Publication

Abstract : A 9-year-old developmentally normal girl presented with fever, headache, and vomiting. She had a history of head injury and intraparenchymal bleed (conservatively managed; Figure 1) 30 months back. This was followed by pneumococcal meningitis (first episode) within next 4 months without any history of impaired hearing, cerebrospinal fluid (CSF) rhinorrhea, and otorrhea. Examination at 9 years of age revealed signs of meningeal irritation without any other focal deficits. CSF was meningitic (4500 cells; 75% neutrophils; protein: 176 mg%, sugar: 42 mg%). CSF culture was sterile and screening for triple antigen (pneumococcus, Hemophilus, and Neisseria meningitidis) was negative. She was diagnosed with the second episode of meningitis and was empirically treated with ceftriaxone and responded well. She was evaluated for an underlying structural defect. High-resolution CT and MR cisternography revealed multiple bony fractures in anterior-ethmoid air cells and right lamina papyracea with encephalocele herniating through anterior-ethmoid air cells [Figure 2a and b]. She underwent endoscopic transnasal repair for the same and has been well since then.