Unusual Differential Diagnosis in Suspected Meningitis

An 87-year-old female patient presented as an emergency with fever and a 10-day history of progressive acute cephalalgia, neck pain, and nausea. Neurological examination was remarkable for marked meningism and pain on percussion of the roof of the skull. Laboratory tests showed significantly elevated inflammatory parameters (CRP: 200  mg/L, leukocytosis 11  /nL, but normal procalcitonin). Due to strong suspicion of meningitis, antimicrobial treatment was initiated (ceftriaxone, ampicillin, and aciclovir). However, cranial computed tomography and lumbar puncture were normal, as were associated diagnostic investigations. Magnetic resonance imaging and computed tomography of the cervical spine (Figure 1a) showed erosive changes to the dens of the axis with bone marrow edema, pannus formation, and embedded calcifications (arrowheads). In the absence of other joint pain and in view of the normal autoimmune serology and normal uric acid levels, crowned dens syndrome, a very rare manifestation of calcium pyrophosphate deposition disease (“pseudogout”), was ultimately diagnosed. Asymptomatic calcification of the triangular fibrocartilage complex (TFCC), a typical manifestation, was also visible on the X-rays of the hands (Figure 1b, see magnification). Etoricoxib and 30  mg oral prednisolone resulted in a rapid resolution of symptoms and signs of inflammation.

Figure

Magnetic resonance imaging and computed tomography of the cervical spine / X-rays of the hands

Philipp Dittert, Prof. Dr. med. Kay Geert Hermann, Prof. Dr. med. Gerd Rüdiger Burmester
Medizinische Klinik für Rheumatologie und Klinische Immunologie, Charité—Universitätsmedizin Berlin, [e-mail]

Conflict of interest statement: The authors state that no conflict of interest exists.

Translated from the original German by Christine Rye.

Cite this as: Dittert P, Hermann KG, Burmester GR: Unusual differential diagnosis in suspected meningitis.
Dtsch Arztebl Int 2021; 118. DOI: 10.3238/arztebl.m2021.0167