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Diffuse Bacterial Meningitis and Myelitis Secondary to a Diplococcus Organism

A 16-year-old, previously healthy, female presented with a 1-week history of sore throat, fever, vomiting, and occipital headache. She also complained of generalized myalgia and lower limb weakness. There was no medication or substance use. Her immunizations were up to date, and she had no recent travel history or contact with persons from overseas. Examination in emergency revealed an unwell girl with nuchal rigidity and generalized hyperesthesia. Muscle strength in the lower extremities was graded 3−/5. In the upper extremities, strength was graded 4+/5 except distally on the right side, which was graded 4−/5 with scooping fingers and difficulty with extension of fingers, along with weak wrist flexion. Sitting was noted to be difficult. Reflexes were decreased in the lower limbs; brisk reflexes were found in the upper limbs. Initial magnetic resonance imaging (MRI) showed extensive T2 signal changes throughout the spinal cord (Figure 1A,B). MRI of the brain did not reveal any significant intracranial abnormality. Initial differential diagnosis included demyelinating myelitis from an infectious, postinfectious, or inflammatory process. Infarction and neoplastic infiltration of the spinal cord were also considered. Her cerebrospinal fluid (CSF) had increased protein (2.29 g/L), lactate (4.2 mmol/L), cell count 840 × 10/L (neutrophils, 39; lymphocytes, 53; monocytes/macrophages, 8) and normal glucose (2.5 mmol/L). A CSF Gram stain revealed gram-negative diplococci versus coccobacilli (orientation of organism unclear). Blood and CSF cultures were obtained before treatment with intravenous cefotaxime and vancomycin at meningitic doses and dexamethasone (7.5 mg every 6 hours). Overnight, she developed progressive flaccid paralysis of extremities; cefotaxime was switched to ceftriaxone and dexamethasone was switched to daily methylprednisone (1 g for 5 days) followed by oral prednisone (1 g/kg) in tapering doses over 20 days. She demonstrated gradual improvement of her extremity weakness. Repeat MRI showed minimal interval improvement (Figure 2). CSF and blood cultures yielded negative results, as did CFS analysis using 16S RNA PCR. CFS, stool, and nasopharyngeal secretion viral cultures (including polio virus) revealed no causative organism. She was treated with 14 days of antibiotics for presumed bacterial meningitis resulting from either Neisseria meningitidis or Haemophilus influenzae, based on the initial CSF Gram stain. Follow-up MRI 1 month after presentation revealed improvements, with minor residual inflammation/demyelination seen within the cervical/thoracic spinal cord (Figure 3). Two months after her presentation, she was ambulating with cane assistance. A repeat MRI 9 months after presentation showed resolution of abnormal findings. Follow-up 11 months after presentation showed almost complete neurological recovery, with only mild residual bowel and bladder dysfunction.