Post-spinal Aseptic Meningitis Following Cesarean Delivery Presenting as an Acute Febrile Meningeal Syndrome: A Diagnostic Challenge

Post-spinal aseptic meningitis is a rare complication of neuraxial anesthesia that may be clinically indistinguishable from bacterial meningitis at presentation.We report the case of an 18-year-old primigravida at approximately 38-39 weeks of gestation who underwent emergency cesarean delivery for acute fetal distress under spinal anesthesia with preservative-free hyperbaric bupivacaine and fentanyl.Within hours of the procedure, she developed somnolence followed by fever, confusion, neck stiffness, and photophobia.Cerebrospinal fluid (CSF) analysis revealed marked neutrophilic pleocytosis and substantial protein elevation with preserved glucose, while Gram staining and cultures remained negative.Empirical antimicrobial therapy was initiated because bacterial meningitis could not initially be excluded.During the subsequent course, the patient developed transient binocular diplopia with limitation of upward gaze.Brain and orbital magnetic resonance imaging showed no explanatory abnormalities.An extensive microbiological investigation, including bacterial, mycobacterial, fungal, and viral testing, remained negative.Although herpes simplex virus type 1 was detected from a subsequently appearing perioral lesion, CSF herpes simplex virus polymerase chain reaction was negative.Repeat lumbar puncture on day 10 demonstrated nearcomplete normalization of CSF findings, and the patient achieved complete neurological recovery, including resolution of diplopia.The close temporal relationship with spinal anesthesia, repeatedly negative microbiological investigations, normal neuroimaging, rapid CSF normalization, and favorable neurological outcome supported the diagnosis of post-spinal aseptic meningitis.This case emphasizes the importance of initially treating suspected post-neuraxial meningitis as a bacterial infection while considering aseptic meningitis when microbiological studies remain negative and the subsequent clinical and biological course supports a noninfectious inflammatory process.