Pneumococcal meningitis with multiple infarcts and hydrocephalus in a vaccinated infant with unusual early intracranial calcifications

A partially vaccinated infant presented with fever, seizures and rapid neurological decline. Magnetic resonance imaging (MRI) revealed diffuse infarcts in the basal ganglia, thalami and brainstem. Cerebrospinal fluid showed neutrophilic pleocytosis (620 cells/μL), elevated protein (237.7 mg/dL) and hypoglycorrhachia (36 mg/dL); multiplex polymerase chain reaction (PCR) confirmed Streptococcus pneumonia despite sterile cultures. MRI of the brain showed multiple infarcts, hydrocephalus and a computed tomography scan of the brain revealed extensive bilateral calcifications. The immunodeficiency workup and PCR for Human immunodeficiency virus were normal. Exome sequencing is negative for variants related to immunodeficiency. Hence, both primary and secondary immunodeficiencies were excluded. The child had refractory seizures, required multiple antiseizure medications (ASMs) and had hydrocephalus requiring ventriculoperitoneal shunt revision. This case highlights that pneumococcal meningitis can occur in a vaccinated child in a severe form, such as multiple infarcts and hydrocephalus. Severe disease with early, extensive intracranial calcifications can be seen in meningitis.