A previously healthy child with meningococcal meningitis developed a cerebellar abscess detectable only on magnetic resonance imaging despite a normal computed tomography scan.
In this case report, published in Cureus, researchers described an 11-year-old male who presented with one day of fever, abdominal pain, vomiting, and irritability, followed by rapid neurological decline requiring endotracheal intubation and intensive care. Cerebrospinal fluid analysis showed 2,300 white blood cells per microliter with 98% neutrophils, elevated protein at 2.23 g/L, and low glucose at 0.67 mmol/L. Polymerase chain reaction confirmed Neisseria meningitidis, establishing meningococcal meningitis.
Initial noncontrast computed tomography of the brain was unremarkable. However, given the atypical clinical course and lack of expected improvement with empiric antimicrobial therapy, magnetic resonance imaging (MRI) was performed on day 2. MRI revealed focal parenchymal changes in the left cerebellar hemisphere consistent with a forming cerebellar abscess, without hydrocephalus or mass effect.
Clinical Course and Treatment
The patient’s clinical course improved with continued antimicrobial therapy. He was extubated by day 3. By day 4, vasopressor support was stopped, and invasive lines and supportive devices were removed, with ongoing neurological improvement. By day 5, the patient was afebrile with improving inflammatory markers, and was transferred out of intensive care. A repeat brain MRI on day 6 demonstrated interval evolution of the left cerebellar abscess with surrounding edema but no mass effect. On day 7, the case was reviewed by a multidisciplinary team, which recommended completion of a 21-day course of intravenous ceftriaxone.
By 26 days postdischarge, the patient had normal clinical and neurological findings, and follow-up brain MRI demonstrated interval resolution of the cerebellar abscess without concerning features. At approximately 10 weeks postdischarge, further outpatient review confirmed continued clinical well-being with no neurological complaints.
Brain abscess is reported in fewer than 1% of invasive meningococcal infections and is rarely described in pediatric patients, particularly outside the neonatal period. The researchers noted that previously reported cases typically involved multiple supratentorial lesions, whereas this case demonstrated an isolated cerebellar abscess in an older child—a presentation not previously described in this age group.
The report highlights diagnostic limitations of computed tomography, which may appear normal in early cerebritis or posterior fossa pathology. In contrast, MRI—particularly with diffusion-weighted imaging—is more sensitive for detecting early parenchymal infection and monitoring lesion progression.
Management was nonoperative, guided by multidisciplinary consensus. Surgical drainage was not pursued due to the small lesion size, absence of mass effect, and favorable clinical trajectory. Serial MRI was used to guide continued medical management.
Study Limitations
Limitations included the absence of meningococcal serogroup data, lack of complement testing, and limited long-term neurodevelopmental follow-up. Audiological assessment was also not formally performed, although hearing loss is less frequent in meningococcal compared with pneumococcal meningitis.
The researchers concluded that “early recognition, targeted antimicrobial therapy, and serial MRI monitoring can lead to favorable outcomes without surgical intervention,” emphasizing the need for heightened clinical suspicion when patients with meningitis show persistent or atypical neurological findings.
Source: Cureus
Disclosures: The researchers reported no financial conflicts of interest.