Presentation
The day before coming to the E.R. the Patient had nausea and vomiting. During the night she had a rapidly progressive alteration of mental status with confusion. Arrival at the E.R. at 3 am. No fever at the door. Leukocytosis.
Patient Data
Brain CT shows no hemorrhage and no ischemic lesions. Only effacement of some sulci is seen at the convexity.
AngioCT (not shown) does not show neither arterial occlusions nor venous sinus thrombosis.
FLAIR images show hyperintense material that fills diffusely the sulci of both hemispheres, the sulci of the cerebellum and basal cisterns. Post-contrast images show diffuse leptomeningeal enhancement (better seen in post-contrast axial FLAIR images than post-contrast axial T1-SE images). T1-SE post-contrast images shows a DVA in left cerebellar hemisphere.
CSF analysis: CSF Clear, Normal opening pressure, Glucose level <2mg/dl (serum glucose 67 mg/dl), Protein level: 2, WBC count: 7 cells/µL (PMN 6 cells/µL)
CSF culture: Streptococcus pneumoniae
Case Discussion
Meningitis is infection of the meninges, most frequently due to hematogenous spread of a bacterial infection.
Some people with the infection die and death can occur in as little as a few hours. However, most people recover from bacterial meningitis. Those who do recover can have permanent disabilities.
Patients often present with fever, meningism (headache, nuchal rigidity and photophobia) and altered state of consciousness.
Diagnosis is based on clinical and laboratory (lumbar puncture) findings.
Imaging helps to exclude other causes, helps to confirm the diagnostic hypothesis and helps to exclude complication (empyema, parenchymal abscess, ventriculitis, hydrocephalus). Sometimes meningitis is due the direct spread of infection from paranasal sinus or mastoid infection, thus imaging helps exclude this source of infection.
Brain CT may be negative or may show effacement of some sulci. Leptomeningeal enhancement is better seen in post-contrast FLAIR images are very helpful to show leptomeningeal enhancement.
Case courtesy of Dr. Francesca Graziani
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