despite recent advances in antibiotic therapy and critical care , bacterial meningitis continues to have high rates of morbidity and mortality . possible causes of acute spinal cord dysfunction in those patients are spinal abscess , epidural hemorrhage , ischemia due to vasculitis and finally , myelitis . we present a case of pneumococcal meningitis in an immunocompetent adult patient treated with hypothermia . the disease course was complicated with acute severe myelitis and consequent paraplegia and loss of bladder control . in february 2009 , a previously healthy 63-year - old male was admitted to hospital for an abrupt onset of fever and progressive mental obtundation . at admission laboratory tests revealed a leukocyte count of 18.5  10/l ( neutrophils 91% , monocytes 7% and lymphocytes 3% ) . erythrocyte sedimentation rate was 80 per h. c - reactive protein was 75.5 mg / l and fibrinogen was 4.13 g / l . mmol / l , magnesium 0.5 mmol / l and phosphorus 0.43 mmol / l . mmol / l , potassium 3.0 mmol / l , chloride 97 mmol / l , urea nitrogen 5.0 mmol / l and creatinine 88 mol / l . cerebrospinal fluid ( csf ) examination revealed 200,000 white cells per cubic millimeter with 95% polymorphonuclear cells . g / l and lactate 15.9 mmol / l . treatment consisted of intravenous ceftriaxone ( 4 g per day ) and dexamethasone ( 48 mg / day ) for the first four days . penicillin - resistant ( prsp ) and ceftriaxone - sensitive streptococcus pneumoniae was cultured from csf . transcranial doppler ultrasonography ( tcd ) revealed absent diastolic blood flow velocities ( bfv ) in both the middle cerebral arteries ( mca ) . bfv in systole were 25 cm / s in the left mca and 23 cm / s in the right mca . pulsatility index ( pi ) was accordingly increased ( 4.3 and 3.4 , respectively ) . carbon - dioxide reactivity ( co2r ) using the breath holding method was significantly impaired [ breath holding index ( bhi ) was 0.80  normal values 1.03 = 1.65 ] . a bilateral increase in optic nerve sheath diameter ( onsd ) was found at admission ( 6.6 mm ) . mild therapeutic hypothermia ( 32 - 34 c ) for the next 72 h , accompanied with low doses of norepinephrine support was started immediately after tcd finding was obtained . hypothermia was induced by intravenous infusion of cold ( + 4 c - + 8 c ) isotonic saline and maintained with continuous veno - venous hemofiltration ( cvvhf ) by using a prismaflex ( gambro dasco s.p.a . , a marked reduction in onsd during hypothermia was noted as well as significant improvement of mean bfv in both the mca . in the week following hypothermia , the patient 's condition improved . on day 5 , the patient became alert and followed simple commands in spite of mild diffuse brain edema observed on follow - up brain ct scan . however , flaccid paraplegia with areflexia , a sensory level at t8 and loss of bladder control were noted . repeated lumbar puncture yielded only few drops of bloody - brown fluid shown to be inappropriate for analysis . magnetic resonance imaging ( mri ) of the spine revealed scattered multiple hyperintensive lesions of the thoracic medulla in t2-weighted image ( t2wi ) consistent with myelitis [ figures 1 and 2 ] . high - dose methylprednisolone ( 1 g / day iv for five days ) followed with total plasma exchange ( tpe ) ( seven exchanges , administered every other day , volume 50 ml / kg each ) were without any effect on the neurological deficit . sagital t1-weighted image shows scattered multiple intramedulary hyperintensities in the thoracic lumbar cord ( arrow ) axial t2-weight image at the level of th 8 shows central intramedullary hyperintensities that predominantly involve the gray matter ( arrow ) the patient was transferred to a rehabilitation center two months after the disease onset . at discharge from the hospital his gcs was 15 , glasgow outcome scale score ( gos ) 3 and karnofsky performance score 60% . acute spinal cord dysfunction is a very rare complication of community - acquired bacterial meningitis . thirty - two cases have been reported in the last 40 years and the great majority was in children ( 25/32 , 78.1% ) . most patients had permanent neurological deficit manifested by spasticity and weakness , walking difficulties and diverse sensory losses . a well defined truncal sensory level in our patient was recognized and therefore the possibility of cerebral lesions or peripheral inflammatory polyneuropathy was discarded . mri of the entire spine was made to rule out the presence of structural lesions or extradural cord compression . among other possible causes of early spinal dysfunction were vascular compromises ( including cerebral septic venous thrombosis with compromised venous drainage of the spinal cord ) or disseminated encephalomyelitis ( adem ) . however , there was no evidence of concomitant multifocal cerebral involvement and the finding of spinal mri dissolved our first concern - epidural or spinal hemorrhage during hypothermia . in a view of mri finding and absence of hypotension , we were also able to exclude the ischemic infarction . the extensive central intramedullary hyperintensities on t1 and t2wi mri and the clinical course of the disease were primarily compatible with myelitis [ figures 1 and 2 ] . unfortunately , a postcontrast t1 weighted image , the best field - wide imaging tool , was not done by mistake . we have not completely discarded the possibility of immune - mediated pathogenic mechanism of such neurological disorder despite prior dexamethasone and hypothermia treatment . therefore , we have commenced an additional immunosuppressive treatment with methylprednisolone and plasmapheresis . based on immunosuppressive treatment failure and timing of neurological deficit onset , it seems that the spinal cord damage in our patient was most probably caused by direct bacterial cytotoxic action .
pneumococcal meningitis represents the most severe community - acquired bacterial meningitis . the disease is frequently associated with various complications . 
 we present a case of pneumococcal meningitis in an immunocompetent adult patient treated with hypothermia . 
 the disease course was complicated with severe myelitis and consequent paraplegia which is an extremely rare complication of pneumococcal disease .