Diarrhea-associated pneumococcal meningitis with complicating hydrocephalus in a child in a resource-limited setting

Abstract

Introduction: Streptococcus pneumonia is the most common and intimidating cause of childhood meningitis. Its delayed diagnosis may be associated with hyponatremia and hypernatremia with fatal outcome.

Case presentation: A previously healthy nine-month-old Bangladeshi female infant was diagnosed with diarrhea, pneumonia, and convulsion due to hypernatremia. Pneumonia was confirmed by respiratory distress and radiological findings. Routine cerebrospinal fluid study detected pneumococcal meningitis. Ampicillin, gentamicin, and dexamethasone were promptly started. On day three of hospitalization, convulsion re-appeared with worsening of consciousness level. Antibiotics were switched to ceftriaxone and vancomycin, although ultrasonography of the brain revealed no abnormality. Contrast-enhanced computed tomography scan of the head was performed and revealed dilated ventricles with diffused enhancement of meninges and basal cisterns, demonstrating meningitis with ventriculomegaly. Ceftriaxone was replaced by meropenem to control fever. Magnetic resonance imaging (MRI) of the brain confirmed the progression of hydrocephalus. An emergency ventriculo-peritoneal (VP) shunt operation was performed with continuation of antibiotics for 21 days. After three months, follow-up MRI showed reduction of ventricular size with functioning VP shunt in situ with no neurological deficits.

Conclusions: Childhood pneumococcal meningitis may be associated with diarrhea, pneumonia, and other related complication. Appropriate antibiotic therapy alone may not be sufficient to avert complications. Communicating hydrocephalus is potentially an ominous ramification of meningitis even when the ultrasonography result is normal. Rapid diagnosis is imperative to attain good outcome. Evidence advocates further research into the risk factors of meningitis in diarrheal children that may help in early diagnosis and management to reduce meningitis-related fatal outcome.