Acute Bacterial Meningitis Complicated by Brain Herniation Shortly after Lumbar Puncture: A Case Report

INTRODUCTION: Brain herniation is a known complication of acute bacterial meningitis. Brain computed tomography (CT) is requested before the lumbar puncture (LP) to rule out increased intracranial pressure. Delay in antibiotic administration, secondary to brain CT, leads to a poor clinical outcome.

CASE PROFILE: A 10-year-old boy, who had a history of skull fracture and pneumococcal meningitis, was presented to emergency room (ER) with a history of fever, headache and vomiting for 2 days. Clinically, he was fully conscious and his vital signs were stable, with positive meningeal signs. Other systemic examinations were normal. Brain CT was normal before LP. LP suggested meningitis in the form of leukocytosis with low glucose and high protein. Antibiotics were adminestered after LP. Two hours after LP, the patient had deteriorations in the level of consciousness; respiratory arrest was followed by a coma. Brain CT was repeated which showed cerebellar herniation and subarachnoid hemorrhage. Neuroprotective strategy was performed without improvements. Blood and CSF cultures showed pneumococcal growth. After one week, brain death was confirmed.

CONCLUSION: Brain herniation is a severe complication of bacterial meningitis. Clinical findings are the best indicators to delay LP and predict the risk of herniation. Normal brain CT does not necessarily mean LP is safe. Early antibiotic administration improves mortality and morbidity. Unnecessary CT before LP leads to a delay in antibiotic administration and poor outcome.