A 78-year-old man with sudden-onset right-sided weakness and mutism had no history of fever, seizures, or headache. On examination, abulia, transcortical motor aphasia, and right dense hemiplegia were noted. Contrast-enhanced brain MRI suggested meningitis (figure 1) and ruled out stroke (figure 2). On CSF analysis, lymphocytic (94%) pleocytosis (163 cells/mm3), abundant Gram-positive cocci, and hyperproteinorrachy (48 mg/dL) with normal CSF:serum glucose ratio were noted. After 14 days of ceftriaxone plus vancomycin and recovery of hemiparesis (MRC 4/5), speech (improved fluency), and CSF–pleocytosis resolution (2 cells/mm3), the patient was discharged. Localized meningitis is rare. We found 2 reports: one stroke mimic1 and another associated with necrotizing vasculitis.2
Contrast-enhanced MRI T1 sequence shows localized unilateral meningeal enhancement on superior and middle left frontal gyri.
MRI shows axial diffusion-weighted imaging (DWI) (A) and fluid-attenuated inversion recovery (FLAIR) (B) sequences. There is increased FLAIR signal on prefrontal, superior, and middle left frontal gyri, without any corresponding changes on DWI.
Author contributions
Sergio A. Castillo-Torres: article concept and writing. Héctor R. Martínez: article concept and editing.
Study funding
No targeted funding reported.
Disclosure
The authors report no disclosures relevant to the manuscript. Go to Neurology.org/N for full disclosures.
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
Teaching slides links.lww.com/WNL/A760
- © 2018 American Academy of Neurology
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