Stroke as showing characteristic of acute bacterial meningitis in a healthy afebrile grownup
We reported a healthy, 45 twelvemonth old male presented in neurology section with terrible concern followed by right hemiparesis. Patient denied any history of febrility, and there was no grounds of subarachnoid bleeding on computed tomographic scan of encephalon. Magnetic resonance imagination of encephalon showed lesion in left frontlet and parietal part consistent with ischaemic shot. Early focal neurological shortage and typical history miming straightforward diagnosing of shot and absence of febrility, makes this instance unusual.
Acute bacterial meningitis is a pussy infection within subarachnoid, Indian arrowroot mater, and embracing CSF of encephalon. Etiological agents and incidence rate varies depending on patients age and immune position. Despite of progresss in medical attention significant figure of patient with acute bacterial meningitis develop morbidity and mortality1.
Stroke is one of the common complications of acute bacterial meningitis, but it normally manifest during the class of good established unwellness2. Septic arteritis, arterial thrombosis, arterial aneurism formation are thought to be the mechanism for causing of shot. We report rare instance of healthy, afebrile grownup, who presented with terrible concern followed by right hemiparesis secondary to acute bacterial meningitis.
The patient was 45 twelvemonth old male patient who was in a good wellness boulder clay he developed terrible concern at around 11 autopsy while he was reading book. The concern was acute in oncoming, holocranial, throbbing type and associated with one episode of purging. There was no history of febrility, loss of consciousness, bulbar failing or recurrent concern. Patient had given injection diclofenac ab initio with merely partial alleviation in concern. Following twenty-four hours forenoon his married woman noticed that patient was unable to travel right half of organic structure and altered consciousness. Patient had inactive class over following 8 yearss, during which he was non hospitalized and did non have any intervention.
At the clip of presentation to neurology section after 8 yearss his unwellness, he was afebrile without any obvious uncomfortableness. He was drowsy ( GCS E3M5V2 ) and all his critical parametric quantities were within normal bounds. His temperature was 97.6 degree Fahrenheit ( unwritten ) . Nuchal rigidness was present and Brudzinski’s mark was positive. He had right UMN 7th cranial nervus paralysis, rest all cranial nervus scrutiny was normal including fundus. There was dearth of motion on right half of organic structure with power about 2/5 on right upper and lower limbs. Deep sinew physiological reactions were 2+ and symmetric and plantation owner was extensor on right side. He had raised leukocyte count ( 14,600/cumm ) , rest all biochemical parametric quantities were normal. He underwent not contrast computing machine imaging ( CT ) scan of encephalon, which was normal. In position of important nuchal rigidness and normal CT, lumber puncture was planned. CSF was turbid and microscopic scrutiny revealed: WBC- 3300 cells/cumm, 90 % polymorphs, 10 % lymph cells, protein- 184.9 milligram % , sugar- 40 milligram % . CSF civilization was unfertile.
He was started on endovenous ( IV ) antibiotics, Rocephin 2 gram and vancomycine 1 gram 12 hourly. His magnetic resonance imagination ( MRI ) was implicative of left MCA district ischaemic shot. His first recorded elevated temperature of 103.2 degree Fahrenheit was 24 hr after hospitalization. At around 10th twenty-four hours of IV antibiotics patient showed betterment in his sensorium and right hemiparesis. He was given complete 2 hebdomads class of endovenous antibiotics. At the clip of discharge around 3 hebdomads after hospitalization, he had merely minimum failing on right half and managed to walk with minimum support.
Annual incidence of bacterial meningitis is 4 to 6 instances per 100,000 grownups. 80 % of all instances of bacterial meningitis in grownups are caused by Streptococcal pneumoniae and Neisseria meningitides3.
15-20 % of patients with acute bacterial meningitis develop CNS complication4. Stroke, ictus, or combination of two are the most normally responsible for causing of focal intellectual abnormalcy ( hemiparesis, monoparesis, or aphasia ) in acute bacterial meningitis5. Multiple pathological mechanisms like infected arteritis, arterial thrombosis, venous thrombophlebitis, formation of intracranial aneurism, and seldom subarachnoid bleeding are responsible for cerebrovascular complication6. In one survey conducted by Geisler et Al, they reviewed over 1300 patients with bacterial meningitis ; focal neurological shortage was seen in 6.6 % of instances during class of disease, and seldom stroke may be seen in its early class7.
In our instance patient made rapid, about complete neurological recovery in period of 3 hebdomads. This suggests that the shortage was caused by comparatively reversible mechanism of hurt. In a instance series, it was suggested that up to 70-80 % of patient with acute bacterial meningitis who had unilateral paralysis during acute class of unwellness, do retrieve with child or no shortage8. The rapid, significant recovery is non unusual.
In our instance diagnosing of acute bacterial meningitis was non straightforward, as patient was afebrile and had presentation in favour of thrombo-embolic shot or subarachnoid bleeding. Up to 5-6 % of patients with bacterial meningitis can show without febrility. Serious bacterial meningitis without febrility is uncommon in healthy grownups, though it can be seen in newborns, aged and immunocompromised patients. There was no obvious ground for absence of febrility in our instance. Furthermore, there was no history of taking any anti-pyretic medicine prior to hospitalization.
Thrombo-embolic shot or subarachnoid bleeding was kept as initial diagnosing. In position of important nuchal rigidness and no grounds of subarachnoid bleeding in non-contrast CT of caput, patient underwent CSF scrutiny as portion of complete rating and possibility of subarachnoid bleeding. The diagnosing of acute bacterial meningitis was made on the footing of CSF analysis. The diagnosing of acute bacterial meningitis would hold been delaied by more than 24 hours when patient became febrile, if in instance determination of nuchal rigidness been missed, or the rating less complete.
In instances with febrility and altered sensorium intuition of meningitis is easy. However, untypical presentation like absence of febrility, focal neurological shortage in early class of bacterial meningitis does occur and should be thought of. It is unrealistic to make CSF scrutiny in all instances of shot, but whenever there is intuition of morbific pathology or physical mark that is beyond a typical shot, delayed diagnosing of bacterial meningitis can be averted by CSF scrutiny.
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- Igarashi M, Gilmartin RC, Gerald B, Wilburn F, Jabbour JT: Cerebral arteritis and bacterial meningitis.Arch Neurol1984 ; 41: 531-534
- new wave de Beek D, de Gans J, Spanjaard L, Weisfelt M, Reitsma JB, Vermeulen M. Clinical characteristics and predictive factorsin grownups with bacterial meningitis. N Engl J Med 2004 ; 351:1849-59. [ Erratum, N Engl J Med 2005 ; 352:950. ]
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- Kastenbauer S, Pfister HW. Pneumococcal meningitis in grownups — spectrum of complications and predictive factors in a series of 87 instances. Brain 2003 ; 126:1015- 25.
- Dodge PR, Swartz MN. Bacterial meningitis — a reappraisal of selected facets. II. Particular neurologic jobs, postmeningitic complications and linicopathological correlativities. N Engl J Med 1965 ; 272: 954-60.
- Geiseler PJ, Nelson KE, Levin S, Reddi KT, Moses VK: Community- acquired pussy meningitis: A reappraisal of 1,316 instances during the antibiotic epoch, 1954-1976. Rev Infect Dis 1980 ; 2:725-745
- Durand MI, Calderwood SB, Weber DJ, et Al: Acute bacterial meningitis in grownups. N Engl J Med 1993 ; 328:21-28.