What's the bug?: An unusual cause of bacterial meningitis in a patient with history of transsphenoidal surgery.

Bacterial meningitis is an increasingly rare disease that carries significant morbidity and mortality. We describe the case of a 38-year-old male with a past medical history of pituitary macroadenoma with prior endonasal surgeries on prednisone therapy daily for resultant hypopituitarism and juvenile myoclonic epilepsy on lamotrigine daily who was transferred to an academic tertiary emergency department due to concern for developing pituitary apoplexy. At the outside emergency department, the patient presented complaining of sudden onset severe headache. CT scan demonstrated residual pituitary mass but no additional findings. On arrival to our emergency department, the patient was altered and newly febrile. Physical exam was notable for the patient moving all extremities and opening eyes spontaneously but unable to follow commands with a positive Kernig's sign. Broad spectrum antibiotics, antivirals, and stress dosed steroids were started due to concern for meningitis, and Neurology and Neurosurgery were consulted. Repeat CT was obtained prior to lumbar puncture (LP). LP demonstrated bacterial meningitis, which later speciated to Streptococcus salivarius. The patient was admitted to the medical ICU and discharged with full neurologic recovery on hospital day 13. This case demonstrates the variable presentation of bacterial meningitis as the patient was not initially febrile or altered. Emergency physicians index of suspicion for meningitis should be increased with risk factors such as immunosuppression and history of transsphenoidal surgery, as in our patient. Our case is a unique case of Streptococcus salivarius meningitis that has been previously associated with primarily iatrogenic etiologies.