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Images in Neurology |

Fulminant Streptococcal Meningoencephalitis

Mark N. Rubin, MD; Eelco F. M. Wijdicks, MD, PhD
JAMA Neurol. 2013;70(4):515. doi:10.1001/jamaneurol.2013.1953.
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A 43-year-old woman presented to her primary physician with a sore neck one night and was found comatose within hours of that visit. The patient had a neurologic history significant for autoimmune limbic encephalitis complicated by status epilepticus, but she had been seizure free for several years while taking stable antiepileptic medications and had not been given immunotherapy for 2 years prior to this event. There was initial concern for recurrent status epilepticus; thus, she was treated with a continuous lorazepam infusion for 18 hours prior to transfer from her local hospital. She was in septic shock on arrival to our medical center. Lumbar puncture revealed a cerebrospinal fluid formula consistent with bacterial meningitis. Cerebrospinal fluid culture results demonstrated growth of Streptococcus pneumoniae. Her neurologic examination on hospital admission was significant for coma (FOUR Score1 was E1M0B4R1) and absence of nuchal rigidity. Magnetic resonance image findings are shown in the Figure. In spite of maximal treatment, the patient demonstrated no neurologic improvement 1 week into her admission. Coma in meningoencephalitis can be due to hydrocephalus, cerebral edema, cerebral thrombophlebitis, or status epilepticus.2 Her prognosis was guarded at admission3; in the setting of continued lack of neurologic progress, she died after withdrawal of support.

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Figure. Magnetic resonance imaging of the brain performed 48 hours into coma revealed diffuse meningeal enhancement, with infectious loculations scattered over the convexities (A, coronal T2 fluid-attenuated inversion recovery image, arrow), purulence filling most sulci (B, axial T2 fluid-attenuated inversion recovery image), diffuse cerebral venous sinus thromboses (C, magnetic resonance imaging venogram; arrow indicates absent right transverse and sigmoid sinuses), and infarctions (D, axial diffusion-weighted imaging; arrow indicates 1 infarct).

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