An 84-year-old woman with new onset mutistic behaviour and a fever of 40°C was found to have marked neck stiffness without any focal abnormalities. There was no immunosup-pressive status. The cranial CT showed intracranial air in the posterior fossa (Figure 1A). Cerebrospinal fliud revealed a granulocytic pleocytosis (l,057/mul) with considerably elevated protein (7,080 mg/l) and lactate (14.4 mmol/l). The microbiological tests confirmed gram-positive diplococcae. Intensive care management and antibiotic therapy (ceftriaxone and ampicillin) was implemented. Examination of the ears showed moderate right-sided mastoiditis. Conservative treatment was advised and the patient recovered within 3 weeks.
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