevated in players experiencing the most sub-CHIs; UCH-L1 levels were also elevated but did not correlate with S100B or sub-CHIs. Beta-2 transferrin levels remained unchanged. No correlation between UCH-L1 levels and mTBI were measured in patients. Low levels of S100B were able to rule out mTBI and high S100B levels correlated with TBI severity. UCH-L1 did not display any interpretable change in football players or in individuals with mild TBI. The significance of UCH-L1 changes in sub-concussions or mTBI needs to be further elucidated.

The runny nose

A 40-year-old woman presented with a ‘‘runny nose’’ of 3 month’s duration. Every morning, she had a gush of watery discharge from her nose. There was no history of headache, fever, head trauma, or neurosurgical procedure, and the patient did not use any medication. She had no coryza or sinusitis symptoms. On physical examination, the patient was alert with normal vital signs. There was a continuous fluid leakage from the right nostril. The examination was otherwise normal including neurologic examination. Laboratory studies including CBC and a complete metabolic panel were within normal limits. Computed tomography (CT scan) of her head was performed. It showed no parenchymal abnormality. There was an air-fluid level (Panel A and B) and a small suspected bony defect in the lateral wall of the right sphenoid sinus (Panel A-arrow) (Fig. 1). Since an air-fluid level in the sphenoid sinus is always abnormal, in the absence of sinusitis symptoms, head trauma, or previous neurosurgical procedures, it connotes a fluid, namely cerebrospinal fluid (CSF). With the impression of a CSF leak, the watery gush in the mornings was attributed to accumulation of CSF in her sphenoid sinus during the night, and sudden discharge by positional change of the head and the effect of gravity. A test for beta-2 transferrin was ordered, which was positive. Thus, a diagnosis of primary spontaneous cerebrospinal fluid rhinorrhea was made. CSF rhinorrhea refers to the drainage of CSF through a skull base defect into the nose. It can be spontaneous, or secondary to trauma, surgical procedures, or tumor. In order to make the diagnosis in the cases of bloody discharge, (which was not present in this case), filter paper to show a double ring sign can be used. A few drops of fluid from a CSF leak placed on absorbent filter paper will show a central circle of blood and an outer clear ring of CSF. Beta-2 transferrin measurement of the leaking fluid has a high specificity for detecting CSF, [1] and the non-contrast head CT scan is the imaging modality of choice [2]. While the exact etiology is unknown, there have been a number of theories postulated: such as embryologic development defect or aberrant arachnoid granulations. The most common sites of skull base leaks are at the floor of the anterior cranial fossa and sphenoid sinus, the cribriform plate being the thinnest bone wall of the area [3]. The risk factors include body mass index higher than 30, female gender, middle age, and low bone density (particularly evidence of osteoporosis) [3]. This condition may have devastating complications in some patients such as CNS infections, decreased intracranial pressure, and brain herniation. Management includes watchful waiting: (bed-rest, head elevation, and avoidance of straining), since leaks often stop spontaneously; if this does not occur then neurosurgical closure is necessary to prevent the onset of infection in the meninges. Hydroxyapatite cement was applied transnasally to the sphenoid region fistula, and the patient recovered uneventfully. Y. Daneshbod Department of Molecular Pathology, Dr Daneshbod Laboratory, Shiraz, Iran

Meningitis bacteriana aguda por Streptococcus agalactiae en una mujer no embarazada asociada a una fístula de LCR: comunicación de un caso

Streptococcus agalactiae is a rare cause of acute bacterial meningitis. We report the case of a middle age non-pregnant female patient, with no comorbitidies, who was hospitalized with acute meningitis. The pathogen was identified both in blood and CSF. She recovered uneventfully with ceftriaxone and dexamethasone. A CSF leak was suspected by previous history of unilateral watery rhinorrhea, that was demonstrated with a high resolution paranasal sinus CT and beta-2 transferrin analysis of the nasal fluid. Vulvovaginitis was also diagnosed after admission, but no cultures were obtained. Streptococcus agalactiae is an infrequent cause of bacterial meningitis that should promote the search of anatomical abnormalities or comorbidities in non-pregnant adults and beyond newborn period.