Pneumococcal Pneumonia Presenting as New-Onset Seizure

A febrile 65-year-old woman who had suffered a new-onset seizure was brought to the emergency department. The patient-a cigarette smoker-was not coughing and had neither chest pain nor a significant medical history. Her temperature was 39.4°C (103°F). She had nuchal rigidity and Kernig's and Brudzinski's signs of meningeal irritation. Lung auscultation revealed signs of right middle lung consolidation. Her white blood cell count was 1,200/µL. A chest film, seen here, showed a masslike density in the right midlung. The suspected diagnosis was a pulmonary neoplasm with possible bone marrow and intracranial metastasis, yet nonenhanced CT of the head revealed no pathologic changes. Cerebrospinal fluid examination showed evidence of bacterial meningitis, and latex examination demonstrated pneumonia caused by Streptococcus pneumoniae. This organism grew in blood and induced-sputum cultures.

The patient was treated with intravenous antibiotics and made a full recovery in 3 weeks. At that time, a second chest film showed resolution of the density. The patient has remained healthy throughout the ensuing 2 years.

Dr Samer Alkhuja of Greenwich, Conn, explains that pneumococcal pneumonia may present radiographically as a lobar or multilobar consolidation that resembles a pulmonary neoplasm. Nevertheless, the presence of fever and signs of meningeal irritation should direct further investigation toward an underlying infection, rather than a neoplastic process. Here the patient's seizure was related to meningitis.