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Título

A INVASIVE INFECTION BY STREPTOCOCCUS AGALACTIAE CAUSING MENINGITIS OF ATYPICAL PRESENTATION

RESUMO

CASE REPORT: A 33-YEAR-OLD MAN, PREVIOUSLY HEALTHY, EVOLVED WITH SEVERE, PROGRESSIVE, PERSISTENT HEADACHE ASSOCIATED WITH VOMITING, PHOTO AND PHONOPHOBIA AND 03 EPISODES OF FEVER (38-39ºC). FIVE DAYS AFTER THE ONSET OF THE CONDITION, HE DEVELOPED BINOCULAR DIPLOPIA WHEN LOOKING TO THE RIGHT SIDE AND WORSENING OF THE HEADACHE INTENSITY. AN SKULL ANGIO-CT REALIZED IN ANOTHER SERVICE THAT SHOWED INDIRECT SIGNS OF INTRACRANIAL HYPERTENSION AND THEN HE SOUGHT MEDICAL CARE IN OUR SERVICE AFTER 15 DAYS OF ONSET OF SYMPTOMS. A LUMBAR PUNCTURE WAS PERFORMED, OPENING PRESSURE OF 37 CMH²O, 1.649 CELLS (59% NEUTROPHILS), PROTEIN OF 135 MG/DL AND GLUCOSE OF 39 MG/DL. THE SAMPLE WAS ANALYZED BY MOLECULAR TEST WHICH DETECTED STREPTOCOCCUS AGALACTIAE. MRI OF HER BRAIN DEMONSTRATED VARIOUS FOCUS OF RESTRICTION TO DIFFUSION IN HIGH FRONTOPPARIETAL CONVEXITY. THE PATIENT WAS TREATED WITH CEFTRIAXONE 4G/DAY FOR 14 DAYS AND EVOLVED WITH TOTAL IMPROVEMENT OF SYMPTOMS. REPEATED LUMBAR PUNCTURE AFTER 10 DAYS OF TREATMENT: OPENING PRESSURE OF 24 CMH²O, 160 CELLS (78% LYMPHOCYTES AND 9% MONOCYTES), WITH 46MG/DL PROTEIN AND 52 MG/DL GLYCORRHACHIA. DISCUSSION: THIS CLINICAL CASE DEMONSTRATES AN ADULT PATIENT WITH ATYPICAL PRESENTATION OF BACTERIAL MENINGITIS WITH AN UNUSUAL ETIOLOGIC AGENT FOR THE AGE GROUP, STREPTOCOCCUS AGALACTIAE (GROUP B STREPTOCOCCUS, GBS). GBS IS A NORMAL FLORAL BACTERIUM THAT COLONIZES THE GASTROINTESTINAL AND GENITOURINARY TRACTS, IT IS THE MAIN CAUSE OF PUERPERAL AND NEONATAL INFECTIONS, INCLUDING MENINGITIS. IN ADULTS, GBS MENINGITIS IS RELATIVELY RARE, ACCOUNTING FOR 0.3 TO 4.3% OF ALL CASES OF BACTERIAL MENINGITIS. GBS MENINGITIS IN ADULTS USUALLY OCCURS IN PATIENTS WITH UNDERLYING CONDITIONS OR IN PREGNANCY/PUERPERIUM, DIABETES MELLITUS IS THE MOST ASSOCIATED COMORBIDITY, DURING HOSPITALIZATION THE PATIENT WAS FOUND TO BE PRE-DIABETIC. DOMINGOS ET AL REVEALED THAT 86% OF THE PATIENTS HAD COMORBIDITIES AND 50% HAD A DISTANT FOCUS OF INFECTION. THE CLINICAL PICTURE OF MENINGITIS BY GBS AND THE CSF FINDINGS DO NOT DIFFER FROM OTHER BACTERIAL MENINGITIS, HOWEVER OUR CASE REVEALED ITSELF WITH 15 DAYS OF EVOLUTION AND SIGNS OF INTRACRANIAL HYPERTENSION. ALTHOUGH GBS ARE 4 TO 10 TIMES LESS SUSCEPTIBLE TO PENICILLIN, PENICILLIN IS STILL THE FIRST CHOICE, AS IS CEFTRIAXONE. CONCLUSION: WITH THE RATE OF INVASIVE DISEASE PER GBS IN ADULTS INCREASING, THE PHYSICIAN MUST BE PREPARED TO RECOGNIZE AND INITIATE EFFECTIVE TREATMENT TO AVOID COMPLICATIONS OF THE DISEASE.

Palavras Chave

ADULT; BACTERIAL MENINGITIS; STREPTOCOCCUS AGALACTIAE