Vertebral osteomyelitis as a hidden cause of persistent meningeal irritation in a patient with pneumococcal meningitis: A case report

RATIONALE: Pneumococcal meningitis generally develops from bacteremia and is often complicated by multiple organ infection. PATIENT CONCERNS: A 62-year-old man with no previous medical history developed progressive disturbance of consciousness preceded by high-grade fever and headache for a few days. DIAGNOSIS: The patient was diagnosed with pneumococcal meningitis based on meningeal irritation, polymorphonuclear cell-predominant pleocytosis of the cerebrospinal fluid (CSF) and a positive pneumococcal urinary antigen test at a different hospital. Despite the administration of meropenem and vancomycin, his consciousness worsened, and the patient was transferred to our hospital. Marked nuchal stiffness was noted. The patient showed a disturbance of consciousness, with a Glasgow Coma Scale score of E3V2M5. No significant cranial nerve palsy, motor weakness or sensory impairment was observed. CSF examination showed polynuclear cell-predominant pleocytosis of 755/μL. Transthoracic echocardiography revealed infectious endocarditis. INTERVENTIONS: After the detection of penicillin-susceptible Streptococcus pneumoniae, the antibiotic regimen was changed to aminobenzylpenicillin 12 g/d and ceftriaxone 4 g/d, which improved the patient's consciousness and CSF findings. However, marked neck stiffness and neck pain persisted; we performed a systemic investigation that revealed cervical vertebral osteomyelitis and aortic aneurysm. OUTCOMES: After surgical treatment, the patient achieved complete remission of both conditions. LESSONS: We should consider vertebral osteomyelitis as a potential complication of meningitis when nuchal stiffness persists despite an improvement in meningitis.