Abdominal aortitis and aneurysm impending rupture during pneumococcal meningitis.

A 77-year-old woman presented to our emergency department in Brescia, Italy with fever, altered conscious state, and neck stiff ness. She was a heavy smoker, with hypertension and dyslipidaemia, and had had right-sided back pain for the previous 3 days. Head CT and chest radiograph were normal, whereas lumbar puncture and blood cultures revealed pneumococcal meningitis with bacteraemia. Antibiotic therapy with ceftriaxone (2 g twice daily) was started. The patient rapidly improved, with resolution of fever and substantial reduction of infl ammatory markers (white blood cell count dropped from 19·7 cells per mL to 14·9 cells per mL, and C-reactive protein dropped from 225 mg/L to 108 mg/L). However, 12 days after the patient was admitted to hospital, and less than a week after the initial clinical and biochemical improvement, she reported worsening backache , and the infl ammatory markers rebounded (white blood cell count to 19·8 cells per mL and C-reactive protein to 171 mg/L). Lumbar spine CT showed no signs of spondylodiscitis, but an enlarged abdominal aorta with signs of perianeurysmal infl am mation. The CT angiography done straight afterwards confi rmed the presence of an abdominal aortic aneurysm with signs of impending rupture (fi gure A). Mycotic aneurysm and microbial aortitis are un common entities that usually occur in people with under lying atherosclerotic vascular disease as a consequence of bacteraemic seeding on the abnormal aortic surface. The clinical presentation is often subacute, and the diagnosis often delayed or not made until after death. Streptococcus pneumoniae, despite being a common cause of bacteraemia, is seldom responsible for vascular seeding. Yet, pneumococcal aortitis should be ruled out in patients with sepsis at high risk of cardiovascular diseases presenting with typical symptoms of abdominal aortic aneurysm. The patient promptly underwent aorto-aortic homograft substitution. The patient recovered after surgery without any complications and returned home shortly thereafter. CT angiography done after 1 month, however, revealed the presence of an initial disease progression (fi gure B), but the patient refused any surgery. Since then, she has had strict clinical and radiological follow-up examinations without evidence of further worsening. After almost 12 months she is still alive and in a good clinical condition.