group b streptococcal disease in nonpregnant adults especially diabetics has been on the rise in the last 20 years and may present as many different disease manifestations , . the reported annual incidence of group b streptococcus in nonpregnant adults in general population is between 4 and 7/100,000 . it is a rare , but serious cause of adult meningitis that can lead to neurological complications and case fatality . in this report , we describe an adult case of streptococcus agalactiae complicated by a hemorrhagic stroke and respiratory distress . to date , no literature has linked hemorrhagic stroke with group b streptococcal infection . we believe that this case represents the first case of hemorrhagic stroke with group b streptococcal infection . a 47 year - old caucasian female came to the emergency department with altered mental status , agitation , confusion , fever and respiratory distress of one - day duration . her family stated that she had been behaving oddly and was not responding to questions appropriately for the past 24  h prior to presentation . her past medical history included chronic sinusitis status post nasal polyp removal and diabetes mellitus type ii . she had no history of tobacco , alcohol or illicit drug use . on initial examination , the patient had a rectal temperature of 106.2  f , a heart rate of 141 beats per minute , a blood pressure of 107/59  mmhg , and a respiratory rate of 32 breaths per minute . the right upper quadrant was tender to palpation , distended and rebound tenderness was observed . laboratory findings included a chemistry panel with a sodium of 135  mmol / l , potassium of 3.3  mmol / l , chloride of 98 mmol / l , bicarbonate of 23  mmol / l , blood urea nitrogen of 12  mg / dl , creatinine of 0.6  mg / dl and glucose of 542  mg / dl . complete blood count included a white blood cell count of 35.1    10  cells / l with 95.7% granulocytes , hemoglobin was 12.1  mg / dl with an mcv of 75.5  fl , the hematocrit was 40.3% , platelets were 258,000/mcl . lumbar puncture revealed an opening pressure of 46  mm h2o and cerebrospinal fluid ( csf ) was cloudy and bloody in appearance . csf exhibited a wbc ( granulocyte ) count of 820/mm , a red blood cell count of 5500/mm , a glucose concentration of 177  mg / dl , a protein concentration of 672  mg / dl and gram stain showed gram - positive cocci in chains . four days into antimicrobial treatment and no change in mental status , a repeat ct of the head was performed and showed a 4  cm acute intracerebral hemorrhage in the right frontal convexity with surrounding edema and mass effect . patient was extubated after a week and was opening her eyes to verbal stimuli but not following commands . patient 's mental status did not improve , went in respiratory distress and was reintubated . a repeat head ct showed intraparenchymal hematoma increased in size and new 1.7  cm hematoma in the left frontal lobe , diffuse cerebral edema and a right to left midline shift . she developed a health care associated pneumonia for which she was treated and later discharged at her baseline mental status . invasive infections , in adults , however , have been on the rise . despite the common association with neonatal meningitis , adult cases with s. agalactiae infections are more common than neonatal cases due to successful screening measures . conditions included cirrhosis , history of stroke , breast cancer , decubitus ulcer , nursing facility residents and especially diabetes mellitus   as our patient had . our patient had uncontrolled diabetes and presented with a glucose level above 500  mg / dl . the patients uncontrolled diabetes put her at an increase risk of infection with group b streptococcus . meningitis is extremely rare , but case fatality is 2734% . in a study by domingo et al . this finding confirms the importance of uncontrolled diabetes in our case . out of the 12 patients , some of the complications included sepsis , coma , consumption coagulopathy , acute renal failure , acute respiratory failure , and rhabdomyolysis . our patient presented in respiratory distress and required intubation thus increasing morbidity in this patient . although domingo et al . found that several subjects had a distant foci of infection none was found in our patient . we believe that hemorrhagic stroke in group b streptococcus meningitis has not been documented before , making our patient 's complication of hemorrhagic stroke noteworthy . in contrast , other causes of bacterial meningitis like streptococcus pneumonia and neisseria meningitidis in adults have been associated with causing ischemic and hemorrhagic stroke . in fact , ischemic stroke is a well known complication of bacterial meningitis and is believed to be caused by vasculitis or vasospasm of the arterial vessels of the brain . intracranial hemorrhage is a less common complication but still important in acute bacterial meningitis although has never been documented in s. agalactiae meningitis . it is estimated that intracranial hemorrhage affects 29% of patients with bacterial meningitis , . in a study on intracerebral hemorrhage during acute bacterial meningitis , parenchymal hemorrhages were the most common . in our case report , we identified two different parenchymal hemorrhages in the frontal lobe . resistance to clindamycin and erythromycin is increasing and can be present in up to 20% of isolates . aminoglycosides have no activity when used alone against group b streptococcus but are synergistic when combined with ampicillin . in our patient we adjusted the antimicrobial regimen once the susceptibilities were established and gave a synergistic combination of ampicillin and gentamicin for duration of two weeks . patients presenting with comorbid conditions as well as neurologic and extra neurologic complications are common . in this case report , we link the first association of s. agalactiae meningitis and the development of hemorrhagic stroke . early recognition of infection , a search for a foci of infection and appropriate antimicrobial treatment are essential for successful management of group b streptococcus associated meningitis .
we report the case of a 47 year - old female with streptococcus agalactiae ( group b beta - hemolytic streptococcus ) meningitis complicated by hemorrhagic stroke . 
 the patient presented to the emergency department with altered mental status , agitation , confusion , respiratory distress and fever of one - day duration . 
 labs showed left shift leukocytosis . 
 csf exhibited a high white blood cell count with a predominant population of polymononuclear cells , high glucose and protein concentration . 
 csf cultures grew s. agalactiae . despite appropriate antimicrobial treatment , her mental status did not improve and head ct showed two hemorrhages , diffuse cerebral edema and a right to left midline shift . after completing the course of her therapy , her mental status improved and the patient was discharged .