Spontaneous Pneumocephalus Caused by Pneumococcal Meningitis
A 62-year-old woman was admitted to our urology department with the diagnosis of urinary tract infection. She complained of a febrile sensation and of night sweats for 2 weeks. At admission, she had mild fever of 37.1℃, but was alert with stable vital signs. There was no history of a trivial head injury and she denied headache. Hematological investigation revealed mild leukocytosis with a total white blood cell (WBC) count of 10.500/µL and an elevated erythrocyte sedimentation rate (ESR) of 42 (normal 0-20 mm/hr). Urine analysis was negative for blood and protein, but urine culture was positive for Escherichia coli (E. coli). Under a diagnosis of urinary tract infection, she was treated with fluid and trimethoprim sulfamethoxazole (cebatrim® Jaytech Biogen, Switzerland), but despite aggressive fluid and antibiotic therapy, she failed to respond to treatment. Five days after admission, while still febrile, she developed a severe headache and acute confusion, and was transferred to the neurosurgical department. Neurological examination revealed disorientation with respect to time and place. At this time, her body temperature was 38.3℃, WBC count 15.200/µL, and ESR 63 mm/hr, but her coagulation profile, urea and electrolytes, liver and thyroid function, calcium, blood sugar, serum folate, and chest X-ray were unremarkable. Simple lateral radiography and computed tomography of the skull showed extensive intraventricular air in lateral ventricles (), which raised the possibility of bacterial meningitis with gas-forming organisms. Accordingly, a lumbar puncture was performed. The opening pressure was 180 mm H2O and a cloudy fluid was obtained. Cerebrospinal fluid (CSF) contained 1059 cells/mL (92% polymorphonuclear cells), protein 6.2 g/dL, and a glucose level of 10% of her serum glucose level. CSF gram staining showed no organism, but CSF culture later revealed streptococcus pneumonia. She was treated with ceftriaxone (Hanmi Pharmaceuticals, Korea) and vancomycin (CJ Pharmaceuticals, Korea) for 14 days, and this resulted in a remarkable improvement as evidenced by level of consciousness and orientation. Repeat CT performed 14 days after initiating ceftriaxone and vancomycin showed complete resolution of the pneumocephalus (). Patient was subsequently discharged and followed regularly on an OPD basis, but remained asymptomatic for 6 months.