A Case on Streptococcal Pneumonia Associated with Leptomeningitis, Osteomyelitis and Epidural Abscess in a Patient with AIDS
A 53-year-old male presented with cough, sputum, and headache for 2 weeks.\nFive years previously, he had been diagnosed with HIV. He noted the onset of cough, sputum, and headache. The cough worsened, his sputum turned more yellowish and headaches accompanied by neck stiffness were related to coughing.\nOver the first five years following the diagnosis of HIV, he was treated with antiretroviral medications (lamivudine and zidovudine; Combivir, Ritonavir; Norvir, atazanavir sulfate; Reyataz).\nVital signs were as follows: temperature, 38.0℃; blood pressure, 110/70 mm Hg; pulse rate, 90/min; respiratory rate, 20/min. He was alert mentally. Auscultation revealed rales in the right lower lung field. A Brudzinski-Kernig test was positive.\nComplete blood count results were white blood cell 18.43×103/µL (neutrophils 91.3%, lymphocytes 3.5%), hemoglobin 14.0 g/dL, hematocrit 40.3%, and platelets 290×103/µL. Serum chemistry showed blood urea nitrogen 14 mg/dL, creatinine 0.66 mg/dL, aspartate aminotransferase 25 IU/L, alanine aminotransferase 23 IU/L, total bilirubin 1.92 mg/dL, and C-reactive protein 38.51 mg/dL. Cerebral spinal fluid (CSF) showed a white blood cell count of 108/µL, red blood cell count 0/µL, glucose 53 mg/dL, and protein 123 mg/dL. CSF and sputum bacterial cultures were negative. A CD4 T-cell count of 139/µL and HIV RNA of 20.7 copies/mL were recorded.\nPlain chest radiography showed ground glass opacity and consolidation in both lung fields (especially the right lower) (). Contrast-enhanced chest computed tomography showed multiple irregular nodular infiltration in both lungs and patchy consolidation with ground glass opacity of the right middle and lower lung (). Contrast-enhanced cervical spine magnetic resonance imaging (MRI) showed a posterior epidural abscess: a peripheral rim-enhancing lesion at the posterior C2-3 epidural space (); osteomyelitis; mild scanning enhancement of the clivus and cervical spine; early leptomeningitis; and prominent leptomeningeal enhancement ().\nThe patient was administered vancomycin (1 g q 12 hr IV), ceftriaxone (2 g q 24 hr), clindamycin (600 mg q 12 hr) and fluconazole (400 mg q 24 hr). The patient's fever reduced 3 days following admission. His epidural abscess was discussed with the neurosurgeon in our hospital. There were no neurological symptoms, no surgical treatment was performed and antibiotic therapy was maintained. At follow-up 5 days after admission, a plain chest radiograph showed improvement, and S. pneumoniae was detected in two blood cultures that showed sensitivity to most antibiotics. The patient was thus switched from vancomycin plus ceftriaxone to ampicillin (2 g) plus sulbactam (1 g q 6 hr IV). Fifteen days after admission, neck stiffness had improved and cough and sputum production reduced. A plain chest X-ray showed decrease in both ground glass opacity and consolidation in both lung fields (). Twenty-six days after admission, laboratory analysis was as follows: white blood cell count 5.42×103/µL, neutrophils 55.9%, lymphocytes 25.9%, and C-reactive protein 0.26 mg/dL. The patient wished to be discharged, so antibiotic therapy was switched from intravenous to oral (amoxicillin/clavulanate 625 mg PO tid). Since discharge, no recurrence of symptoms or evidence of pneumonia according to plain chest radiography have been observed. One year after discharge, there is no abnormal finding on cervical MRI ().