A febrile old man with xanthochromic hypoglycorrhachia.

Meningitis is a commonly seen disease in the daily practice of emergency departments. Cerebrospinal fluid (CSF) examination including Gram stain and culture are crucial for identifying between bacterial and viral meningitis and should be completed prior to antibiotic administration. Hypoglycorrhachia is one of the certain independent predictors of bacterial meningitis.

A 69-year-old male having a past medical history of alcoholism and liver cirrhosis presented to the emergency department with intermittent fever and chills for one day. Sudden onset of a tonic-clonic seizure for a few minutes with agitation, and neck stiffness on physical examination were noted. Lumbar puncture was performed and xanthochromic turbid cerebrospinal fluid (CSF) was retrieved. CSF analysis showed pleocytosis with a white blood cell count of 4608/cm²; the neutrophil-to-lymphocyte ratio was 96:4. The CSF also showed extreme hypoglycorrhachia (4 mg/dL) and high protein levels (865 mg/dL) were noted. Bacterial meningitis was diagnosed. The CSF yielded Klebsiella pneumoniae on the third day of admission. After 4 weeks of meropenem complete treatment, the patient recovered uneventfully without any neurological deficit and was discharged one1 month later.

Hypoglycorrhachia is one of the certain independent predictors of bacterial meningitis. Elevated CSF protein over 150 mg/dL may turn normal crystal-clear CSF into yellowish or turbid CSF. Aerobic Gram-negative bacteria like Klebsiella species are uncommon community-acquired pathogens and are more likely to occur after neurosurgical procedures complicated with pyogenic liver abscess and septic endophthalmitis. The appropriate antibiotic should be monitored and adjusted clinically.

In febrile patients, epileptic episodes may hint towards an inflammatory process in the central nervous system. Grossly turbid and xanthochromic CSF with hypoglycorrhachia raise the concern for bacterial meningitis. Adequate antibiotic adjustment according to CSF culture results can also lead to the successful outcome without neurologic deficits.