Streptococcus group C meningitis with cavernous sinus thrombosis
An eighteen year old African American male presented to the emergency room with a 1-week history of sore throat, muscle aches, fever, headache, and photophobia. He also complained of nausea, one episode of vomiting, and abdominal pain. He was a college student and lived in a dormitory. He denied any recent travel or contact with ill people. Past medical history was significant for sickle cell trait and Osgood Schlatter’s disease. He was up to date on vaccinations.\nPhysical examination revealed a tall, thinly built young man, in mild pain with an oral temperature of 97.5°F, blood pressure of 114/69 mmHg, heart rate of 89 beats per minute (BPM) and respirations of 18/minute. He had injected conjunctiva of the right eye, and pharyngeal and tonsillar exudates. The examination of the central nervous system revealed neck stiffness; Kernig’s and Brudzinski’s signs were not elicited. Cranial nerves were intact. The power and deep tendon reflexes were essentially normal. The rest of the systemic examinations were unremarkable.\nHemoglobin was 17.5 g/dL, hematocrit 50.8 g/dL, and white count 20.3 × 109/L with 89% granulocytosis, and platelet count of 35 × 109/L. Basic metabolic profile was within normal limits, except for a potassium level of 3.2 meq/L, blood urea nitrogen of 44.9 mg/dL, and creatinine of 2.3 mg/dL. Chest X-ray revealed bilateral infiltrates in the middle and lower lung fields. Computed tomography (CT) of the head was unremarkable. The patient declined lumbar puncture. The blood culture grew penicillin sensitive Group C Streptococcus (GCS) within 24 hours of incubation. A few hours into the admission, he developed third and sixth nerve palsy. Further work-up revealed right cavernous and ophthalmic vein thrombosis on magnetic resonance imaging ( and ). Multiple patchy cavitary lesions on both lungs were seen in the chest CT. There was no vegetation on transesophageal echocardiogram. The oculomotor and abducens palsies resolved after medical management for 16 days.