A 20 year-old man presented to the emergency department with a 4-hour history of severe bifrontal headache, neck pain and vomiting associated with fever and a 1-week history of productive cough. About 5 months earlier he had been admitted to another hospital with Streptococcus pneumoniae meningitis. On presentation, the patient was found to have fever, tachycardia, nuchal rigidity, positive Kernig and Brudzinski signs and leukocytosis. Lumbar puncture revealed an elevated leukocyte count and neutrophilia and no detectable glucose, although Gram's staining of a sample of his cerebrospinal fluid (CSF) was negative. The patient's condition improved dramatically over 24 hours after empirical treatment with ceftriaxone, vancomycin and dexamethasone. Blood cultures eventually grew S. pneumoniae sensitive to penicillin.
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