Case Presentation:

A 23–year–old Mexican male with no known medical history presented to the emergency department with headache, fever, nausea, vomiting and photophobia. He stated that he was well 1 week prior to admission. On examination, he was uncomfortable, with a fever of 102.8, and nuchal rigidity. Laboratory studies showed a leukocyte count of 20.6 with 95.5% neutrophils. Head CT scan was normal. Lumbar puncture yielded clear CSF with the following characteristics: leukocyte count of 2130 with a predominance of polymorphonuclear cells, total protein of 225 mg/dl, glucose of 39 mg/dl, and a gram stain that showed few white blood cells and no organisms seen. The patient was started on Ceftriaxone, Vancomycin, Ampicillin and Dexamethasone intravenously. On hospital day three, blood cultures were negative, but the CSF culture was positive for Klebsiella pneumonia that was sensitive to Ceftriaxone. Steroids and all other antibiotics were stopped and Ceftriaxone was continued for a total of 2 weeks. After learning the results of the CSF culture, an induced sputum sample and multiple stool samples were collected and sent for microscopic examination for ova and parasite identification. Strongyloides stercoralis larvae were present in the stool. However, serologic testing and sputum samples were negative. HIV testing was negative and diabetes mellitus was ruled out. The patient was discharged on hospital day 16 and had an uncomplicated hospital course.

Discussion:

Infections with K. pneumonia are usually hospital–acquired and occur primarily in immunocompromised individuals. In adults, bacterial meningitis caused by K. pneumonia is rare, but cases have been reported in Asia. In a Taiwanese case series, the proportion of K. pneumonia meningitis rose from 8% between 1981 and 1986 to 18% between 1987 and 1995. Infections with enterobacteriaceae, such as K. pneumonia, are also associated with strongyloidiasis. Strongyloides is a nematode that replicates itself within the host. Adult female lives within the small bowel mucosa where they deposit their eggs. These eggs hatch and the larvae migrate into the lumen where they are either excreted with feces, penetrate perianal skin or go through the colonic mucosa to the bloodstream. Gram negative organisms (GNO) may enter the blood through ulcerative bowel disease caused by strongyloidiasis resulting in bacterial meningitis. In this case, the cause of K. pneumonia meningitis is almost certainly due to migration of larvae. In a review of 38 reported cases of serious bacterial infections associated with Strongyloidiasis, 21 (55%) had meningitis. In the 20 patients with a positive CSF culture, K. pneumonia was the second most common cultured organism.

Conclusions:

The goal of this case report is to remind the medical community to think of Strongyloidiasis in those patients with GNO meningitis, especially in those from endemic areas.