A 66-year-old Caucasian man was admitted to the ICU for altered mental status and respiratory failure. Upon review of his symptoms, he was positive for headache and right ear stuffiness during the preceding week. Head CT obtained before lumbar puncture showed pneumocephalus (arrows) in areas overlying mastoids, petrosal bone without midline shift (Picture 1, 2) and mastoid inflammation. Cerebrospinal fluid (CSF) analysis was suggestive of bacterial meningitis and confirmed by CSF culture which grew streptococcus pneumoniae resistant to ceftriaxone. Ear exam showed right middle ear effusion with air bubbles and intact tympanic membrane. He was treated with vancomycin, moxifloxacin and decadron with subsequent improvement. Repeat MRI two days later showed resolution of the air pockets (Picture 3). He was discharged after completion of ten days of intravenous antibiotics.Pneumocephalus is caused by the presence of air or gas within the cranial cavity. Pneumocephalus as a complication of otogenic meningitis is very rare and the literature is limited to only a few case reports. All of the reported cases of pneumocephalus secondary to streptococcal meningitis have had concomitant mastoiditis, as in our case (1). The patho-

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