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The 6-year-old boy complained of nausea, vomiting and headache for one week. He received
medical treatment at local medical clinics initially, but his condition still persisted
without improvement. Progressed symptoms and fever were also noted after initial medical
treatment, and, he was transferred to our emergency department (ED) for further evaluation.
At the ED, the previous history of the patient was obtained from his family. This
boy had experienced one earlier episode of AOM in his young-infant stage and experienced
a single episode of acute sinusitis about 2 months prior to admission. Moreover, no
any history of skull trauma was noted before admission. However, the physical examinations
revealed general appearance as lethargy and neck stiffness with positive meningitis
signs (Brudzinski’s sign and Kerning sign). After admission, blood was sampled for
complete blood count (CBC) with differential count (DC) analysis, biochemistry, glucose
levels, and blood culture. Immediately lumbar puncture with CSF survey (CSF analysis,
bacterial culture, virus culture and CSF biochemistry test) was also performed. The
blood laboratory tests showed leukocytosis with shift to the left (white blood cell
(WBC) count: 29190/mm
³
, and bands: 4 %), and the results of CSF analysis revealed WBC count as 3240/uL with
predominant neutrophils as 91 %, glucose levels as 55 mg/dL, and total protein levels
as 160.5 mg/dL. Moreover, the gram stain of CSF showed Sptreptococcus Pneumoniae (Fig. 1), and antibiotics with vancomycin and cefotaxime were given immediately. The cultures
of CSF and blood both showed Sptreptococcus Pneumoniae 23 F. Based on the report of the sensitivity to antibiotics in the strain of 23 F, vancomycin was useful and given continuously for 14 days. To trace back his past
history, about 6 months ago, this pediatric patient suffered from bacterial meningitis,
and was admitted for survey and treatments. The CSF gram stain showed Sptreptococcus Pneumoniae. Both CSF and blood cultures also showed Sptreptococcus Pneumoniae 23 F. After complete antimicrobial treatment with vancomycin for 14 days, he was discharged
home without complication.

Fig. 1. Gram stain of the CSF showed Streptococcus Pneumoniae (black arrow) in the patient

To further survey the cause of recurrent bacteria meningitis in such short period,
we analyzed immunological functions of this boy, including complements and various
immunoglobulins. However, the results showed normal immunity. According to the previous
history of recurrent sinusitis for several weeks, we suspected that recurrent meningitis
may be due to a bony defect caused by chronic sinusitis. Sinus computed tomography
(CT) was performed but only right side maxillary sinusitis was noted without any bony
defect. Moreover, nuclear scan was arranged and performed for studying CSF leakage.
Notably, the results showed CSF leaked originating from the right petrooccpital region
into the middle ear (Fig. 2). Subsequent high resolution CT (HRCT) and magnetic resonance imaging (MRI) of bilateral
ears were both carried out. The HRCT reports showed focal enlargement of the right
facial nerve canal, erosion of the bony canal at geniculate ganglion and tympanic
segment with tiny high-density spots (Fig. 3) and the reconstruction HRCT showed multiple bony defect at petrous part of temporal
bone (Fig. 4). The MRI reports revealed multifocal bony destruction with CSF collection in the
right petrous ridge (near the Meckel cave and facial nerve canal at geniculate body
ganglion region), carotid canal and jugular foramen (Fig. 5). Eventually, CSF leakage to the right middle ear was confirmed and this may explain
the cause of the recurrent bacteria meningitis in this boy. Further surgical approach
for bony defect was suggested, but his family refused and asked for medical treatments.
Therefore, after complete antimicrobial treatments with vancomycin for 14 days, this
patient was discharged home, and received conjugated streptococcus pneumoniae vaccination
(Prevenar 7) by self-payment, which is not included in the program of our national
schedule vaccination at that time.

Fig. 2. Radioisotope cisternography showed CSF leak into right side middle ear area (red arrow)

Fig. 3. HRCT of the right side ear showed enlargement to facial nerve cannel (red arrow)

Fig. 4. Reconstruction in brain HRCT showed multiple bony destructions at the right side (black arrow) compared to the left side (red arrow)

Fig. 5. MRI showed CSF accumulation at right middle ear