(P39) A Headache out of This World

Chief Complaint : A 55 year-old Bengali female with a history of hypertension presented to the Adult Emergency Department with a headache and fever for 2 days.

History of Present Illness : On translator-assisted interview, the patient reports that the headache is biparietal and radiates to her neck. It is different from her well-established, prior headache episodes. She denies associated nausea, vomiting, visual changes or photophobia, neck stiffness, or altered mental status. She took acetaminophen without improvement of symptoms. She is in otherwise good health, but reports undervaccination against COVID-19.

Pertinent Physical Exam: On presentation, her vitals were: temperature 103.2 F, blood pressure 139/72, heart rate 121, respiratory rate 18, oxygen saturation 97% on room air. She was able to range her neck but reported pain with such movement that was consistently reproducible. Although ill-appearing and diaphoretic, she was alert, attentive, moving all extremities without difficulty through a full range of motion, and ambulating well. The remainder of the neurologic exam was unremarkable.

Pertinent Laboratory Data: Her blood work revealed leukocytosis of 15.1 and normal electrolytes. Chest x-ray was clear. Urinalysis was negative. Tests for covid, influenza, and respiratory syncytial virus were negative. Noncontrast head CT head was negative. A lumbar puncture was done and cerebrospinal fluid results revealed normal glucose, elevated protein, white blood cell 95. The CSF culture was positive for GBS.

Case Discussion: Group B Streptococcus (group B strep, GBS; alternatively, S. agalactiae) typically affects neonates and is an important cause of neonatal meningitis, pneumonia, and sepsis. In adults, GBS infection is rare but has been increasing in prevalence in recent years. It is estimated that GBS meningitis represents from 0.3% to 4.3% of all cases of adult bacterial meningitis. Adult GBS meningitis is usually found in puerperal patients or patients with immunocompromise, CSF leakage, or endocarditis. It cannot be distinguished on clinical grounds from any other infection causing meningitis. Since GBS meningitis in an otherwise healthy adult is unusual, it is important to assess the patient for potential causes. We present a case of GBS meningitis in an adult who presented to the Emergency Department.

Following admission, further blood tests were unhelpful. An echocardiogram was negative for endocarditis. As the meticulous search for predisposing conditions evolved, further imaging of the sinuses with both CT and MRI revealed an encephalocele extending from the intracranial fossa to the ethmoid air cells. Her CNS infection was eradicated without complication, and her headache resolved. Operative resection of the encephalocele was subsequently performed.

The risk factor for GBS meningitis in this patient was an encephalocele, which is brain tissue that herniates through a defect in the skull. This herniation, which is most commonly in the ethmoid sinus, exposes brain tissue to the external environment, greatly increasing the risk of infection. Most encephaloceles are congenital and may remain undetected until complications arise such as CSF leakage or, as in this case, meningitis.

Treatment for acute GBS meningitis requires empiric antibiotic combinations and often first-dose corticosteroid administered prior to a definitive antibiogram or other microbiologic study. Following resolution of infection, surgery is indicated to repair the defect.

References and Acknowledgements (Optional): Muzulu SI, Meigh R, Nanda BS. Streptococcus agalactiae meningitis in a previously healthy adult. J Infect. 1993 Sep;27(2):210-1. doi: 10.1016/0163-4453(93)95052-k.

Go K, Ge J, Abdelattif M, Zaw M. Recurrent Meningitis in the Context of an Encephalocele. Cureus. 2022 Sep 26;14(9):e29594. doi: 10.7759/cureus.29594.

Khan FY. Streptococcus agalactiae Meningitis in Adult Patient: A Case Report and Literature Review. Case Rep Infect Dis. 2016;2016:6183602. doi: 10.1155/2016/6183602.