Spontaneous Pneumorrhachis and Transverse Myelitis Complicating Purulent Meningitis
The patient is a 21-year-old male without significant medical history. He was admitted in the emergency department for cephalalgia, fever, and frequent easy vomiting lasting 1 week duration. Symptoms were associated to a puffiness of the face and dyspnea of level I according to Sadoul classification.\nAt admission, the patient was conscious with a fever of 39°C. The blood pressure was 120/70 mmHg with a heart rate of 80 beats/min and a respiratory frequency of 24 cycles/min. The neurological examination objectified signs of meningeal irritation without any motor and sensory deficit. The pleuropulmonary examination found subcutaneous emphysema in the top part of the thorax and upper limbs extending to the cervical region and the face. Associated air effusion syndrome was not evidenced.\nThe initial cerebral computed tomography (CT) scan was normal. Afterward, a lumbar puncture was performed and revealed a blurred liquid with predominant polynuclear neutrophils (80%). The glycorrhachia was 0.40 g/l (with concomitant glycemia of 1.20 g/l); total albumin level was 0.98 g/l, and the classical cerebrospinal fluid (CSF) gram’s stain and culture was negative. The immunochemistry study of lumbar puncture was in favor of meningitis diagnosis, which oriented to start the antibiotherapy. The routine biological and hematological studies included blood cells count and blood culture, ionogram, and sedimentation rate were found to be normal. The hepatic assessment was also without abnormalities. The diagnosis of bacterial meningitis was retained. The patient was treated using adequate antibiotherapy consisting of 2.0 g of ceftriaxone every 12 h. Ceftriaxone dose was maintained at the meningitis rate of 100 mg/kg/day.\nThe thorax X-ray showed a pneumomediastinum in the left paratracheal border along the left edge of the heart; the image also showed subcutaneous emphysema without associated pneumothorax []. Evermore, thorax CT scan confirmed all abnormalities described in the thorax X-ray and revealed the presence of air collection in the spinal canal between C7 and D6 levels []. The laryngoscopy, bronchoscopy, and digestive opacification did not show any abnormality in the respiratory-digestive tracts. These invasive gestures were achieved under general anesthesia without remarkable event.\nThe clinical evolution within 48 h was marked by the occurrence of apyrexia, coupled with disappearance of the subcutaneous emphysema and the meningeal steepness. However, the neurological status of the patient worsened gradually; a paraparesis occurred and was followed by a tetraparesis. The patient started with presenting neurovegetative disorders with hemodynamic instability which was in favor of central affection. The sepsis was discarded since the patient was afebrile. The patient experienced acute respiratory syndrome that required artificial ventilation. Afterward, a spinal magnetic resonance imaging (MRI) was performed and showed a cervical medullary edema extending from C2 to C6 without any sign of spinal cord compression. This result was consistent with a general clinical profile of acute transverse myelitis []. The hemodynamic support consisted initially of administrating vasoactive Drugs and dopamine then adrenaline since nor adrenaline was not available. The patient died within 15 days with a profile of vasoparalysis resistant to vasoactive drugs.