Complex Presentation of Bacterial Meningitis in 2 Year Old

Case Diagnosis: Bacterial meningitis complicated by cranial nerve palsies, low-pressure hydrocephalus, and ischemic strokes.

Case Description or Program Description: A 2-year-old boy presented to inpatient rehab with brain injury secondary to Strep pneumoniae meningitis. Upon admission, he had right cranial nerve (CN) 4 and bilateral CN6 palsies. He later developed low pressure hydrocephalus and bilateral basal ganglia and frontal lobe ischemic infarcts resulting in left hemiplegia.

Setting: Specialty Hospital

Assessment/Results: An external ventricular drain (EVD) was placed after imaging demonstrated ventriculomegaly concerning for communicating hydrocephalus. He had low-normal intracranial pressure (ICP) so it was concluded that the CN findings were not related to ICP, but likely secondary to the meningitis itself. EVD was removed and he did not require ventriculo-peritoneal shunt placement long term. He later presented with basal ganglia and frontal strokes and was started on steroids and aspirin. He regained some extremity strength but saw no change in his cranial nerve deficits.

Discussion (relevance): The striking bilateral CN6 and right CN4 abnormalities appeared unique for bacterial meningitis infection. The literature indicates that CN palsies are often associated with basilar meningitides (tubercular meningitis) and are less common in nontubercular meningitides as these tend to affect convexities of the brain. In addition, while stroke complications can be seen in bacterial meningitis at any timepoint, strokes in the basal ganglia are more commonly associated with tuberculous meningitides as opposed to S. pneumoniae. These uncommon complications led to difficulties with visual-motor tasks, standing, and ambulation, affecting his rehabilitation. At his age, these changes could have serious implications on his fine motor, gross motor, and social/cognitive development.

Conclusions: Bacterial meningitis is debilitating to patients and special care should be taken to minimize comorbidities. Physicians should be wary of the common and uncommon complications of bacterial meningitis to prevent long term sequelae, especially in children who depend on the critical developmental gains made in early childhood.