Persistent Neutrophilic Meningitis in an Immunocompetent Patient after Basilar Skull Fracture: Case Report

A 47 year-old female presented after basilar skull fracture with persistent neutrophilic meningitis unresponsive to empiric broad-spectrum antibiotics. After more than weeks of intensive therapy, 4 hospitalizations and 3 relapses, Nocardia cyriacigeorgica was identified from cerebral spinal fluid. Induction therapy was begun with Ceftriaxone and trimethoprim-sulfamethoxazole (TMP-SMX) for 6 weeks followed by therapy with TMP-SMX and doxycycline for one year. The patient made a complete recovery without sequelae.Due to the difficulty in obtaining a microbiologic diagnosis, appropriate treatment in cases of persistent neutrophilic meningitis is often delayed leading to morbidity, This case highlights a number of the unique features of Nocardia meningitis and the importance of considering Nocardia infection as a cause of persistent neutrophilic meningitis even in immunocompetent patients.Persistent neutrophilic meningitis is a syndrome defined by: clinical meningitis (headache, altered sensorium, fever and/or meningismus) with neutrophilic cerebrospinal fluid (CSF) pleocytosis (differential containing >50% neutrophils), elevated protein and hypoglycorrhachia that persists for greater than 7 days despite appropriate empiric antimicrobial treatment [1]. Numerous infectious and non-infectious etiologies have been identified as causes of this syndrome including: saprophytic intracellular bacteria (eg. Nocardia, Actinomyces and Brucella), mycobacteria, fungi (eg. Candida spp., Aspergillus spp., zygomycetes, endemic fungi), connective tissue disease (eg. Lupus, adult Still's disease [2], central nervous system (CNS) vasculitides), chemical meningitis, intracranial tumors (eg. craniopharyngiomas), and hypersensitivity reactions [1,3]. In the majority of cases of persistent neutrophilic meningitis due to an infectious etiology, the syndrome is part of a multi-system disseminated process usually in an immunocompromised individual. The atypical nature of many of the organisms as