LAUSR

A 60-year-old woman was comatose with a fever. A cerebrospinal fluid test revealed pneumococcal meningitis. Although computed tomography and T2-star-weighted imaging showed subcortical hemorrhaging (Picture 1A, B), no cerebral infarction or vasoconstriction was detected on the second day of hospitalization (Picture 2A). She became oriented after treatment with dexamethasone, meropenem and vancomycin, which were de-escalated later to penicillin G. On day 8, however, despite continuation of treatment with penicillin G, vasoconstriction in the bilateral proximal and right distal portions of the middle cerebral artery was detected (Picture 2B). On day 13, vasoconstriction had progressed bilaterally in both the anterior and posterior circulation from morning (Picture 2C) to evening (Picture 2D) with multiple infarctions on diffusion-weighted imaging (Picture 2E, F). Treatment with intravenous methylprednisolone following oral prednisolone gradually improved her cerebral vasculitis (Picture 2G, H) and neurological symptoms. Pneumococcal meningitis shows delayed cerebral vasculitis (DCV) after initial good recovery in rare cases. A rebound effect of abrupt termination of dexamethasone administration may be involved (1, 2). In this case, although we were unable to perform vessel wall imaging because of the patient’s poor condition, including unsteadiness, especially in the evening on day 13, DCV was consistently observed. Therefore, hemorrhaging as well as termination of dexamethasone administration may have triggered DCV, and continual steroid administration may be needed to improve vasculitis in pneumococcal meningitis.