(1469) Otitis Media to Meningitis: A Rare Group A Streptococcus Meningitis Case

Introduction: Group A Streptococcus (GAS) is a rare meningitis cause. The mean annual GAS meningitis incidence is 0.03 cases per 100,000 patients, and it accounts for less than 1% of meningitis infections. We present a rare GAS meningitis case from otitis media further complicated with GAS bacteremia.

Description: An immunocompromised 43-year-old male with a history of polycystic kidney disease s/p left kidney transplant (2015 on tacrolimus and mycophenolate), left cerebral infarct (2022) with no residual deficit, CAD s/p PCI to RCA (2021), IDDM-2, presented to the ER for disorientation and agitation. A few days prior, sinusitis and a right ear infection were diagnosed, but he failed prompt antibiotic initiation. On admission, he had DKA, tachycardic, tachypneic, and WBCs of 11. CT brain showed acute sinusitis. He was given empiric broad-spectrum antibiotics, and blood cultures were drawn shortly thereafter. After ICU admission, he had encephalopathy likely secondary to sepsis and DKA. Eventually, he developed a 39.8 C Tmax, stiff-neck, and obtundation. He was intubated for airway protection. These changes raised meningitis concerns. An LP was performed, and his antibiotics became vancomycin, ceftriaxone, and ampicillin. The CSF findings showed WBCs 3274 (Neutrophils 97%, Lymphocyte 3%), RBCs 120, protein 214, lactic acid 6.1, and glucose 37. Results consistent with bacterial meningitis. CSF cultures were negative. Both blood cultures grew group A Streptococcus. Follow-up CT brain showed right anterior temporal lobe hypodensity. MRI brain w/out contrast showed acute/early subacute right middle cerebral artery (MCA) territory infarct that involved the temporal lobe. MRA head showed occluded distal right M2 opercular branches with decreased right M2 through M4 MCA flow. EEG showed right cerebral focal slowing, potential infection/stroke. Infectious disease was consulted, and he was given prophylactic acyclovir. Hypertonic saline and mannitol were given. Further management required tertiary facility transfer.

Discussion: The patient’s immunocompromised state and untreated otitis media caused his GAS meningitis. Prompt antibiotic initiation produced negative CSF cultures. Our case’s literature contribution can bring GAS meningitis awareness and vigilance. Particularly, the immunocompromised population.