[An autopsied case of purulent meningitis associated with ocular flutter]

We report a 72-year-old autopsied case of purulent meningitis associated with ocular flutter. She was admitted to our hospital because of disturbances of consciousness and fever. Physical examination revealed fever, tachycardia, and tachypnea. Neurological examination showed disturbance of consciousness (Japan Coma Scale 30), agitated state, anisocoria, sluggish and fixed reaction of pupils to light, and nuchal stiffness. Routine blood examination showed leukocytosis, thrombocytopenia, positive CRP, and elevated myocardial enzymes. Cerebrospinal fluid revealed pleocytosis with predominant leukocytes, elevated protein, and decreased glucose (22% of blood glucose), and Streptococcus pneumoniae was proved in culture. Brain CT scan revealed no abnormal findings. Electrocardiography showed tachycardia, left axis deviation, and elevated ST segment in aVF, and V3-V6. Ultrasonic echocardiography revealed slight hypokinesis of the left anterior wall, septum, and apex. She was diagnosed as having purulent meningitis, myocarditis, probable encephalitis. Thus, antibiotics, acycrovir, glycerol, and aspirin were administrated. But her respiration deteriorated and ocular flutter was observed for 15 minutes. After that, She required artificial ventilation and eventually died after 29 hours the admission to our hospital. Pathological examination revealed leukocyte accumulation in the arachnoid space of the derebral surface, especially frontal and parietal lobes. Uncal herniation was not observed. The brainstem and cerebellum were histologically within normal limits. These findings suggest that ocular flutter observed in this patient was caused by functional damage of the brainstem.