Recurrent Nontypeable Pneumococcal Meningitis in a Child With Bilateral Cochlear Implants

To the Editors: Children with cochlear implants (CIs) have a markedly increased risk of pneumococcal meningitis, largely due to structural alterations of the cochlea, electrode tract vulnerabilities or congenital inner ear malformations. Although vaccination reduces the overall incidence of invasive pneumococcal disease, recurrent episodes should always raise concern for anatomical defects or cerebrospinal fluid (CSF) pathways that predispose the patient to direct bacterial invasion. We report a child with bilateral CIs who developed recurrent nontypeable pneumococcal meningitis, in whom magnetic resonance imaging (MRI) demonstrated findings suspicious for dural discontinuity near the implant. A 14-year-old boy with congenital bilateral sensorineural hearing loss underwent his first right cochlear implantation at age 2 and a second implant at age 12; however, the latter remained nonfunctional. Two years before the current presentation, he experienced pneumococcal meningitis confirmed by culture and polymerase chain reaction. He presented again with severe headache, fever, vomiting, right otalgia and photophobia for 2 days. Physical examination revealed high fever, marked nuchal rigidity and positive meningeal signs. Laboratory evaluation showed leukocytosis and elevated inflammatory markers. Lumbar puncture produced turbid CSF with 800/mm³ predominantly polymorphonuclear leukocytes, protein 109 mg/dL, glucose 34 mg/dL and normal chloride levels. Gram stain revealed numerous neutrophils, and culture grew Streptococcus pneumoniae. Polymerase chain reaction identified a nontypeable pneumococcal strain. Because of documented immediate-type urticaria with β-lactams, meningitis-dose meropenem and vancomycin were initiated. Neurologic symptoms improved within 48 hours, and he completed 14 days of intravenous therapy without complications. Contrast-enhanced temporal bone MRI demonstrated 2 focal areas adjacent to the right cochlear implant corresponding to the 7th–8th segment region, consistent with possible dural discontinuity. Although implant-related artifact limited evaluation, the radiology team considered these foci suspicious for a CSF-adjacent defect with minimal parenchymal reaction. Otologic surgery consultation recommended further assessment of the nonfunctional implant and potential exploration of the suspected dural defect to prevent future recurrence. Recurrent bacterial meningitis is uncommon in children and typically indicates an underlying anatomical predisposition. In CI recipients, trauma to the cochlea, electrode migration, microfissures of the otic capsule and dural discontinuities along the implant trajectory have been reported. Even subtle defects may create pathways for pathogen entry. Nontypeable pneumococcus, lacking its capsular polysaccharide, is rarely implicated in invasive infections; however, it may cause disease when structural barriers are compromised. This case underscores the importance of imaging evaluation in CI patients presenting with recurrent meningitis, even when artifacts limit study sensitivity. Optimized MRI sequences or computed tomography cisternography may help detect minor defects. Early identification and surgical repair of dural or temporal bone abnormalities are essential to prevent repeated life-threatening infections. Long-term otologic follow-up and adherence to pneumococcal immunization schedules remain critical components of management in this high-risk population. In conclusion, recurrent pneumococcal meningitis in a child with CIs should prompt a thorough search for dural defects or CSF fistulas. Recognition of such structural vulnerabilities enables timely otologic intervention and may prevent further episodes.