Bacterial meningitis is a severe infection that affects the meninges, the protective layers surrounding the brain and spinal cord, leading to inflammation. This condition is both serious and life-threatening, demanding immediate diagnosis and treatment.[1][2][3]  Acute meningitis can lead to various intracranial complications, including cerebrovascular accidents, brain edema, hydrocephalus, and hearing impairment. Additionally, it may result in systemic issues such as septic shock, adult respiratory distress syndrome, or disseminated intravascular coagulation. [⁴] While spinal cord dysfunction is typically a rare complication, it is more frequently observed in children but has also been documented in adults. [⁵]

Acute Transverse Myelitis (ATM) constitutes a rare neuroimmune condition characterized by inflammation of the spinal cord. The disorder is typically marked by the rapid onset of muscle weakness, disturbances in sensory function, and impairments in bowel or bladder regulation. (6). Although it primarily manifests in adults, its occurrence among children, especially those under the age of two, is notably less common. (7,8)

The causes range from spinal cord compression to ischemic infarction and acute myelitis. Compression may result from a spinal abscess or hemorrhage following a lumbar puncture, while infarction could stem from conditions such as vasculitis, shock, herniation, or arachnoiditis. Acute transverse myelitis, though uncommon, accounts for 1 to 4 cases per million annually as a cause of myelopathy.[9] We report a case of a 47-year-old gentleman with acute meningitis, who developed Acute transverse myelitis as a complication which was confirmed by magnetic resonance imaging (MRI) of the spine.

Case Report

A 47-year-old man from Damietta presented with a 3-day history of headache, fever, vomiting after then   neck pain and rigidity and disturbed level of consciousness. He was previously healthy and had no medical history in the past. He is married and is working as a carpenter. He is a smoker and nonalcoholic. He was admitted as a case of suspected meningoencephalitis. Initial laboratory tests in the Emergency Department showed a WBC count of 33,600/uL with 85% neutrophils, hemoglobin 11.2gm/dl, platelets 435,000/uL, Creatinine 1.3 mg l/dl, calcium 9.0mg l/dl, EBG normal. An ECG showed sinus tachycardia, chest x-ray was normal, head CT scan was normal.

An urgent cerebrospinal fluid (CSF) examination showed very tick CSF not flow in spinal needle and aspirated by syringe Purulent aspect with high white blood cell (WBC) of 114400 (90% neutrophils), very high protein of 140 g/L, very low glucose less than 10 g/L (<50% of serum glucose), and Gram stain and culture of CSF were negative. The CSF viral panel, tuberculosis (TB) smears and cultures, and TB polymerase chain reaction were negative. Radiological CT brain revealed normal and MRI revealed diffuse abnormal S1 of both temporal lobes involving mainly white matters and more the left side. It extends to involve most of left basal Anglia and mildly to right basal ganglia. It also extends to left cerebral hemisphere. It displays high signal on FLAIR and T2WI and low signal on TIWI   highly suggested encephalitis.

Based on the CSF findings as well as systemic signs, a presumptive diagnosis of Purulent meningococcal sepsis was made and Meropenem  (2 g every 8 hours I.V.) ,Vancomycin (1g every 8 houres)  and Dexamethasone given at the time of antibiotic administration, follow up labaratory as table (1) . On day 5 of admission, her impaired consciousness persisted; therefore, we decided to repeat lumber puncture  revealed marked decrease of WBC but still high and very low glucose ,after 8^th day the level of consciousness improved and temprature became normal .

Repeated CSF analysis because unusual purulent as follow up in a 5^th day ,9^th day ,20^th day and lastly in 25^th day before discharge   time showed improvement as in (Table 2). 

As the patient showed very slow recovery, the power in the lower limbs worsened to zero in 15^th days of admission; therefore, an urgent MRI spine was done which demonstrated Swollen upper dorsal cord with slight increased S1on T2W1, Finding is suggesting transverse myelitis. MRI brain was normal, consultation of neurological to follow up.

The patient was therefore considered disease-free in 25^th day and was committed to a neurology for monitoring transverse myelitis and rehabilitation center.

Figure 1: Routine peripheral blood test results.

Figure 2: Serial CSF reports during the course of illness.