To report a unique case of bacterial myelitis secondary to Streptococcus Intermedius infection.

S. intermedius is a Streptococci viridans species which is a part of the oral cavity and gastrointestinal tract normal flora, like other S. angiosus species it can cause brain, epidural and subdural abscesses. It can rarely cause meningitis and cerebral venous thrombosis, however this is a unique case report of acute bacterial myelitis due to S. intermedius infection.

We report a case of a 58-year-old male who presented with rapidly progressive lower limbs weakness for four days associated with fecal and urinary retention and headcahe, he had no upper extremity symptoms except for a residual left upper extremity numbness secondary to an old stroke. He was afebrile with no systemic signs of infection, he was paraplegic with areflexia and sensory loss and no signs of meningeal irritation.

MRI thoracic spine showed extensive increased T2 signal extending from T4 to the conus. CSF analysis revealed an elevated WBC of 4,405 cells/µL (96% neutrophils), high protein (452mg/dl) and low glucose (20mg/dl) consistent with bacterial infection. Gram stain showed gram positive cocci with subsequent identification of S. intermedius, blood cultures were negative. He was treated with IV pulse steroids therapy for 5 days in addition to Vancomycin, Rifampicin and Metronidazole for 4 weeks with marked improvement in follow-up MRI and clinical status (power 4/5 bilaterally).

S. intermedius CNS infections usually happen with either local extension of mouth, head, neck and gastrointestinal infection, bacteremia or after surgical manipulation. However, these organisms can enter the circulation spontaneously and blood cultures are not consistently positive. Bacterial myelitis is empirically treated with the same regimens used for bacterial meningitis. S. Intermedius usually responds to Ceftriaxone and Vancomycin. Anaerobic coverage is suggested if there is a concern for abscesses as these tend to be polymicrobial.