Pterygomaxillary space infection complicated by meningitis due to Streptococcus constellatus: Two case reports and literature review

Rationale: Streptococcus constellatus is a common oral bacterium implicated in pterygomaxillary space infections. Due to the deep anatomical location of these infections, they are often misdiagnosed as temporomandibular joint disorders. Although rare, concurrent meningitis in immunocompetent individuals can occur and may be life-threatening. Patient concerns: We report 2 older male patients who presented with facial pain and headache, initially misdiagnosed as temporomandibular joint disorders. Their conditions rapidly progressed to fever, altered mental status, and neurological deficits. Diagnoses: Cerebrospinal fluid analysis and metagenomic next-generation sequencing confirmed S constellatus meningitis. Computed tomography or magnetic resonance imaging revealed concurrent pterygomaxillary space infections. Interventions: Both the patients received targeted antibiotic therapy (meropenem followed by vancomycin/linezolid plus metronidazole); 1 patient also underwent surgical drainage. Outcomes: Both the patients recovered completely without neurological sequelae. Lessons: Although S constellatus meningitis is rare, odontogenic sources should be considered in patients with poor oral hygiene. Our report highlights the diagnostic value of next-generation sequencing for early pathogen detection in cerebrospinal fluid.