Complicated pneumococcal meningitis as the presenting illness in a patientwith HIV infection

Case report - A severe and complicated Streptococcus pneumoniae meningitis, prompting the diagnosis of a concurrent occult HIV infection, is presented . The initial finding of a remarkable lymphopenia suggested the study of T- lymphocyte subsets, which disclosed a very low CD4(+) cell count (below 60 cells/mu L). Subsequently, our patient tested positive at HIV serology, and showed an elevated plasma viral load. Despite a favorable in vitro suscept ibility profile of the isolated S. pneumoniae strain, and a timely and adeq uate antibiotic treatment (ceftriaxone and chloramphenicol, followed by tic arcillin-clavulanate plus netilmicin), our patient experienced a very slow clinical improvement, and suffered from permanent neurological sequelae, in cluding severe bilateral hypacusia of neurological origin. During the subse quent 18-month follow-up, a triple combination antiretroviral treatment obt ained a significant improvement of ail laboratory markers of HIV disease pr ogression. Comments - Although S. pneumoniae is a frequent and well-recognized pathoge n in the setting of HIV infection, only 25 cases of HIV-associated pneumoco ccal meningitis have been reported to date, none of them as the presenting illness of HIV disease. Our case report focuses on the potential occurrence of S. pneumoniae meningitis as the first manifestation of an occult, under lying HIV infection. Provided that HIV infection acts as a risk factor for invasive pneumococcal disease, the occurrence of such an illness should pro mpt a search for an underlying immunodeficiency, especially in the absence of concurrent systemic diseases. (C) 1999 Editions scientifiques et medical es Elsevier SAS.