Pneumococcal meningitis without neck stiffness in a pregnant woman with diabetes mellitus

A 24-year-old pregnant woman was admitted at 32 weeks of gestation because of vomiting. She had a fever of 39.5°C and a white cell count of 23, 300 per cubic millimeter. She developed reduced consciousness without neck stiffness and her score on the Glasgow coma scale was 13. There were no signs of infection according to urinalysis, chest radiograph, computed tomography of the head or ultrasonography of the abdomen. Cerebrospinal fluid (CSF) and blood cultures yielded Streptococcus pneumoniae. As the patient became delirious, we sedated and managed her with a respirator. Antibiotics and glucocorticoids were administered to treat pneumococcal meningitis and bacteremia. On the second hospital day, C-reactive protein increased to 24mg per deciliter but this level decreased to 2mg per deciliter on the twelfth day. Cytokine concentrations in the CSF decreased as the patient recovered. She delivered a healthy boy at 36 weeks of gestation. This is a rare case of bacterial meningitis in which a basicranial bone defect from Wegener's granulomatosis was a cause of direct infection from the paranasal sinuses to the meninx. Diabetes mellitus caused the infection to spread.