CP 6 - Cerebral Vasculitis and Multi-infarct Stroke: A Catastrophic Complication of Invasive Pneumococcal Disease- A Case Report

Mathew EA, Liyanage NS, Manampery RN, Kalubowila DN  , Department of Microbiology, Colombo North Teaching Hospital, Ragama

Abstract

Introduction

Streptococcus pneumoniae is a Gram-positive diplococcus with more than 100 known serotypes. Invasive Pneumococcal Disease (IPD) remains a significant cause of morbidity and mortality worldwide. This case highlights the aggressive nature of systemic dissemination, leading to the concurrent involvement of the central nervous system and the endocardium.

Case report

A 25-year-old immunocompetent woman presented with a two-week history of intermittent fever and cough, followed by a generalized tonic–clonic seizure. On admission, findings included a Glasgow Coma Scale (GCS) of 8/15, meningism, tetraparesis, and a pansystolic murmur. Laboratory investigations revealed elevated inflammatory markers (WBC 11,850/mm³, CRP 63 mg/L, and ESR 110 mm/hr).

Empirical treatment with intravenous ceftriaxone, acyclovir, and dexamethasone was initiated. Blood culture yielded Streptococcus pneumoniae. The isolate was sent to the reference laboratory for serotyping and Minimum Inhibitory Concentration (MIC) testing for penicillin and ceftriaxone to guide definitive antibiotic blood culture sensitivity (ABST). Cerebrospinal fluid analysis was consistent with bacterial meningitis, and a brain MRI demonstrated leptomeningitis with multiple early subacute infarcts. Consequently, acyclovir was discontinued, and IV vancomycin and rifampicin were added.

Subsequently, a transesophageal echocardiogram (TEE) was performed to evaluate for Austrian syndrome which revealed anterior mitral valve leaflet thickening and Grade IV mitral regurgitation, strongly reinforcing a diagnosis of infective endocarditis. Despite aggressive antimicrobial escalation to meropenem, vancomycin, and rifampicin, her condition progressively deteriorated. Complicated by hospital-acquired pneumonia, she ultimately succumbed to her illness on day 47.

Discussion

IPD carries a 20.8% mortality rate. Prognosis depends on host vulnerability, clinical presentation severity, and pathogen characteristics; hypervirulent strains (e.g., Serotype 1-ST217) drive high transmissibility and large-scale meningitis outbreaks.

The infection triggered severe cerebral vasculitis, small-vessel thrombosis, and vasospasm from an intense subarachnoid inflammatory response. Vasculitis should be suspected if a patient's neurological status worsens or if fever persists despite targeted antibiotics. Furthermore, the lack of visible vegetations on TEE highlights a diagnostic challenge; vegetations may be small, already embolized, or present only as valvular thickening. This case highlights the need for early suspicion, clinical diagnosis and prompt antimicrobial treatment of IPD to reduce the burden of IPD and prevent catastrophic multi-organ failure.