Yokoyama Daiki, Ikenouchi Hajime, Miyamoto Tatsuo, Yamamoto Naoki, Endo Kaoru
Department of Neurology, Sendai City Hospital, Sendai, JPN.
Cureus. 2023 Jan 6;15(1):e33439. doi: 10.7759/cureus.33439. eCollection 2023 Jan.
Pneumococcal meningitis as an overwhelming post-splenectomy infection (OPSI) has a higher risk of neurological complications and is sometimes life-threatening. In acute pneumococcal meningitis, four days of dexamethasone is widely used for the prevention of neurological complications. Herein, we report a 68-year-old woman with the diagnosis of pneumococcal meningitis as OPSI. With adequate antibiotics and dexamethasone, her symptoms gradually improved. However, after dexamethasone withdrawal, her consciousness got worse and got into a coma. Brain magnetic resonance imaging revealed acute cerebral infarctions in the bilateral middle cerebral artery territory with multiple vascular stenoses and hydrocephalus. Vascular stenoses improved by follow-up, suggesting cerebral vasospasm. There were no suggestive findings of cerebral vasculitis. Follow-up cerebrospinal fluid analysis showed remained pleocytosis with no bacteria, which could not suggest meningitis recurrence. Since steroid therapy was rapidly withdrawn, we diagnosed that the cerebral vasospasm was due to the steroid rebound phenomenon. The steroid rebound phenomenon due to the excessive immune response to bacterial microstructures has been reported in pneumococcal meningitis. Especially, the present case was asplenia and the usual dexamethasone use would not adequately suppress the immune response to bacterial microstructures. Since pneumococcal meningitis as OPSI has a higher risk of neurological complications, clinicians should consider longer and more cautious steroid tapering.
肺炎球菌性脑膜炎作为脾切除术后暴发性感染（OPSI），具有较高的神经并发症风险，有时甚至会危及生命。在急性肺炎球菌性脑膜炎中，四天的地塞米松广泛用于预防神经并发症。在此，我们报告一名68岁女性，诊断为肺炎球菌性脑膜炎合并OPSI。使用足量抗生素和地塞米松后，她的症状逐渐改善。然而，停用 地塞米松后，她的意识恶化并陷入昏迷。脑部磁共振成像显示双侧大脑中动脉区域急性脑梗死，伴有多处血管狭窄和脑积水。随访显示血管狭窄有所改善，提示脑血管痉挛。未发现脑血管炎的提示性表现。随访脑脊液分析显示仍有细胞增多但无细菌，这不能提示脑膜炎复发。由于迅速停用了类固醇治疗，我们诊断脑血管痉挛是由于类固醇反跳现象所致。在肺炎球菌性脑膜炎中，已报道过因对细菌微结构的过度免疫反应导致的类固醇反跳现象。特别是，本例患者为无脾状态，常规使用地塞米松不足以抑制对细菌微结构的免疫反应。由于肺炎球菌性脑膜炎合并OPSI具有较高的神经并发症风险，临床医生应考虑更缓慢、更谨慎地减少类固醇用量。
