Pneumococcal Meningitis Presenting With Normocellular CSF
Pneumococcal Meningitis Presenting With Normocellular CSF
Introduction: Normocellular bacterial meningitis is rarely observed in adult patients. We here report two cases of adult patients with pneumococcal meningitis with a normal cerebrospinal fluid leukocyte count and review eight other cases in the literature.
Case presentation: Case 1 was a 34-year-old Japanese woman with a history of splenectomy who presented with pyrexia, nausea, headache, and loss of hearing in her right ear. She was in a hypotensive state with no neck stiffness and had a normal mental status at the initial presentation. She became progressively disoriented during out-patient management. A cerebrospinal fluid examination showed a normal leukocyte count despite the presence of Streptococcus pneumoniae, which was detectable with Gram staining. She survived after prompt treatment, but her hearing loss remained. Case 2 was a 62-year-old Japanese man with a history of laryngeal cancer who was transferred to our emergency department after an acute onset of delirium and rapid progression to septic shock. As in Case 1, cerebrospinal fluid examination showed a normal leukocyte count despite the presence of S. pneumoniae, which was detectable with Gram staining. Within 1 hour of arrival, he developed hypotension and subsequent cardiopulmonary arrest, and resuscitation was unsuccessful.
Conclusions: These cases imply that a normal leukocyte count in the cerebrospinal fluid does not exclude the possibility of bacterial meningitis. Gram staining of cerebrospinal fluid and immediate administration of antibiotics should be performed in all patients with suspected bacterial meningitis.
Lumbar puncture and examination of the cerebrospinal fluid (CSF) are essential steps in the diagnosis of meningitis. Typically, the CSF shows significant neutrophilic pleocytosis, a decreased glucose concentration, and an elevated protein level. The absence of pleocytosis in the CSF has occasionally been described in cases of pediatric meningitis, especially in the very acute phase of bacterial meningitis. By contrast, bacterial meningitis with a normal CSF leukocyte count has rarely been described in adults. We herein describe cases involving two adult patients with normocellular pneumococcal meningitis and present a review of eight previous cases.
Abstract and Introduction
Abstract
Introduction: Normocellular bacterial meningitis is rarely observed in adult patients. We here report two cases of adult patients with pneumococcal meningitis with a normal cerebrospinal fluid leukocyte count and review eight other cases in the literature.
Case presentation: Case 1 was a 34-year-old Japanese woman with a history of splenectomy who presented with pyrexia, nausea, headache, and loss of hearing in her right ear. She was in a hypotensive state with no neck stiffness and had a normal mental status at the initial presentation. She became progressively disoriented during out-patient management. A cerebrospinal fluid examination showed a normal leukocyte count despite the presence of Streptococcus pneumoniae, which was detectable with Gram staining. She survived after prompt treatment, but her hearing loss remained. Case 2 was a 62-year-old Japanese man with a history of laryngeal cancer who was transferred to our emergency department after an acute onset of delirium and rapid progression to septic shock. As in Case 1, cerebrospinal fluid examination showed a normal leukocyte count despite the presence of S. pneumoniae, which was detectable with Gram staining. Within 1 hour of arrival, he developed hypotension and subsequent cardiopulmonary arrest, and resuscitation was unsuccessful.
Conclusions: These cases imply that a normal leukocyte count in the cerebrospinal fluid does not exclude the possibility of bacterial meningitis. Gram staining of cerebrospinal fluid and immediate administration of antibiotics should be performed in all patients with suspected bacterial meningitis.
Introduction
Lumbar puncture and examination of the cerebrospinal fluid (CSF) are essential steps in the diagnosis of meningitis. Typically, the CSF shows significant neutrophilic pleocytosis, a decreased glucose concentration, and an elevated protein level. The absence of pleocytosis in the CSF has occasionally been described in cases of pediatric meningitis, especially in the very acute phase of bacterial meningitis. By contrast, bacterial meningitis with a normal CSF leukocyte count has rarely been described in adults. We herein describe cases involving two adult patients with normocellular pneumococcal meningitis and present a review of eight previous cases.
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