A 68-year-old Caucasian man was admitted 1 day after flying back from Madagascar to
Marseille, France. He was in remission from chronic lymphoid leukemia with no chemotherapy
for 6 months and had had unilateral purulent otorrhea for several days. At the time
of admission, our patient’s temperature was 38 °C and he presented with a stiff neck
and confusion. His left ear was painful and inflamed, and an examination revealed
pus without tympanic membrane perforation. A cranial computed tomography (CT) scan
showed evidence of a left mastoid infection without bone erosion, cholesteatoma or
brain abscess. Ear pus was sampled by Sigma-Transwab (Elitech France, Puteaux, France).
CSF was collected after a lumbar puncture and our patient received 300 mg/kg cefotaxime
and 20 mg dexamethasone 3], 4]. Relevant biological parameters included pancytopenia with 3.68 T/L red cells, a
hemoglobin level of 117 g/L, and 1.13 G/L leukocytes including 0.39 G/L lymphocytes
and 74 G/L platelets. Appropriate point-of-care (POC) tests excluded malaria, dengue
and Chikungunya viral infections 5].
Direct microscopic examination of the Gram-stained CSF revealed 930 polymorphonuclear
cells and 170 red cells per cubic millimeter, along with numerous Gram-positive cocci.
Our patient’s CSF contained 3.63 g/L total protein and 1.31 mmol/L glucose. S. pneumoniae antigen detection was positive (BinaxNOW, Alere, Jouy-en-Josas, France) 6] along with positive real-time PCR detection of S. pneumoniae Lyt-A and Ply-N genes with cycle thresholds of 33 and 34, respectively. POC real-time PCR detection
of enterovirus, herpesvirus, varicella-zoster virus and Neisseria meningitidis remained negative in the CSF 5]. CSF grew colonies on chocolate agar and 5 % sheep-blood agar (bioMérieux, Marcy
l’Etoile, France) after a 5-day incubation period at 37 °C under a 5 % CO
2
atmosphere. Colonies were identified as S. pyogenes by matrix-assisted laser desorption-ionization time-of-flight mass spectrometry (MALDI-TOF-MS)
with an identification score of 2.26 7]. Antibiotic susceptibility testing using the disk diffusion method found the S. pyogenes isolate to be susceptible (according to EUCAST guidelines) to amoxicillin [minimum
inhibitory concentration (MIC), 0.250 mg/L], ceftriaxone (MIC, 0.5 mg/L), rifampicin
(MIC, 0.052 mg/L), clindamycin (MIC, 0.4 mg/L) and doxycycline (MIC, 4 mg/L), but
resistant to erythromycin (MIC, 1 mg/L). S. pneumoniae was not cultured from the CSF, though both S. pneumoniae and S. pyogenes were cultured from the ear pus after 1-day and 2-day incubations at 37 °C and 5 %
CO
2
, respectively. Colonies were identified by MALDI-TOF-MS with identification scores
of 2.22 and 2.35, respectively. The ear pus S. pyogenes isolate exhibited the same antibiotic susceptibility pattern as the CSF S. pyogenes isolate. The antibiotic susceptibility of the ear pus S. pneumoniae isolate, tested by using the E-test method (BioMérieux), indicated in vitro susceptibility to penicillin (MIC, 0.012 mg/L), amoxicillin (0.016 mg/L), ceftriaxone
(0.016 mg/L), imipenem (0.004 mg/L) and vancomycin (0.250 mg/L). Susceptibility testing
to oxacillin, gentamicin, erythromycin, rifampicin, clindamycin and doxycycline by
using the disk diffusion method found the isolate to be susceptible to all these antibiotics.
One day after admission, our patient suffered epileptic seizures resistant to 1 mg
clonazepam. An electroencephalogram confirmed status epilepticus and our patient was
given sodium valproate and levetiracetam and was admitted to the intensive care unit.
Cefotaxime (18 gr/day) was intravenously administered with a syringe pump for 14 days
in association with dexamethasone the first day. Our patient eventually recovered
after 4 weeks of hospitalization. A follow-up at 4 months postdischarge found no sequelae.
The otolaryngologist prescribed long-term treatment with amoxicillin to prevent any
further otitis.