![]() 130311 Serum CRP and procalcitonin are useful markers as well, with the latter carrying a strong diagnostic odds ratio. CSF lactate has the ability to differentiate bacterial meningitis from aseptic meningitis with robust accuracy however, this test is often unavailable. The CSF glucose/blood glucose ratio is a simple marker that is often utilised, but it should be emphasised that it was shown to predict the presence of bacterial meningitis more precisely than routine CSF measurements. Īdditional markers that may assist in the diagnosis of acute bacterial meningitis exist, but their diagnostic role in the current guidelines is modest. We have noted only eight similar cases of acellular pneumococcal meningitis in the literature. Normal CSF meningitis may occur when underlying immunosuppressive states are present however, this acellular phenomenon is exceptionally rare in an immunocompetent adult. There have been documented cases of bacterial meningitis in the absence of pleocytosis, with a particular occurrence in children. While CSF Gram stain testing has a high specificity for bacterial meningitis, it lacks sensitivity and was proven to be helpful in only 30 - 40% of patients. CSF Gram stains and culture results confirming Streptococcus pneumoniae were only available after 48 hours. Based on clinical suspicion, CSF and laboratory determinants, she was treated for acute bacterial meningitis. Despite our patient's reduced CSF glucose and raised protein, the inconsistent polymorph cell count was striking. Consistent CSF findings with acute bacterial meningitis include a polymorphonuclear pleocytosis, hypoglycorrhachia and a raised CSF protein level. The performance of a lumbar puncture is fundamental, as CSF examination is needed to establish the diagnosis. The classic clinical signs of Kernig and Brudzinski have value in ruling in the diagnosis of meningitis however, these traditional signs have poor sensitivity and their absence cannot be used to rule out the disease. It is integral to note that the symptoms of meningitis, which may include headache, nausea and vomiting, have poor sensitivity and specificity for the diagnosis of meningitis, as demonstrated in a meta-analysis of 845 patients. We were fortunate that our patient presented with the classic signs and symptoms of meningitis. ![]() Her symptoms resolved 2 days later, and she had an uncomplicated inpatient stay with no neurological sequelae. The patient was started empirically on high-dose intravenous ceftriaxone in view of the clinical suspicion of meningitis. Other tests performed included a non-reactive HIV ELISA and syphilis serology. The findings of the cerebrospinal fluid (CSF) examination are shown in Table 1. As no clinical signs of raised intracranial pressure were present, a lumbar puncture was performed. Her C-reactive protein (CRP) was markedly raised at 381 nmol/L and the plasma glucose level was 7.1 mmol/L. The laboratory investigations revealed a haemoglobin concentration of 9.5 g/dL, a normal platelet count (352 χ 10 9/L) and leuco-cytosis (white cell count 14.98 χ 10 9/L). Other systems were clinically unremarkable. There were no cranial nerve palsies, and neither motor nor sensory abnormalities were elicited. Signs of meningism were present, which included Kernig's and Brudzinsksi's signs. On examination she was haemodynamically stable with a temperature of 38☌. This was her first presentation for medical care. She had no surgical history of splenectomy and did not consume alcohol. She had no symptoms of an upper respiratory tract infection and had not travelled recently. Ī 60-year-old woman with no comorbidities had complained of headache, fever, general malaise and photophobia. ![]() ![]() īetter outcomes have resulted from early initiation of appropriate therapy however, this has to be balanced with prompt confirmation of diagnosis, as inappropriate empirical therapy carries the risk of side-effects, cost burden and increased nosocomial infection. ![]() Up to 50% of survivors may suffer from long-term neurological sequelae. The incidence ranges from 5 per 100 000 persons in southern Africa to 12 per 100 000 in Africa. IIMB BCh, Department of Internal Medicine, Addington Hospital, Durban, South AfricaĪn immunocompetent adult presenting with acellular pneumococcal meningitis is a rare occurrence and may pose a diagnostic challenge.Īcute bacterial meningitis is a medical emergency and requires prompt diagnosis because it is associated with significant morbidity and mortality. IMB ChB, FCP (SA), MMed, Department of Internal Medicine, Addington Hospital, Durban, South Africa Diagnostic challenges with acellular bacterial meningitis ![]()
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