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Paper text:
bacterial meningitis has an annual incidence of 46 
 cases per 100 000 adults and results in approximately 135 000 
 deaths worldwide each year .
since the development of the 
 haemophilus influenzae type b vaccine , the most 
 common bacterial pathogen for community - acquired meningitis is 
 streptococcus pneumoniae which has a fatality 
 rate from 19% to 37% . in patients that survive the 
 initial insult , neurologic sequelae including seizures , hearing 
 loss , impaired mental status , and/or cognition may occur in as 
 many as 30% of all cases .
local extension from contiguous extracerebral infection ( e.g. , otitis media , mastoiditis , or sinusitis ) is a 
 common cause .
patients with bacterial meningitis will usually 
 present soon after the onset of symptoms with a classic triad of 
 fever , neck stiffness , and altered mental status .
prompt 
 recognition and treatment are key steps to reducing the morbidity 
 and mortality associated with bacterial meningitis . in this case 

report , we describe a patient who presented during the third 
 trimester of pregnancy with fever , mental status changes , and a 
 subsequent diagnosis of bacterial meningitis .
we will review the 
 evaluation and management of this case as well as provide a 
 literature review of other case reports of pneumococcal 
 meningitis in pregnancy .
a 38-year - old multigravida with an intrauterine pregnancy at 35 
 weeks was found unconscious at her home and airlifted to the 
 nearest tertiary care center . throughout transport and upon 
 arrival at the ed ,
her mental status alternated between combative 
 and lethargic and was unable to provide any coherent information 
 regarding her present condition or past medical history .
her 
 family later reported that the patient had presented to her 
 primary care physician five days earlier with complaints of left 
 otalgia and low grade fever .
treatment was initiated with 
 azithromycin for otitis media , but her pain continued to worsen 
 precipitating an emergency room visit the day before her admission 
 to the hospital .
she received prescriptions for 
 amoxicillin - clavulanate and opioids at this visit but had not yet 
 started these medications .
her husband reported several bouts of 
 emesis that same evening before her changes in mental status the 
 following morning .
her primary obstetrician was also contacted and 
 she verified an uncomplicated prenatal care with a term vaginal 
 delivery in her first pregnancy , followed by a caesarian delivery 
 for breech presentation in her second pregnancy .
the patient had 
 been counseled during this pregnancy regarding mode of delivery 
 and opted for repeat caesarean section at 39 weeks . on arrival in the ed , she was febrile to 38.7 c , with a pulse rate 
 of 152 bpm , respiratory rate of 40 , blood pressure of 147/80 , 
 and glasgow coma score of 11 ( 4 for eye opening , 1 verbal , 6 
 movement ) .
uterine contractions were noted every 2 - 3 
 minutes and initial sterile vaginal exam indicated cervical 
 dilation of 4 cm with 50% effacement .
the fetus was 
 vertex in presentation with a size consistent for stated 
 gestational age and a normal amniotic fluid index .
the remainder 
 of the physical examination was significant for purulent drainage 
 from her left ear with marked erythema of both tympanic 
 membranes .
she was also noted to have decreased breath sounds at 
 the base of the right lung .
complete blood count revealed a 
 leukocytosis of 55 000 with 70% granulocytes and 
 22% bands .
chest x - ray indicated a possible infiltrate in 
 the right middle and lower lobes .
the patient was then intubated 
 for airway protection , sedated , and given cetriaxone ( 2 g q 12 
 hours , iv ) for empiric treatment of meningitis before being sent 
 to the radiology suite .
ct scan of the head revealed fluid 
 collection in the middle ear and mastoid on the left .
she was 
 transferred to the intensive care unit and lumbar puncture 
 obtained with 12 750 leukoctyes ( 80% pmn ) , glucose < 5 , 
 and protein of 965 .
preliminary blood and cerebrospinal fluid 
 cultures indicated gram positive cocci in chains , consistent with 
 s. pneumoniae .
vancomycin ( 1 g q 24 hours , 
 iv ) was then added for broader coverage , and dexamethasone ( 10 
 mg q 6 hours , iv ) started as adjuvant therapy .
myringotomy at 
 bedside revealed frank purulence in the middle ear which was 
 evacuated and sent for culture .
continuous fetal and uterine 
 monitoring was initiated with an experienced labor and delivery 
 nurse posted at bedside for signs of fetal distress or continued 
 preterm labor .
this comprehensive level of care was continued 
 until the level of sedation was decreased and the patient was 
 extubated .
uterine contractions ceased in regularity after the 
 first 24 hours with no further cervical change noted .
patient 
 remained intubated until hospital day eight when her mental 
 status had returned to baseline . at this time , she was 
 transferred to the antepartum floor for two additional days of 
 surveillance before discharge home .
final cultures from blood , 
 csf , and ear were consistent with s. pneumoniae 
 with sensitivity to vancomycin .
patient completed the final four 
 days of a 14-day course of vancomycin and ceftriaxone at home . 

her obstetrical care was then returned to her primary 
 obstetrician . at 38 weeks gestation ,
the patient presented to her primary 
 obstetrician with uterine contractions and was noted to be 9 cm 
 dilated .
she had a successful vbac delivery of a male infant 
 weighing eight pounds with apgar scores of 8 and 9 , at 1 and 5 
 minutes , respectively .
mother and child are doing well at the 
 time of this writing , with no sequelae since delivery .
bacterial meningitis is a medical emergency in which early 
 diagnosis and treatment is imperative to prevent death and reduce 
 long - term complications .
lumbar puncture is used to confirm the 
 diagnosis in patients presenting with clinically suspected 
 meningitis ; however , imaging should be completed first in patients 
 with new - onset seizures , an immunocompromised state , signs 
 concerning for mass lesion or moderate - severe level of 
 consciousness .
if imaging is to be performed before lumbar 
 puncture , empiric therapy should be initiated first as a delay in 
 treatment can result in poor outcomes .
the choice of initial 
 antimicrobial therapy is based on the most common bacteria causing 
 the disease according to the patient 's age and the clinical 
 setting and on patterns of antimicrobial susceptibility . with the 
 worldwide increase in the prevalence of penicillin - resistant 
 pneumococci , combination therapy with vancomycin plus a 
 third - generation cephalosporin ( ceftriaxone or cefotaxime )
iv ) 
 before or with the first dose of antibiotics has been shown to 
 reduce the risk of death ( 14% versus 34% ) and 
 neurologic disability ( 26% versus 52% ) in adults 
 with pneumococcal meningitis when compared to placebo . in a recent prospective study ,
the clinical features and 
 prognostic factors were described in adults with bacterial 
 meningitis .
risk factors for an unfavorable outcome were advanced 
 age ( > 60 years ) , presence of otitis / sinusitis , absence of rash , 
 low score on glasgow coma score ( < 8) , tachycardia ( > 120 
 bpm ) , a positive blood culture , an elevated erythrocyte 
 sedimentation rate ( > 56 ) , decreased platelet count 
 ( < 180 000/mm ) , low csf white - cell count ( < 100/mm ) , 
 and causative species s. pneumoniae .
in the current case , the 
 likely mechanism for transmission of the pathogen was through 
 invasion of the central nervous system from a case of severe 
 otitis media .
hence , our patient met a minimum of six of these 
 ten criteria ( tachycardia , otitis , absence of rash , positive 
 blood culture , low csf white - cell count , s. 
 pneumoniae ) placing her at increased risk for a poor outcome . in 
 addition , it is not clear what impact the state of pregnancy has 
 on prognosis for both mother and neonate .
a review of the literature was conducted using medine 
 search and review of references cited .
this revealed five single 
 case reports and a small case series of women diagnosed with 
 pneumococcal meningitis during pregnancy or the postpartum period . 

lucas described 26 cases of pneumococcal meningitis in nigerian 
 during pregnancy ( n = 15 ) or the immediate postpartum period ( n 
 = 11 ) during a time period from 1958 to 1962 .
the overall fatality rate for 
 this group of women was 27% ( 7/26 ) , and the rate of 
 neurologic sequelae in survivors at time of discharge was 
 53% ( 10/19 ) .
the type of complications included hearing 
 loss , severe emotional disturbance , aphasia , and hemiplegia .
of 
 the 15 women diagnosed during pregnancy , 3 of the mothers died 
 and the fetal loss rate from spontaneous abortion , stillbirth , 
 and neonatal death was 47% ( 7/15 ) . the high incidence of 
 cases in nigeria during this time period led the author to 
 suggest that pregnancy predisposes women to pneumococcal 
 meningitis .
although pregnancy does result in a diminished immune 
 response , there is no data to conclude that there is increased 
 risk specific to s. pneumoniae .
the single patient case reports are outlined in 
 table 1 ( see [ 59 ] ) .
the time 
 interval between onset of maternal illness and the delivery of 
 the neonate is less than 36 hours in three cases .
each of these 
 cases resulted in either a fetal or maternal death , and in one 
 instance both mother and infant died . in the other two cases ,
the 
 time frame between onset of maternal illness and delivery was 
 extended with a favorable outcome for both mother and infant . 

with the current case , discussion initially focused on whether it 
 was prudent to move towards delivery , especially in light of her 
 early signs of labor and her family 's strong desire for a 
 caesarian delivery . however , continuous fetal monitoring 
 indicated a reassuring status throughout her hospitalization , and 
 all signs of preterm labor had diminished leaving no indication 
 for a premature delivery .
it is difficult to draw conclusions from 
 isolated reports , but the scant literature available suggests that 
 an extended interval between the onset of maternal illness and 
 delivery provides an important window of time for maternal and 
 neonatal well - being .
background . 
 bacterial meningitis is a medical emergency for which prompt diagnosis and treatment are imperative to reducing the rate of death and long - term neurologic compromise . 
 few cases of meningitis have been reported during pregnancy , many of which had devastating outcomes for mother , neonate , or both . case . a 38-year - old multigravida at 35 weeks of gestation presented with mental status changes , fever , and preterm contractions . 
 lumbar puncture revealed gram positive cocci consistent with s. pneumoniae . 
 patient was intubated and admitted to icu where she was given antibiotics and adjunctive therapy with dexamethasone . 
 continuous fetal monitoring was utilized throughout her course of her hospitalization . 
 patient was discharged home after ten days in the hospital and had an uncomplicated vaginal birth after caesarean section ( vbac ) at 38 weeks . 
 both she and the infant are doing well with no permanent neurologic sequelae . 
 conclusion . 
 a review of literature indicates only isolated cases of pneumococcal meningitis being described during pregnancy . 
 an extended period of time between onset of maternal illness and delivery appears to reduce the risk of neonatal transmission and improve both maternal and fetal outcomes .