A cranial CT provides information concerning intracranial complications such as brain oedema, hydrocephalus and infarcts. Moreover, bone window imaging identifies parameningeal foci such as sinusitis, mastoiditis or odontogenic abscess. Those patients who present with focal neurological deficits or seizures and those who have a disturbed consciousness should have a cranial CT before lumbar puncture. Of those patients without focal signs or seizures and with a normal level of consciousness, CT abnormalities are found in less than 3 % and CSF can be drawn without prior CT scanning. Under no circumstances the CCT should delay antibiotic treatment in highly suspicious cases. MRI scans in the acute setting are not recommended since no further information is gained (Fig. 29.2). In our patient, due to fluctuating qualitative impairment of his consciousness, a CCT scan revealed no pathologies and was performed only because the procedure did not delay treatment (<15 min).

The CSF was withdrawn and proved the diagnosis of pneumococcal meningitis (12 × 10³ leucocytes/ml, 99 % neutrophils, CSF protein 1.3 g/l, lactate 0.8 g/l glucose CSF/blood ratio 0.2). In the CSF extracellular Gram-positive cocci were seen and qualified as pneumococci (Fig. 29.1). The CSF culture confirmed Streptococcus pneumoniae as suggested by Gram staining, 36 h later, as well as the blood culture results (Fig. 29.1). The MIC (minimal inhibitory concentration) was <0.1 μg/ml for penicillin. Together with systemically lowered leucocytes, fever of 38.8 C and a heart rate of 110 sepsis criteria are fulfilled.

Pneumococcal meningitis with sepsis

Bacterial meningitis is an inflammation of the meninges, in particular the arachnoid and the pia mater, associated with the invasion of bacteria into the subarachnoidal space. A hallmark of bacterial meningitis is the recruitment of highly activated leucocytes into the CSF. Besides bacteria, viruses, fungi and noninfectious causes as in systemic and neoplastic disease as well as certain drugs can induce meningeal inflammation.

Streptococcus pneumoniae and Neisseria meningitidis are the most common and most aggressive pathogens of meningitis. Symptomatic headache results from the activation of trigeminal C fibres in the meninges and is categorized as headache attributed to bacterial meningitis and meningoencephalitis (9.1.1, HIS 3rd edition, 2013).

Bacterial meningitis is a medical emergency requiring immediate diagnosis and immediate treatment.

Antibiotic treatment (cefotaxime 3 × 4 g i.v. and ampicillin 6 × 2 g i.v., Table 29.1) followed the administration of dexamethasone 10 mg i.v. (every 6 h/4 days) and the patient was transferred to our neurocritical care unit for one night. Once pneumococci were confirmed in the CSF culture, only cefotaxime was continued for 10 days.