Acute Severe Spinal Cord Dysfunction in Bacterial Meningitis in Adults MRI Findings Suggest Extensive Myelitis
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OBSERVATION Acute Severe Spinal Cord Dysfunction in Bacterial Meningitis in Adults MRI Findings Suggest Extensive Myelitis Stefan Kastenbauer, MD; Frank Winkler, MD; Gunther Fesl, MD; Xaver Schiel, MD; Helmut Ostermann, MD, PhD; Tarek A. Yousry, MD, PhD; Hans Walter Pfister, MD, PhD Background: Bacterial meningitis is rarely compli- the cervical to the lumbar cord. Leptomeningeal and dis- cated by acute spinal cord involvement (eg, myelitis, is- crete nodular intramedullary enhancement on T1- chemic infarction, spinal abscess, or epidural hemor- weighted images was detected only in 1 patient. Fol- rhage). In spinal cord dysfunction, magnetic resonance low-up examinations revealed that hyperintensities imaging (MRI) is the imaging modality of choice. Still, resolved completely in 1 patient, while a central cavita- MRI findings of myelitis due to bacterial meningitis in tion developed in the cervical spinal cord of another, and adults have not been reported. the MRI findings were progressive during the first 4 weeks in the third patient. In all cases, severe paresis and bowel Methods: Spinal MRIs were obtained during the acute and bladder incontinence persisted. stage of meningitis and on follow-up in 3 adults with bac- terial meningitis that was complicated by paraparesis or Conclusion: We demonstrate for the first time the MRI tetraparesis and bowel and bladder incontinence. The findings of adults with acute spinal cord involvement dur- causative pathogens were Streptococcus pneumoniae and ing bacterial meningitis. Magnetic resonance imaging Neisseria meningitidis; in 1 patient, the pathogen was not showed central intramedullary hyperintensities on T2- identified. weighted images that extended from the cervical to the lumbar cord, indicating myelitis. Clinical follow-up ex- Results: In all cases, spinal MRI ruled out a compres- aminations suggest that myelitis during bacterial men- sion of the cord by an extramedullary mass but demon- ingitis has an unfavorable prognosis. strated hyperintensities on T2-weighted images that pre- dominantly involved the gray matter and extended from Arch Neurol. 2001;58:806-810 ACTERIAL MENINGITIS is fre- We describe 3 patients who devel- quently accompanied by oped severe spinal cord dysfunction dur- intracranial complications, ing the acute stage of bacterial meningi- such as cerebrovascular tis and their MRI findings during this involvement, brain edema, condition. Bhydrocephalus, or hearing impairment, as well as systemic complications, such REPORT OF CASES as septic shock, adult respiratory distress syndrome, or disseminated intravascular CASE 1 coagulation.1-3 Spinal cord involvement is a rare complication of bacterial menin- A 36-year-old woman was admitted to a gitis.4 Besides cord compression by a local hospital with a 4-day history of fe- spinal abscess or epidural hemorrhage ver, back pain, and weakness of both legs. following lumbar puncture, the cord can be affected by ischemia due to vascu- For editorial comment litis, shock, herniation, or arachnoiditis, From the Departments of and by myelitis.4 Spinal magnetic reso- see page 717 Neurology (Drs Kastenbauer, nance imaging (MRI) during the acute Winkler, and Pfister), stage of spinal cord dysfunction has been Three years previously, she had under- Neuroradiology (Drs Fesl and reported in only 2 children: no abnor- gone splenectomy for idiopathic throm- Yousry), and Internal Medicine 4 (Drs Schiel and Ostermann), malities were detected in one child, and bocytopenic purpura, and 3 months prior Klinikum Großhadern, enhancement of the cauda equina and to admission, she had received her last Ludwig-Maximilians lumbosacral nerve roots was seen in the pneumococcal vaccination. On admis- University, Munich, Germany. other.5 sion, the patient was febrile, agitated, and (REPRINTED) ARCH NEUROL / VOL 58, MAY 2001 WWW.ARCHNEUROL.COM 806 ©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 confused. Neurologic examination revealed neck stiff- travenous treatment with ceftriaxone was started. His CSF ness, an incomplete bilateral sixth nerve palsy, and a tet- contained 300 cells/µL (71% granulocytes), the protein raparesis (muscle power grade, 4/5 in the arms and 2/5 level was 1.66 g/L, and the CSF glucose level was less than in the legs). Muscle tone and tendon reflexes were de- 40% of the serum glucose level. There were no findings creased in the legs compared with the arms. The plantar on Gram stain and cultures from CSF and blood, but DNA response of the left foot was extensor. Blood cultures were from Neisseria meningitidis was detected in the CSF and positive for Streptococcus pneumoniae. Intravenous ben- blood by polymerase chain reaction. When sedation and zylpenicillin and ceftriaxone were administered, and the ventilator support were discontinued 5 days after admis- patient was transferred to our hospital. The cerebrospi- sion, flaccid paraplegia and a sensory level at T8 were nal fluid (CSF) contained 792 cells/µL (94% granulo- noted. The patient was given intravenous prednisolone cytes), the protein level was 6.3 g/L, and the CSF glu- (150 mg/d for 3 days, then 75 mg/d) for suspected my- cose level was less than 10% of the serum glucose level. elitis. Seventeen days after onset, the patient was trans- Gram-positive diplococci were present in the CSF, and ferred to our department. Despite repeated corticoste- the latex agglutination test result was positive for pneu- roid treatment, the spinal cord dysfunction was mococcal antigen; however, CSF cultures remained ster- progressive until 4 weeks after onset. Seven weeks after ile. Because myelitis was suspected, the patient was given onset, the patient still had a flaccid tetraparesis (muscle intravenous dexamethasone (24 mg/d) for 4 days. The power grade, 4/5 in the arms and 0/5 in the legs) and a clinical course was further complicated by ischemic in- sensory level at T6. Furthermore, bowel and bladder in- farction in the right frontal lobe due to cerebral vascu- continence were present. litis. Three months after the onset of disease, the patient had a spastic tetraparesis (muscle power grade, 4/5 in the METHODS arms and 2/5 in the legs). Sensibility was intact, but blad- der and bowel control were still absent. In all patients, MRI was performed on a 1.5-T MRI scan- ner (Magnetom Vision; Siemens, Munich, Germany). CASE 2 Detailed information on the sequences is given in the figure legends. A 33-year-old man who had been hospitalized because of bronchitis and mild graft-vs-host disease of the liver RESULTS following allogeneic bone marrow transplantation for chronic myeloid leukemia 6 months previously devel- For all 3 patients, T2-weighted images showed intramed- oped fever and headache despite oral antibiotic therapy ullary hyperintensities during the acute stage of spinal (amoxicillin, ciprofloxacin, and fluconazole). Within 24 cord dysfunction (day 5 of meningitis/day 5 of spinal cord hours of admission, weakness of both legs and bowel and dysfunction in patient 1; day 2 of meningitis/day 2 of spi- bladder incontinence appeared. Examination revealed dis- nal cord dysfunction in patient 2; day 6 of meningitis/ crete neck stiffness, spastic paraplegia, and a sensory level after day 1 of spinal cord dysfunction in patient 3), which at C1. The CSF contained 2976 cells/µL (94% granulo- appeared to be most pronounced in the gray matter. The cytes, no malignant cells), the protein level was 1.07 g/L, signal abnormalities extended from the cervical to the lum- and the CSF glucose level was less than 40% of the se- bar cord in patients 1 and 2 and from the cervical to the rum glucose level. There were no findings on Gram stain thoracic cord in patient 3 (Figure 1 and Figure 2). of CSF, and cultures of blood and CSF were sterile. Trans- While swelling of the spinal cord was clearly evident in cranial Doppler sonography and cranial MRI were nor- patient 3, it was not observed in the other patients. In- mal. Nosocomial bacterial meningitis was suspected, and tense leptomeningeal and discrete nodular intramedul- the patient was treated with intravenous vancomycin, me- lary gadolinium enhancement was observed in patient 1 ropenem, metronidazole, and a 4-day regimen of oral but not in patients 2 and 3 (Figure 1A). On native T1- dexamethasone, 24 mg/d. Six weeks after onset of men- weighted images, the central spinal cord lesion ap- ingitis, follow-up examination showed a motor level at peared hypointense in patient 1 and isointense in pa- C8, with a power grade of 4/5 in the small muscles of tients 2 and 3. In none of the patients did we detect an the hand and 2/5 in the legs. No clear sensory level could intramedullary abscess or compression of the cord by a be determined, but sensibility and vibratory sense were mass, such as an epidural hemorrhage, extramedullary decreased in both legs. Bowel and bladder incontinence abscess, or subdural empyema. were still present. On follow-up, the intramedullary signal abnormali- ties had completely resolved in patient 2. In patient 1, the CASE 3 extensive hyperintensities had almost completely re- solved by day 17 after onset of meningitis, but on day 24, A previously healthy 17-year-old boy was admitted to a a central hyperintense lesion was detected in the cervical local hospital with a 1-day history of fever, nausea, and spinal cord at the level of C6. This lesion was interpreted headache. Examination revealed no focal neurologic defi- to be a newly formed syrinx. In patient 3, the T2 signal ab- cit, but a discrete neck stiffness and a petechial rash on normalities that initially involved only the thoracic cord the trunk and extremities. Shortly after admission, he had extended to C4 by day 17 (Figure 2) and to C3 by day 29. a respiratory arrest, at which time no blood pressure could Furthermore, the high intensity of the T2 signal was sub- be detected.