a 35-year - old man was admitted because of headache , fever , nausea , vomiting , and a generalized seizure attack that had appeared 1 day previously . he had suffered from three other episodes of meningitis within the previous 4 years , each of which was preceded by a mild infection of the upper respiratory tract . a physical examination showed a fever of 39.5 , signs of meningeal irritation , and a stuporous mental state . a laboratory investigation revealed 14,600 leukocytes / mm , an erythrocyte sedimentation rate of 12 mm / hour , and c - reactive protein at 249 mg / l . csf was turbid and contained 149 leukocytes / mm ( 70% polymorphonuclear leukocytes and 30% lymphocytes ) , protein at 169.4 mg / dl , and glucose at 60 mg / dl ( serum glucose was 143 ) . serologic testing for human immunodeficiency virus , immunoglobulin ( ig ) g , iga , igm , and complement levels including terminal components ( c5-c8 ) produced normal findings . gram - positive diplococci were identified on csf gram staining , and csf culturing yielded s. pneumoniae . antibiotic therapy consisting of ceftriaxone ( twice at 2 g / day ) and vancomycin ( once at 2 g / d ) was initiated . however , a computed tomography scan of the paranasal sinus showed a bony defect in the right frontal base and a teme ( fig . 1 ) , and radioisotope ( ri ) cisternography showed radioactive foci in the right frontal base ( fig . brain magnetic resonance imaging revealed right - sided cortical lesions overlying the teme ( fig . 3-a ) , and that the left lateral ventricle was filled with small amounts of irregular debris on a diffusion - weighted image , indicating pyogenic ventriculitis ( fig . electroencephalography revealed spike - and - slow wave complexes with phase reversal in the right frontal regions ( fig . 4 ) . no bacterium was seen or cultured with gram staining and culturing of blood or urine . the fever resolved on the second day , and nuchal rigidity and brudzinski signs disappeared on the third day . the patient refused immediate neurosurgical repair of the anterior cranial fossa , and was discharged on the 16 day of hospitalization . he had completely recovered 2 weeks after discharge , and was free of any disease at a 2-year follow - up . in the present case , recurrent pneumococcal meningoencephalitis was associated with a teme without csf leakage evident either symptomatically or objectively . to our knowledge , this is the first report of a teme related to recurrent meningitis with no csf leakage . history taking , an otorhinolaryngological examination , and ri cisternography did not reveal a csf leak . the finding of the inward entry of s. pneumoniae into the csf without evident outward csf leakage suggests that the meningoencephalocele worked as a unidirectional gate , although the reason for the absence of csf leakage with the teme remained unclear since this was not confirmed histologically . the high - signal - intensity lesions in the overlying right frontal cortex and the electroencephalographic findings in fig . 3 and 4 confirmed a definitive diagnosis of meningoencephalitis rather than of simple meningitis . the prognosis of pneumococcal meningoencephalitis varies from a good recovery10 to mortality.2 steroids were added in a previous study,10 but they were not used in our patient . in a nontraumatic teme , an osseous defect might result from a failure of the germ layer to close.11 in addition to the present case of pneumococcal meningitis , there have been two reports of recurrent pyogenic meningitis with a nontraumatic teme : ( 1 ) a 12-year - old boy who presented with csf rhinorrhea and recurrent meningitis for 3 years,12 and ( 2 ) a 52-year - old man with csf rhinorrhea,13 in which staphylococcus aureus was cultured . here we present a case of recurrent pneumococcal meningoencephalitis with a nontraumatic teme but without an evident csf leak . this case suggests that recurrent bacterial meningoencephalitis can be associated with a teme even in the absence of clinically demonstrable csf leakage .
we report a case of recurrent streptococcus pneumoniae meningoencephalitis with a transethmoidal meningoencephalocele ( teme ) but without cerebrospinal fluid ( csf ) leakage.a 35-year - old man was admitted with s. pneumoniae meningitis . 
 he had suffered from four episodes of recurrent pneumococcal meningitis during the previous 4 years . 
 a computed tomography scan of the paranasal sinus showed the teme protruding through a bony defect of the right frontal base . 
 however , the patient did not have symptoms that could be attributable to csf leakage , and radioisotope cisternography did not identify a leak . 
 brain magnetic resonance imaging revealed cortical lesions overlying the teme , and electroencephalography revealed epileptiform discharges in frontal regions . 
 appropriate antibiotics therapy without steroids was given to improve his condition.the presented case suggests that even in the absence of clinically demonstrable csf leakage , an occult skullbase defect and its associated meningoencephalocele should be considered in patients with recurrent bacterial meningitis .