Volume 3, Number 3; July 16, 2004
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Volume 3, Number 3; July 16, 2004 |
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Middle-aged woman at a MARTA station: disoriented and combative
Recommended reading:
Streptococcal meningitis in adult patients: current epidemiology and clinical spectrum.
(Dr. Shah)
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Resident Report 7/16/04—Maunank Shah
Case: An unidentified middle aged woman is found disoriented and combative by EMS at a MARTA station. She reports nausea, vomiting, and visual hallucinations. She is unable to give any further history. Vital signs on admission reveal BP 96/61, HR 102, RR 19, accucheck 70, and normal oxygen saturation. She is agitated and uncooperative, but has no focal neurological deficits. A II/VI apical holosystolic murmur at is also noted. Labs are remarkable for a positive UDS for Cocaine. Portable CXR is interpreted as a possible LLL infiltrate. Within hours of admission she develops respiratory distress and requires intubation. Head CT is negative and she is admitted to the MICU. An LP is performed consistent with bacterial meningitis and the patient is started on Acyclovir, Ampicillin, Vancomycin, Ceftriaxone, and Dexamethasone. Initial gram stain is positive for GPC in pairs. An echo is performed and reveals PA pressures of 90-100 and a dilated RV. No vegetations are seen. Final identification of bacteria from both blood and CSF reveals S. bovis.
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Clinical Question: What is the incidence and management of Streptococcus bovis meningitis?
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Readings:
Link Directly to Fulltext Article at Publisher <3> Unique Identifier:10452643 Authors: Cabellos C. Viladrich PF. Corredoira J. Verdaguer R. Ariza J. Gudiol F. Institution: Infectious Diseases Service, Ciutat Sanitaria i Universitaria de Bellvitge, University of Barcelona, Spain. ccabellos@csub.scs.es Title: Streptococcal meningitis in adult patients: current epidemiology and clinical spectrum.[see comment].
Source: Clinical Infectious Diseases. 28(5):1104-8, 1999 May. Abstract: Streptococci other than Streptococcus pneumoniae are a rare cause of bacterial meningitis in adults. We report 29 cases of streptococcal meningitis (1977-1997). The patients comprised 19 men and 10 women, with a mean age +/- standard deviation of 47 +/- 18 years. Nine cases were secondary to neurosurgical procedures, seven to brain abscess, five to cerebrospinal fluid pericranial fistula, and three to endocarditis. Causative microorganisms included the following: viridans group streptococci, 20 cases; anaerobic streptococci, 3; Streptococcus agalactiae, 3; Streptococcus bovis, 2; and Streptococcus pyogenes, 1. Four Streptococcus mitis strains showed decreased susceptibility to penicillin (MIC, 0.5-2 microg/mL). Five patients (17%) died. The infection is increasing in the hospital setting. Streptococci resistant to penicillin should be considered in the empirical treatment of nosocomial meningitis. In cases of community-acquired infection, anaerobic streptococci or streptococci of the Streptococcus milleri group should alert the clinician to the presence of an undiagnosed brain abscess, whereas oral streptococci of the viridans group suggest the diagnosis of bacterial endocarditis. CAS Registry/EC Number 0 (Antibiotics, Combined).
Link Directly to Fulltext Article at Publisher <5> Unique Identifier:9356795 Authors: Cohen LF. Dunbar SA. Sirbasku DM. Clarridge JE 3rd. Institution: Department of Pathology, Baylor College of Medicine, Houston, Texas, USA. Title: Streptococcus bovis infection of the central nervous system: report of two cases and review. [Review] [24 refs]
Source: Clinical Infectious Diseases. 25(4):819-23, 1997 Oct. Abstract: Streptococcus bovis is an uncommon cause of meningitis and subdural empyema. We report one case each of meningitis and subdural empyema in which S. bovis biotype II was isolated from both the spinal fluid and blood. In one case, the organisms were seen on a gram-stained preparation of cerebrospinal fluid. The first patient presented with gastrointestinal symptoms of unknown etiology, was immunosuppressed, and recovered. The second patient presented with syncope, developed a subdural empyema, and died; at autopsy, a colonic adenoma was found. A review of the English-language literature revealed only 14 previously reported cases of meningitis due to S. bovis and no cases of subdural empyema due to S. bovis. These cases indicate the importance of complete laboratory identification of specific organisms and confirm the need for a thorough neurological examination and search for underlying gastrointestinal disease in cases of S. bovis infection. [References: 24]
<6> Unique Identifier:2234437 Authors: Purdy RA. Cassidy B. Marrie TJ. Institution: Department of Medicine, Dalhousie University, Halifax, NS, Canada. Title: Streptococcus bovis meningitis: report of 2 cases. [Review] [18 refs]
Source: Neurology. 40(11):1782-4, 1990 Nov. Abstract: We describe 2 cases of Streptococcus bovis meningitis and review the 9 cases previously reported. This microorganism is a rare cause of meningitis in which there are no distinctive clinical or laboratory features. The Gram stain of the CSF is usually negative. Ten of the 11 cases had some underlying disease or comorbid condition that predisposed to S bovis infection: gastrointestinal disorder, endocarditis, CSF leak, polymyalgia rheumatica, and mandibular block. Treatment with high-dose penicillin is usually adequate. [References: 18] CAS Registry/EC Number 0 (Penicillins).
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Resident Report / Department of Medicine & Grady Branch Library Emory University School of Medicine 2004 Edition Participating Faculty: Carlos Del Rio MD / Joyce Doyle MD / Lorenzo Difrancesco MD / Monica Adams MD / Josh Larned MD
Contact:
Karl Woodworth
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