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Introduction: We hope to stimulate discussion about the role of diagnostic lumbar puncture (LP) in suspected bacterial meningitis. Raised intracranial pressure (RICP) almost always accompanies bacterial meningitis and brain herniation can be precipitated by LP.

Aims and Methods: A 10-year-old girl presented with severe progressive headache, photophobia, vomiting, neck stiffness but no fever, rash. Past medical history included pneumococcal septicaemia with meningitis, at ages 5 & 8 years respectively with full recovery. Immunodeficiency screen was negative.

During this admission, there were no signs of RICP. LP revealed purulent CSF with gram-positive cocci (Pneumococcus serotype F7). One hour post LP she collapsed with generalised extensor posturing and cyanosis, requiring ventilation. CT head post-LP was reported normal. She subsequently developed asymmetric pupils. MRI brain showed tonsillar herniation with patchy infarction of lower brain stem, cerebellum, upper cervical cord with early hydrocephalus. Emergency foramen magnum decompression with ventricular drainage was performed. She regained consciousness but was paralysed below mid-pontine level with bilateral facial/bulbar palsies, respiratory failure, flaccid quadriplegia and absent sensory/autonomic function. One year on she is ventilator dependent with no significant improvement in function.

Discussion:  We highlight the need for caution before diagnostic LP in bacterial meningitis. Rapidly worsening headaches and vomiting may reflect RICP even without clinical signs. Normal CT brain does not exclude RICP. In suspected bacterial meningitis, empirical treatment should be started after blood cultures until neurological status is confidently ascertained. CSF microbiological analyses are good proxies at a later, safer time.

Rapidly progressive headaches, lumbar puncture in bacterial meningitis