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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 6  |  Issue : 1  |  Page : 46-48

Cerebral vein thrombosis due to meningococcal meningitis


1 Department of Infectious Diseases, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Neurology, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Web Publication10-Jun-2019

Correspondence Address:
Dr. Atousa Hakamifard
Department of Infectious Diseases, School of Medicine, Isfahan University of Medical Sciences, Isfahan
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ami.ami_67_18

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  Abstract 

Bacterial meningitis is a life-threatening condition and Neisseria meningitidis is a major cause. Cerebrovascular complications can occur. Cerebral venous and sinus thrombosis (CVST) is an uncommon type of these complications, especially in meningococcal meningitis. The initiation of anticoagulant in septic thrombosis is controversial. A 35-year-old man was admitted to a hospital with fever and confusion. The diagnosis of N. meningitidis meningitis was established. Antimicrobial regimen (ceftriaxone) was continued. On the 3rd day, the patient's consciousness was improved; however, according to the patient's headache on day 7, brain imaging was performed which revealed a cerebral thrombosis in transverse and sigmoid sinuses. Although initiation of anticoagulant is controversial in septic thrombosis, the anticoagulant treatment also was started. Control brain magnetic resonance venogram done revealed complete resolution of cerebral CVST after 2 weeks. CVST as a complication of meningococcal meningitis should be considered. Anticoagulant treatment may be considered in the management of septic cerebral thrombosis if there are no contraindications. The use of anticoagulant needs further studies.

Keywords: Bacterial meningitis, CVST, cerebral vein thrombosis, meningitis, meningococcal infection


How to cite this article:
Hakamifard A, Hemasian H. Cerebral vein thrombosis due to meningococcal meningitis. Acta Med Int 2019;6:46-8

How to cite this URL:
Hakamifard A, Hemasian H. Cerebral vein thrombosis due to meningococcal meningitis. Acta Med Int [serial online] 2019 [cited 2019 Jun 17];6:46-8. Available from: http://www.actamedicainternational.com/text.asp?2019/6/1/46/259897


  Introduction Top


Bacterial meningitis is a disease with high mortality that requires immediate antimicrobial treatment.[1] Neisseria meningitidis is a Gram-negative diplococcal bacterium and is part of the normal microbiota of nasopharynx, which can cause invasive diseases, such as meningitis and bacteremia. Meningococcus is a major cause of meningitis worldwide. Humans are the only natural hosts.[2] Its common clinical manifestations are meningitis and meningococcemia.[3] Cerebral vein thrombosis as a neurological complication of meningitis is uncommon. In this paper, we report a case of cerebral venous and sinus thrombosis (CVST) as a complication of meningococcal meningitis which showed improvement after antibiotic and anticoagulant treatment.


  Case Report Top


A 35-year-old man prison patient was referred to Alzahra Hospital, a tertiary center in Isfahan University of Medical Sciences, Isfahan, Iran, with loss of consciousness and fever in January 2018. No history of head trauma was declared. On examination, petechial skin rashes were noticeable. He was febrile, was confused, and had neck stiffness with no lateralizing signs or papilledema. The brain computed tomography scan was normal. According to meningismus signs, the lumbar puncture was performed, and considering clinical manifestation, an empirical antimicrobial regimen consists of ceftriaxone, vancomycin, and acyclovir in addition to corticosteroid being started. The cerebral spinal fluid (CSF) analysis revealed white blood cell = 200, polymorphonuclear = 75%, Glucose (Glu) = 32, and Protein (Pro) = 75, which was suggestive of bacterial meningitis. Other laboratory studies showed leukocytosis and high levels of serum erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) (78 mm/h and 55 mg/dL, respectively). International normalized ratio was 2.1. On the 3rd day, the patient's consciousness was improved and he was afebrile. The CSF and blood culture were positive for N. meningitidis. Hence, according to CSF analysis and its culture, the administration of vancomycin and acyclovir was stopped, and treatment with ceftriaxone was continued. After 1 week, the patient's complaint was headache, so brain magnetic resonance imaging and magnetic resonance venogram (MRV) were performed which revealed cerebral venous thrombosis in transverse and sigmoid sinuses [Figure 1], [Figure 2], [Figure 3], with no subdural collection or midline shift. A thrombophilic evaluation was performed and it was normal. The diagnosis of cerebral vein septic thrombosis as a complication of meningococcal meningitis was established. Anticoagulant therapy with heparin (5000 unit intravenous [IV] stat and then 1000 unit/h IV infusion) was started. Treatment with ceftriaxone was continued for 4 weeks. Control brain MRV was done which revealed complete resolution of CVST after 2 weeks. The patient's symptoms include headache that was also improved. The serum level of ESR and CRP diminished to 5 mm/h and 4 mg/dL, respectively.
Figure 1: Coronal view of magnetic resonance venogram demonstrating lack of flow in right sigmoid and transverse sinuses

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Figure 2: Coronal T2-weighted magnetic resonance imaging demonstrating hypersignal clot in the right sigmoid sinus

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Figure 3: Coronal view of contrast-enhanced magnetic resonance imaging showing lack of filling in the right sigmoid sinus

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  Discussion Top


We report a patient presenting with meningococcal meningitis and CVST. Acute bacterial meningitis is a medical emergency with high mortality rate and neurological sequels.[1] Invasive meningococcal infection can present as meningitis, meningococcemia, or both. Petechial or purpuric rash is one of the important distinctive features.[3] In bacterial meningitis, cerebrovascular complications are common (10%–36%).[4] Since the introduction of antibiotics, septic cerebral and sinus thrombosis is an uncommon type of these cerebrovascular events.[5] Depending on the location of the thrombosis, the range of clinical symptoms associated with CVST varies. The most common symptoms are headache, seizures, and loss of consciousness.[6] Although CVST reported to occur in 9.2% in pneumococcal meningitis,[7] it is a rare complication of meningococcal infection.[8] As mentioned, few cases have also been reported. In the case reported by Chirakkara et al., a case of meningococcal meningitis with CVST was described and medical treatment with ceftriaxone was started. In the mentioned study, the authors stated that the use of anticoagulation in CVST secondary to meningococcal infection needs further studies to confirm its usefulness.[9] Further, in the case reported by Bozzola et al., a 8-month-old patient with multiple cerebral sinus thrombosis complicating meningococcal meningitis was reported. Thrombophilic evaluation revealed hyperhomocysteinemia and methylenetetrahydrofolate reductase variants (C677T and A1298C). Anticoagulant therapy was started.[10] Against this case, our patient had no thrombophilic abnormalities. Treatment of intracranial septic thrombophlebitis includes the administration of antibiotic according to the bacteria found in blood culture or CSF. The use of anticoagulant in this condition is controversial although, in septic cavernous sinus thrombosis, the initiation of anticoagulant is recommended.[11] We initiated anticoagulant therapy. The control brain MRV was done after 2 weeks which revealed complete resolution of thrombosis. At this time, the anticoagulant was stopped. The patient was clinically improved.


  Conclusion Top


The main emphasis of this case describes CVST as a possible complication of meningococcal meningitis. Anticoagulant treatment may be considered in management of CVST associated with meningococcal meningitis although it needs further studies.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004;39:1267-84.  Back to cited text no. 1
    
2.
Stephens DS, Greenwood B, Brandtzaeg P. Epidemic meningitis, meningococcaemia, and Neisseria meningitidis. Lancet 2007;369:2196-210.  Back to cited text no. 2
    
3.
Johri S, Gorthi SP, Anand AC. Meningococcal meningitis. Med J Armed Forces India 2005;61:369-74.  Back to cited text no. 3
    
4.
Weisfelt M, van de Beek D, Spanjaard L, Reitsma JB, de Gans J. Clinical features, complications, and outcome in adults with pneumococcal meningitis: A prospective case series. Lancet Neurol 2006;5:123-9.  Back to cited text no. 4
    
5.
Bousser MG, Chiras J, Bories J, Castaigne P. Cerebral venous thrombosis – A review of 38 cases. Stroke 1985;16:199-213.  Back to cited text no. 5
    
6.
Hennerici M, Bogousslavsky J, Sacco RL, editors. Clinical Practice Series: Stroke. Philadelphia: Elsevier; 2005.  Back to cited text no. 6
    
7.
Kastenbauer S, Pfister HW. Pneumococcal meningitis in adults: Spectrum of complications and prognostic factors in a series of 87 cases. Brain 2003;126:1015-25.  Back to cited text no. 7
    
8.
Heckenberg SG, de Gans J, Brouwer MC, Weisfelt M, Piet JR, Spanjaard L, et al. Clinical features, outcome, and meningococcal genotype in 258 adults with meningococcal meningitis: A prospective cohort study. Medicine (Baltimore) 2008;87:185-92.  Back to cited text no. 8
    
9.
Chirakkara SK, Bakhsh AR, Pariyadath AK, Rathinavelu B. Cerebral venous sinus thrombosis in a patient with meningococcal meningitis. Oman Med J 2018;33:61-4.  Back to cited text no. 9
    
10.
Bozzola E, Bozzola M, Colafati GS, Calcaterra V, Vittucci A, Luciani M, et al. Multiple cerebral sinus thromboses complicating meningococcal meningitis: A pediatric case report. BMC Pediatr 2014;14:147.  Back to cited text no. 10
    
11.
Masuhr F, Einhäupl K. Treatment of cerebral venous and sinus thrombosis. InHandbook on Cerebral Venous Thrombosis Vol. 23. Karger Publishers 2008. pp. 132-143.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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