Awais Khan

TMC Health Medical Education Program,
United States of America

Abstract Title: Chronic CSF Rhinorrhoea Presenting as Acute Meningitis

Biography:

Dr. Awais Khan completed his Transitional year at Merit Health Wesley, Hattiesburg, MS and is currently a PGY-2 Internal Medicine resident at Tucson Medical Center, Tucson, AZ. His academic interests include infectious disease, host immune responses, and antimicrobial stewardship, and he intends to pursue fellowship training in infectious disease.

Research Interest:

Introduction: Acute pneumococcal meningitis is a neurologic emergency with significant morbidity and mortality. Although sinusitis is a recognized risk factor, structural skull base defects with occult cerebrospinal fluid (CSF) leak are an underrecognized pathway for intracranial infection. Case Presentation: A 51-year-old female with a history of hypothyroidism and obesity presented to ER with acute fever, chills, severe headache, ocular fullness, sinus and dental pain, bilateral ear pain, neck pain, nausea, and generalized weakness that began during air travel and worsened over one day. She also reported viral upper respiratory infection resolved one week prior. On presentation, she was tachycardic, tachypneic and febrile (102.4 F), with an otherwise unremarkable physical examination. Initial laboratory studies showed no leucocytosis, normal lactic acid, negative respiratory panel. CT head showed near complete opacification of left sphenoidal sinus. Due to the severe, persistent headache and concern for meningitis, lumber puncture was performed and empiric IV vancomycin, ceftriaxone, acyclovir and dexamethasone were initiated. CSF analysis showed WBC 4502 cells/µL (neutrophil predominant), 76 red blood cells, elevated protein >200 mg/dL, and glucose of 48 mg/dL. CSF PCR was positive for Streptococcus pneumoniae. Further history revealed intermittent clear nasal drainage for five years previously attributed to allergic rhinitis. MRI brain demonstrated left temporal tip cerebritis and sphenoid sinus dehiscence through a pneumatized pterygoid plate into the middle cranial fossa, suggesting a skull base defect with CSF leak. ENT recommended continued IV antibiotics followed by outpatient endoscopic endonasal skull base repair after stabilization.

Discussion: This case highlights an uncommon cause of bacterial meningitis: occult skull base defects with chronic CSF rhinorrhoea. Intermittent clear nasal drainage may be misdiagnosed as allergic rhinitis, delaying recognition of a CSF leak and increasing the risk of intracranial infection. Early identification with appropriate imaging and multidisciplinary management is essential to prevent recurrent meningitis.