A 54-year-old woman with a history of obesity and smoking, from a rural area.
He came to the doctor's office because of abdominal pain, vomiting and headache for two days, where symptomatic treatment was indicated.
Consciousness and psychomotor agitation were subsequently added, so she consulted again in her health center and was referred to our hospital.
Upon admission, the patient was tachypnea, tachypnea, afferent and confused.
The segmental physical examination showed meningeal signs, with no other important findings to highlight.
Leukocytosis detected at admission showed a leukocyte count of 27,080 cells/mm3, with 91.8% neutrophils.
Venous gas showed metabolic acidosis.
C-reactive protein (CRP) was 20.92 mg/dl. The coagulation study showed a prothrombin time of 58% (INR 1.47).
The rest of the hematological count, coagulation, plasma electrolytes and biochemical tests were normal.
A VDRL and ELISA for human immunodeficiency virus were also performed, which were negative.
Neurological evaluation was complemented with computed axial tomography (CAT) of the brain that showed no pathological findings.
A turbid CSF was obtained with a median lumbar puncture, with a cytochemical study that highlighted a proteinorrhachia of 7.8 g/l, glycorrhachia less than 2 mg/dl and a cell count of 92%.
Due to the clinical picture and laboratory findings, acute bacterial meningitis was diagnosed, starting empirical treatment with ceftriaxone (2 g c/12 h) and dexamethasone (10 mg c/6 h) intravenously.
Gram stain of CSF revealed abundant cocci.
The patient was admitted to the Intensive Care Unit (ICU), presenting in the following hours a picture of septic shock requiring the use of vasoactive amines and connection to mechanical ventilation for stabilization.
Notably, it was observed that only after 48 hours of admission the patient had fever (maximum 38.9° C), persisting with consciousness compromise.
Sedation was suspended for weaning from IMV after which psychomotor agitation was observed, without other neurological manifestations.
Complementarily, an EEG was performed, which identified the presence of a continuous generalized slowness, without identifying an epileptiform activity.
The CSF was plated on blood agar, chocolate agar and thioglycolate broth and incubated at 37°C in the atmosphere of aerobiosis and microaerophilia.
After 48 h of inoculation into agar blood and aerobiosis, the development of small, transparent colonies of 1 mm in diameter with a small β haemolysis was observed.
Gram stain of the colony showed grouped cocci in short or isolated chains.
Biochemical tests showed negative results for catalase, bile and lactate 6.5%, and hypurate hydrolysis.
The CSF culture was reported as S. serotype 2, sensitive to penicillin, ampicillin, ceftriaxone, levofloxacin, tetrazolium, vancomycin, lineid.
Cultures obtained from urine, bronchial secretion and blood showed no bacterial development.
Identification and susceptibility testing were performed by Vitek 2® (bioMérieux) and MicroScan® systems.
After six days of antibacterial treatment, fever and delirium persisted, so new cultures were requested (CRL, hemocultives, bronchial secretion, central venous catheter and urine); in all of them there was no microbial development
The fever was interpreted as secondary to drugs, yielding after discontinuation of haloperidol.
After 10 days of antibacterial treatment, the patient was vigilant, but had episodes of occasional disorientation without fever.
A total of 13 days on IMV was maintained due to poor tolerance to spontaneous ventilation.
Antimicrobial treatment was maintained for a total of 14 days, with favorable clinical and laboratory evolution.
The patient was evaluated by neurology in which the presence of signs of neurological focalization at discharge was ruled out.
Retroactively, the patient was asked about her epidemiological history and found that she was raising pigs and was directly responsible for her care.
