A54-25 Pneumococcal Meningitis With Isolated Cranial Nerve III Palsy and Multifocal Infarcts—A Rare Neurologic Complication Requiring ICU-level Care

Abstract Introduction Bacterial meningitis remains a major cause of morbidity and mortality, often leading to cardiovascular collapse, respiratory failure, or severe neurologic deficits requiring intensive care. We present a case of meningitis with rare neurologic manifestations, emphasizing the spectrum of possible sequelae. Case A 44-year-old male was brought to the emergency room by his family with one day history of decreased consciousness and headache following three months of worsening right ear pain. On arrival, he was febrile to 101.4 °F, with leukocytosis (17.8) and lactate 3.2. A CT head before LP was performed and revealed findings concerning meningitis with cerebral edema. Dexamethasone, cefepime, vancomycin and acyclovir for presumed meningitis were administered, and was then admitted to the ICU. A dedicated examination showed neck stiffness, right ptosis, and impaired adduction and elevation of the right eye, consistent with oculomotor nerve palsy. MRI subsequently demonstrated meningitis with punctate infarcts in the right posterior thalamus and cerebellar hemisphere. Lumbar puncture showed CSF WBC 2375/uL and RBC 90/uL, glucose 26 mg/dl and protein 336 mg/dl. CSF culture revealed gram-positive diplococci and blood cultures grew Streptococcus pneumoniae. Antibiotics were narrowed to ceftriaxone, and a tympanostomy tube was placed. His mental status improved, though the oculomotor palsy persisted. The oculomotor nerve palsy and multifocal strokes were ultimately attributed to Streptococcus pneumoniae meningitis. MRI Brain demonstrating diffuse leptomeningeal enhancement consistent with meningitis Discussion Bacterial meningitis carries a fatality rate of 1 in 6. Early ICU admission allows prompt recognition of neurologic deficits and initiation of therapy, which is associated with lower mortality compared to delayed transfer. As seen with our patient, neurologic complications are well documented; ischemic strokes occur in 16% of cases and are strongly associated with increased mortality. Conversely, oculomotor nerve palsy is an exceedingly rare sequela of S. pneumoniae meningitis. While cranial nerve III palsies are reported with N. meningitidis, isolated oculomotor involvement due to S. pneumoniae has not been described. Cranial nerve palsies have been shown to predict unfavorable outcomes. The rarity of this presentation highlights the need for ICU-level monitoring, as subtle focal neurologic findings may signal intracranial complications requiring rapid diagnosis and treatment. Timely empiric therapy with steroids, broad-spectrum antibiotics and source control via tympanostomy tube contributed to rapid improvement in mental status despite multifocal strokes, highlighting that favorable outcomes are possible even in severe and unusual presentations with early intervention. This abstract is funded by: None