APURULENT MENINGITIS AS THE PRESENTING SY NDROME OF BACTERIAL-ENDOCARDITIS

Bacterial meningoencephalitis with very low leucocyte count in the cer ebrospinal fluid (CSF) (''apurulent' meningitides) is uncommon and car ries a severe prognosis. We report a case of apurulent meningitis as t he heralding syndrome of bacterial endocarditis. A 55-year-old men pre sented with headache, confusion and nuchal rigidity. The CSF contained 13 cells and masses of streptococci. CSF protein was markedly increas ed. Two presumably embolic cerebral infarctions developed. A systolic murmur not present at admission was noted, and the diagnosis of endoca rditis was confirmed by echocardiography. After a complicated course, the patient recovered almost completely. Endocarditis as the underlyin g cause in a patient presenting with meningitis may be easily overlook ed because symptoms and laboratory findings show considerable overlap. We conclude that if endocarditis is suspected, all CSF samples must b e examined microscopically and by culture even in those cases that mig ht be labelled ''aseptic'' by the cell count alone. If vascular compli cations compatible with embolic infarctions develop in a patient with bacterial meningitis, transesophageal echocardiography should be consi dered.