title: Persistent neutrophilic meningitis in an immunocompetent patient after basilar skull fracture: case report.
abstract: BACKGROUND
  Persistent neutrophilic meningitis is an unusual form of chronic meningitis that is defined as clinical meningitis with a neutrophilic pleocytosis that persists for greater than 7 days despite empiric antimicrobial therapy. Although numerous disease processes can cause this syndrome, the majority of cases are due to opportunistic pathogens infecting immunocompromised hosts.
  
  
  METHODS
  A 47 year-old female presented after basilar skull fracture with persistent neutrophilic meningitis unresponsive to empiric broad-spectrum antibiotics. After more than weeks of intensive therapy, 4 hospitalizations and 3 relapses, Nocardia cyriacigeorgica was identified from cerebral spinal fluid. Induction therapy was begun with Ceftriaxone and trimethoprim-sulfamethoxazole (TMP-SMX) for 6 weeks followed by therapy with TMP-SMX and doxycycline for one year. The patient made a complete recovery without sequelae.
  
  
  CONCLUSIONS
  Due to the difficulty in obtaining a microbiologic diagnosis, appropriate treatment in cases of persistent neutrophilic meningitis is often delayed leading to morbidity, This case highlights a number of the unique features of Nocardia meningitis and the importance of considering Nocardia infection as a cause of persistent neutrophilic meningitis even in immunocompetent patients.
authors: Department of Medicine, Division of Infectious Diseases, University of California, San Diego, California, USA. jsgreen@ucsd.edu
authors: Jaime S
authors: JS
authors: Green
authors: Shira R
authors: SR
authors: Abeles
authors: Daniel Z
authors: DZ
authors: Uslan
authors: Sanjay R
authors: SR
authors: Mehta
references: J Clin Microbiol. 2007 Jul;45(7):2257-9
references: 17475753
references: Medicine (Baltimore). 1984 Nov;63(6):379-95
references: 6390082
references: J Clin Microbiol. 2008 Jan;46(1):265-73
references: 18003809
references: Gene. 1992 Jun 15;115(1-2):213-7
references: 1612439
references: J Infect Dis. 1983 Nov;148(5):861-7
references: 6355320
references: J Infect Dis. 2002 Feb 1;185(3):273-82
references: 11807708
references: J Orthop Trauma. 2009 Mar;23(3):232-6
references: 19516101
references: J Infect Dis. 1985 Jan;151(1):47-56
references: 3880799
references: Scand J Infect Dis. 2007;39(8):737-41
references: 17654355
references: J Med Microbiol. 2007 Apr;56(Pt 4):545-550
references: 17374898
references: J Clin Microbiol. 2006 Jan;44(1):280-2
references: 16390991
references: Clin Infect Dis. 1996 Jun;22(6):891-903; quiz 904-5
references: 8783685
references: Infection. 2010 Apr;38(2):89-97
references: 20306281
references: Rev Infect Dis. 1991 Jan-Feb;13(1):160-5
references: 2017617
references: Rheumatol Int. 2012 Dec;32(12):4031-4
references: 20495923
references: Infect Dis Clin North Am. 1990 Dec;4(4):747-67
references: 2277197
references: Antimicrob Agents Chemother. 1988 Dec;32(12):1776-9
references: 3072921
references: Infect Immun. 1985 Jan;47(1):135-41
references: 3880721
references: J Clin Microbiol. 2005 Sep;43(9):4895-7
references: 16145170
references: Scand J Infect Dis. 2006;38(6-7):545-8
references: 16798710