Title: A Tale of Two Infections: A case of concurrent bacterial and viral meningitis in an immunocompromised patient

Author(s): Ma. Beatrice Gaviola, MD; Kayla Trautman-Buckley, DO; Vipin Villgran, MD

 Email: Mgaviola@mercy.com

Introduction: Meningitis is a life-threatening inflammatory disease of the leptomeninges which can be obtained through nasopharynx colonization, hematogenous spread, retrograde transmission, or most commonly, direct entry. Some risk factors include crowded living conditions, immunosuppression, and extremes of age. The most common etiology is Streptococcus pneumoniae (25-41%)¹. Viral meningitis cases outnumber all other causes, and are usually caused by Enterovirus or HSV². Presented here is a  case which highlights concurrent bacterial and viral meningitis in an immunocompromised patient, exemplifying the need for lumbar puncture and empiric treatment in suspected meningitis.

Case Report(s): An 84-year-old female presented with new-onset generalized tonic-clonic seizure. She had a history of hypertension, atrial fibrillation, and chronic lymphocytic leukemia on Rituximab. Initial workup was unremarkable, and she was started on empiric treatment with Vancomycin and Ceftriaxone, Dexamethasone for suspected sepsis. She had a recurrence of seizures within her first 24 hours and blood cultures grew streptococcus pneumoniae and staphylococcus lugdunensis, staph hominis. Antibiotics were then narrowed to Levofloxacin based on blood culture resistance patterns. Reassessment showed signs of meningitis. LP was performed 3 days into her hospital stay, showing bacterial and viral meningitis. She was started on Acyclovir and Meropenem, but care was transitioned to comfort care per the patient’s POA.

Discussion: There have been very few reports of concurrent bacterial and viral meningitis in adults since it was first documented in 1962^3,4,5. Many of the case reports in the literature show this phenomenon in children, but less commonly in adults^6,7.  Increased suspicion for concurrent bacterial and viral meningitis, especially in patients at higher risk, allows for appropriate treatment and increased chance of recovery. Adult patients at high risk for both bacterial and viral infections include the elderly and otherwise immunocompromised. This patient was both elderly and immunocompromised due to her recent Rituxumab use.