A previously healthy 35-year-old man presented with altered mental status. One day prior to admission, the patient fell and landed on his back but sustained no noticeable injury. He complained of a sudden onset of severe headache associated with photophobia and nuchal rigidity.
The patient's temperature was 101.2° C. He was agitated and moved all 4 extremities spontaneously, but did not follow commands. Nuchal rigidity was prominent. The remainder of the physical examination findings were unremarkable. A lumbar puncture revealed purulent liquid with 26.63 × 109/L of white blood cells (7% bands, 92% segmented neutrophils, 1% monocytes), undetectable glucose, and 10.56 g/L of protein. Gram stain findings showed gram-positive cocci. The cerebrospinal fluid culture grew group B streptococcus (Streptococcus agalactiae); the patient's antibiotic regimen was changed to ampicillin and gentamicin, then to penicillin G after sensitivities returned. A midline tuft of hair and area of bluish discoloration with a 1-mm pit in the center was later found over the lumbosacral spine (Figure 1). A magnetic resonance image revealed a dorsal dermal sinus tract extending from the skin to the spinal canal at the level of L4. The cord was tethered with the conus at L4 (Figure 2). A culture of this tract grew Prevotella biva and Peptostreptococcus. The patient's neurologic status returned to baseline, and he was discharged on a regimen of intravenous ceftriaxone.
Reimer CM, Sharma G, Grelinger BA. Dermal Sinus Presenting as Group B Streptococcal Meningitis. Arch Neurol. 2001;58(5):820. doi:10.1001/archneur.58.5.820