Case Presentation: A 70-year-old woman with history of hypertension, asthma, and vertigo presented with acute onset of confusion and slowed speech in the setting of worsening headache, neck stiffness and paralysis of bilateral lower extremities for three days. Her headache was described as bitemporal with burning sensation, worsened by bright light and neck movement, similar to previous vertigo exacerbation. She also endorsed bilateral hand tremors, blurry vision and chills. She denied any sick contacts or recent travels. On presentation, she was febrile to 100.4F and tachycardic at 104bpm. Physical examination demonstrated non-fluent speech with intermittent breaks and stuttering; left facial droop; bilateral intention tremors in upper extremities; 2/5 motor strength in bilateral lower extremities; pronator drift on the left side; dysdiadochokinesia in left upper extremity; positive Brudzinski’s sign but negative Kernig’s sign. Given concern for acute cerebrovascular accident (CVA), CT and MRI brain were performed but both were negative for acute intracranial process. Laboratory results were notable for WBC of 12.8k/uL but otherwise unremarkable. Lumbar puncture (LP) was performed, and she was started on empiric broad spectrum antibiotics for suspected bacterial meningitis. CSF analysis revealed a clear fluid with protein 206 mg/dL, glucose 54 mg/dL, RBCs 110, and total nucleated cells 205 with neutrophil predominance. HIV, COVID-19 PCR and IgG, West Nile PCR, Strongyloides Antibody, and HSV 1/2 PCR were negative. Ultimately, both blood and CSF cultures isolated Pasteurella multocida and her antibiotic regimen was switched to ampicillin for total 4 weeks. Upon further questioning, she reported close contact – kissing and licking -with her cat Pumpkin who had been exhibiting symptoms of vomiting and lethargy. Throughout hospitalization, she continued to improve on symptoms with regaining of her strength and speech and Pumpkin was eventually taken to the veterinary for treatment.
Discussion: Pasteurella multocida is a common cause of local infection after an animal bite but is an extremely rare cause of adult meningitis. A history of recent animal contact is strongly associated in approximately 90% of all cases, with licking of mucus surfaces or injured skin being most common. Clinical symptoms are characteristics of bacterial meningitis, with fever, headache, nuchal rigidity and confusion. Concurrent bacteremia is present in about 60% of the cases. Our patient presented with a constellation of symptoms including headache, neck stiffness as well as significant focal neurological deficits (flaccid paralysis, dysphagia and intention tremors). She had no predisposing factors such as immune compromise, cirrhosis or recent neurosurgical intervention, which are commonly reported in P. multocida disseminated infection. Due to the rarity of the disease, it can be misdiagnosed as CVA, brain abscess or complex migraine. Empiric antibiotic therapy should be initiated promptly as the mortality could be as high as 25% if not treated in a timely manner.
Conclusions: This case highlights the importance of a detailed history in elucidating a cause of unusual infections in patients with prior animal contact, regardless of their immune status as delay in diagnosis can lead to significant mortality and potential for re-infection.