# Recurrent Pneumococcal Meningitis From Post-traumatic Frontoethmoidal Encephalocele: A Case Report

## TL;DR

A 22-year-old man with two pneumococcal meningitis episodes was found to have a post-traumatic encephalocele, highlighting the need for imaging and immune evaluation in recurrent cases.

## Contribution

This case emphasizes the importance of diagnosing skull-base defects and immune deficiencies in adults with recurrent pneumococcal meningitis.

## Key findings

- The patient had a left frontal encephalocele linked to recurrent pneumococcal meningitis.
- Imaging and immune evaluation are critical for preventing further episodes in such cases.
- Endoscopic repair and vaccination can effectively manage and prevent recurrence.

## Abstract

Recurrent bacterial meningitis (≥2 episodes with complete recovery between episodes) warrants evaluation for skull-base defects with cerebrospinal fluid (CSF) leak and for immune deficiencies. In adults, Streptococcus
pneumoniae often indicates an anatomic breach (e.g., post-traumatic encephalocele/CSF rhinorrhea), whereas Neisseria suggests complement deficiency. We report a case of a 22-year-old man with his second attack of pneumococcal meningitis within a one-year timeframe after sustaining a road traffic accident about four years ago. The patient sustained a left frontal bone fracture communicating with the left frontal sinus, along with a left frontal encephalocele. His current complaint was fever and cough of one week duration; they were associated with headache, rhinorrhea, vomiting, sore throat, fatigue, and generalized body pain. The patient denied having any past history of recurrent or severe infections, especially during childhood and adulthood. Upon assessment, his temperature was 37.6 °C, and his vitals were within normal limits. Physical examination was remarkable for positive neck stiffness. Otherwise, no skin rashes were noted; neurological assessment included a Glasgow Coma Scale of 15/15, no focal neurological deficits, and intact cranial nerves. His abdomen was soft, lax, and non-tender; his spleen was not palpable. Labs were significant for leukocytosis, elevated inflammatory markers, hypoglycorrhachia, and elevated CSF protein. Both blood and CSF cultures were positive for S.
pneumoniae. His HIV test was negative. He was empirically treated with IV ceftriaxone and vancomycin, and later tailored to ceftriaxone after the cultures’ susceptibility results were out. In adults with recurrent pneumococcal meningitis, prompt skull-base imaging for occult CSF leak/encephalocele, and parallel immune evaluation are essential. Definitive endoscopic repair plus pneumococcal vaccination can prevent further episodes. Structured pathways that trigger beta-2 transferrin testing and high-resolution CT/MRI after a second episode may reduce diagnostic delay.