Pneumococcal meningitis with myelitis

Case contributed by Dr Christine Goh


Febrile. Headache and confusion. New sensory level at C5 with upper motor neuron signs in the upper limbs and lower motor neuron signs in the lower limbs.

Patient Data

Age: 40
Gender: Male

Ill defined high T2 signal within the central to dorsal aspect of the cervical cord extends from C2/3 to C4/5. Smaller peripheral foci of T2 hyperintensity involve the right side of the cord at C2 and the left dorsolaterally at C5.  There is a small amount of associated predominantly superficial enhancement.

There is no rim enhancing intramedullary or extradural collection, and no focal enhancing mass within the cord.

Additional findings are small regions of T2 hyperintensity and enhancement in the cerebellar hemisphere near the tentorium cerebelli, which suggest an intracranial component to the process.

CT brain demonstrated mild hydrocephalus, for which an extraventricular drain tube was inserted.

Right frontal extraventricular drain tube, with reduced ventricular size compared to previous CT brain. 

Trace of sulcal T2 FLAIR hyperintensity superiorly and diffusion restricting material layering in the occipital horns is compatible with meningitis and ventriculitis.

There are also parenchymal areas of diffusion restriction and T2 hyperintensity bilaterally, the largest involving the posterior cerebellum bilaterally adjacent to the falx cerebelli and the splenium of the corpus callosum.  There are also several scattered punctate cortical foci of diffusion restriction.

The small cortical foci are presumably infarcts. The larger foci are not in typical vascular territories, but in this clinical context are still most likely infarcts. The differential would be encephalitis.

CSF analysis demonstrated elevated protein and pleocytosis.  Streptococcus pneumoniae antigen was detected.

Case Discussion

This case is an example of a bacterial myelitis, which is an uncommon complication of pneumococcal meningitis.

Cord involvement in pneumococcal meningitis can be due either to infective myelitis or vascular compromise related to vasculitis, vasospasm or septic shock.  In this case two features strongly favoring bacterial myelitis were the distribution of cord abnormality (not typical of ischemia) and the near complete resolution of cord changes on follow-up imaging.

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