Fulminant pneumococcal meningitis manifesting as acute abdomen

In January 2007, a 21-year-old woman presented to the emergency department with abdominal pain, fever, nausea, vomiting and diarrhoea for 6 hours. She had no other associated symptoms with unrevealing previous history. On examination she was ill-looking, conscious and oriented, with a temperature of 39.2°C, blood pressure 96/52 mmHg and pulse rate 140 beats per minute, and had clinical evidence of dehydration. Her abdomen was rigid, mainly in the right lower quadrant, with sluggish bowel sounds. The rest of the clinical examination was normal including the neurological examination. The results of blood tests were white blood cell count= 19 × 10 9 /litre (normal range (NR) 4–11× 10 9 /litre) with 91% neutrophils, sodium 138 mmol/litre (NR 135–145 mmol/litre), potassium 3.4 mmol/litre (NR 3.5–5 mmol/litre), serum glucose 7.1 mmol/litre (NR 4–6 mmol/litre). A chest radiograph was normal; the abdominal X-ray showed dilated bowel loops and no free gas under the diaphragm. The initial differential diagnosis was gastroenteritis vs acute appendicitis. The normal abdominal ultrasound and normal computed tomography (CT) scan made the diagnosis of appendicitis very unlikely. The patient was admitted as a case of gastroenteritis and improved on intravenous hydration, pain control, and intravenous ciprofloxacin 400 mg 12-hourly and metronidazole 500 mg 8-hourly. Twenty-nine hours after admission she complained of headache, became increasingly lethargic and febrile (39°C), and the abdomen was still rigid. Her level of consciousness deteriorated with Glasgow Coma Scale of 8/15 (eye opening 2/4, verbal response 2/5 and motor response 4/6) and nuchal rigidity was obvious at this stage. Formal neurological exam was not feasible because of the patient's condition, but she was moving all her limbs and had no obvious clinical evidence of lateralizing signs. Bacterial meningitis was suspected and treated with intravenous dexamethasone 6-hourly, ceftriaxone 2 g 12-hourly and vancomycin 1 g 12-hourly. An hour later, while awaiting a CT scan she developed tonic clonic seizures with fixed dilated pupils and was transferred to the intensive care unit where she was immediately intubated and ventilated. CT of the brain was normal (Figure 1). Lumbar puncture revealed a total cell count of 80 × 10 9 /litre with 52% polymorphs and 48% mononuclear cells, protein concentration 8.3 g/litre (NR 0.1–0.4 g/litre), glucose concentration was <0.03 mmol/litre (NR <20 mg/dl), and Gram staining of CSF showed Gram-positive diplococci. Subsequently, CSF and blood cultures yielded Streptococcus pneumoniae sensitive to penicillin so she was given intravenous penicillin G 4 million units 4-hourly. Over 2 days she developed septic shock requiring inotropes, and remained in a deep coma. Magnetic resonance imaging of the brain showed diffuse leptomeningeal enhancement and multiple infarctions in both cerebral hemispheres, the brainstem and cerebellum (Figure 2). Unfortunately the patient never regained consciousness and 5 days after presentation she died despite all supportive measures.