Unresponsive and Undiagnosed: A Journey Through SAG Meningitis and AOP Stroke

Document Type

Article

Publication Date

4-8-2025

Abstract

Objective: To report a case of Streptococcus anginosus (SAG) meningitis manifesting as Artery of Percheron (AOP) stroke, emphasizing need for early recognition and management. Background: SAG meningitis, though uncommon, is signifcant cause of brain infarcts and should be included in differential diagnoses. It can lead to serious complications including ventriculitis, brain abscesses, vertebrobasilar strokes, and acute hydrocephalus. Prompt recognition and treatment with intravenous antibiotics, and surgical drainage if needed, are essential for better outcomes. Design/Methods: Case Report Results: A 73-year-old female was brought to hospital in unresponsive state, following six days of headaches and fevers. Her blood pressure was 90/50 mmHg, and Glasgow Coma Scale was 4, necessitating intubation. Examination revealed comatose state, left gaze deviation, and no response to noxious stimuli in right extremities. Initial stroke assessments, including non-contrast CT, CT angiogram and perfusion, were unremarkable. Due to unknown last known well, she wasn't a candidate for thrombolytics. Bloodwork showed mild leukocytosis, diabetic ketoacidosis, and uremia. She was admitted to ICU and started on antimicrobials with meningitis coverage. Blood cultures grew SAG. CSF studies on day three suggested bacterial meningitis. CSF cultures, gram stains, and panels for meningitis/encephalitis and paraneoplastic syndromes returned negative, leading to discontinuation of antivirals. Although her metabolic issues improved, her neurological status declined. Long-term EEG revealed no seizures. MRI was not performed due to incompatible spinal nerve stimulator. Subsequent CT scans revealed evolving infarcts in left internal capsule, bilateral thalami, and midbrain. With no additional sources of infection identifed, and after discussions with family, she was transitioned to comfort care. Conclusions: AOP infarcts present a diagnostic challenge that demands strong clinical suspicion. To our knowledge, this is frst reported case of AOP stroke resulting from SAG meningitis. This case highlights importance of early recognition of stroke and its etiology, for timely intervention and improved patient outcomes.

Publication Title

Neurology

Volume

104

Issue

7 Supplement 1

First Page

P11-14.016

Comments

Annual Meeting of the American Academy of Neurology, AAN 2025 held 2025-04-05 to 2025-04-09 in San Diego, CA, USA.

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