Successful Management of Acute Streptococcal Meningoencephalitis Complicated by Bilateral Third-Nerve Palsies, Wall-Eyed Bilateral Internuclear Ophthalmoplegia, Blindness, and Deafness: Case Report

Amitouj S Sidhu; Charles E L Walker; Thomas D Riisfeldt; Peter J Tweedie; Natasha Gerbis; Emily J Sutherland; Neil G Simon; Lucy K Somerville; Ross Bradbury; Raymond Cook; Jonathon Parkinson; Robert Goetti; Ian C Francis

doi:10.1159/000538821

Successful Management of Acute Streptococcal Meningoencephalitis Complicated by Bilateral Third-Nerve Palsies, Wall-Eyed Bilateral Internuclear Ophthalmoplegia, Blindness, and Deafness: Case Report

Case Rep Ophthalmol. 2024 May 8;15(1):423-429. doi: 10.1159/000538821. eCollection 2024 Jan-Dec.

Authors

Amitouj S Sidhu^{1

2

3}, Charles E L Walker^{3

4}, Thomas D Riisfeldt⁵, Peter J Tweedie², Natasha Gerbis⁵, Emily J Sutherland⁵, Neil G Simon⁵, Lucy K Somerville⁶, Ross Bradbury⁷, Raymond Cook⁸, Jonathon Parkinson⁸, Robert Goetti⁹, Ian C Francis^{2

10

11}

Affiliations

¹ Department of Ophthalmology, Westmead Hospital, Sydney, NSW, Australia.
² Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.
³ Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.
⁴ Department of Ophthalmology, Royal North Shore Hospital, Sydney, NSW, Australia.
⁵ Department of Neurology, Northern Beaches Hospital, Sydney, NSW, Australia.
⁶ Department of Infectious Diseases, Northern Beaches Hospital, Sydney, NSW, Australia.
⁷ Department of Infectious Diseases, Dubbo Base Hospital, Dubbo, NSW, Australia.
⁸ Department of Neurosurgery, Royal North Shore Hospital, Sydney, NSW, Australia.
⁹ Department of Radiology, Northern Beaches Hospital, Sydney, NSW, Australia.
¹⁰ Department of Ophthalmology, Prince of Wales Hospital, Sydney, NSW, Australia.
¹¹ Department of Ophthalmology, Northern Beaches Hospital, Sydney, NSW, Australia.

Abstract

Introduction: Streptococcal meningoencephalitis (SME) is a rare, and frequently lethal, acute infection, and inflammation of the central nervous system parenchyma, with associated meningeal involvement. Bacterial meningoencephalitis is generally associated with high rates of morbidity and mortality, despite available antimicrobial and corticosteroid treatments. While Streptococcus pneumoniae is well recognised to cause bacterial meningitis, direct extension into the central nervous system parenchyma is rare.

Case presentation: A previously well 49-year-old man presented with sudden onset severe headache, fevers, neck stiffness, and reduced consciousness. The manifestations of SME in this patient were bilateral pupil-involving third-nerve palsies, wall-eyed bilateral internuclear ophthalmoplegia (WEBINO), bilateral blindness, bilateral deafness, a right lower motor neuron facial palsy, and upper motor neuron signs in his limbs. Initially, a partial response to high dose intravenous antibiotics occurred, but with administration of intravenous corticosteroids, further substantial resolution of the patient's neurological and neuro-ophthalmological deficits occurred.

Conclusion: This case highlights the benefit of multidisciplinary diagnostic and therapeutic interventions in a case of SME complicated by bilateral pupil-involving third-nerve palsies, WEBINO, bilateral blindness, bilateral deafness, a right lower motor neuron facial palsy, and upper motor neuron signs. It appears to be the first reported case of SME with this rare collection of neuro-ophthalmological abnormalities.

Keywords: Antibiotics; Corticosteroids; Cranial nerve palsies; Streptococcal meningoencephalitis; Wall-eyed bilateral internuclear ophthalmoplegia.

Publication types

Case Reports

Grants and funding

The authors received no financial support for the research, authorship, and/or publication of this article. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.