Spinal cord infarction and tetraplegia–rare complications of meningococcal meningitis

Abstract

A previously healthy 25-yr-old female developed flaccid areflexic tetraplegia, with intact cranial nerve function, 36 h after the diagnosis of bacterial meningitis. Polymerase chain reaction studies of cerebrospinal fluid and blood were positive for Neisseria meningitidis, serogroup B. Magnetic resonance of the cervicothoracic spine revealed increased signal intensity and expansion in the lower medulla, upper cervical cord and cerebellar tonsils. Neurosurgical consultation recommended hyperventilation, dexamethasone and regular mannitol therapy rather than decompressive intervention. The clinical course over the following 12 days was complicated by the development of progressive central nervous and multisystem organ failure with disseminated intravascular coagulopathy. Autopsy revealed cerebral oedema with cystic infarction extending from the medulla to the upper cervical cord and cerebellar tonsils. Flaccid areflexic tetraplegia with spinal cord infarction has not been reported following bacterial infection in an adult. The clinical implications would suggest complete central nervous system evaluation of patients recovering from meningococcal meningitis, since spinal cord lesions, although uncommon, do occur. In those very rare situations where a patient develops significant peripheral neurological deficits, urgent magnetic resonance imaging is warranted, to rule out an infective focus or an underlying anatomical anomaly.

Brain death and the cervical spinal cord: a confounding factor for the clinical examination

“…[15][16][17][18][19][20][21][22][23][24][25] These reports have remarkable similarities: a patient with Spinal cord in brain death AR Joffe et al an altered level of consciousness has a lumbar puncture, and shortly thereafter has a respiratory arrest followed by high cervical spinal cord quadriplegia with variable partial later recovery. Two cases died and autopsy showed infarction of the upper cervical cord without evidence of arachnoiditis.…”

“…Two cases died and autopsy showed infarction of the upper cervical cord without evidence of arachnoiditis. 19,24 Three cases had MRI and this showed swelling or compression of the upper cervical spinal cord. [23][24][25] Several of the reports specifically mention that the findings were compatible with anterior spinal artery compression resulting in high cervical spinal cord injury.…”

“…19,24 Three cases had MRI and this showed swelling or compression of the upper cervical spinal cord. [23][24][25] Several of the reports specifically mention that the findings were compatible with anterior spinal artery compression resulting in high cervical spinal cord injury. 15,17,19 We identified nine cases reported of brain herniation without meningitis that resulted in quadriplegia ( Table 2).…”

“…11 Many case reports in the setting of sudden brain herniation both with and without meningitis show that permanent or partially reversible cervical spinal cord injury can occur, and the clinical, autopsy and MRI findings suggest this is due to direct compressive injury to the spinal cord, its arterial supply and its venous drainage. [15][16][17][18][19][20][21][22][23][24][25][26][27][28] Furthermore, the autopsy series of BD show that high cervical spinal cord injury is a common finding (56-100% of cases), and most likely due to compression of the upper cervical spinal cord and its blood supply during cerebellar herniation. [36][37][38] This is compatible with early pathological reports of BD in other languages that found necrosis of the upper cervical segments of spinal cord, 40,41 and with early cat and baboon animal models of BD showing demarcation at the C1/C2 cord segments.…”

Meningococcal meningitis with myelopathy: case report and review of literature

“…[1][2][3][4][5][6][7][8]. Majority of these cases are from the pre MRI era, some of whom underwent myelography which turned out to be normal (Table 1).…”