Meningococcal Pneumonia and Empyema HENRY S. SACKS, Ph.D., M.D. New York, New York A case of pneumonia and empyema caused by Neisseria meningitidis is described in which the diagnosis was initially missed. Meningococcal pneumonia and empyema are rare. It is important to recognize unusual manifestations of meningococcal infection promptly because of the risk of spread to contacts including health care personnel and other pa- tients. Neisseria meningitidis, as its name suggests, is associated by most physicians with meningitis, and with overwhelming septicemia. infection of the respiratory tract is known to occur [ 1,2], but the organism is not commonly considered in the differential diagnosis of pneumonia, and empyema is extremely rare. We recently saw a patient in whom the organism was cultured from blood and pleural fluid and in whom the diagnosis was initially missed. CASE REPORT From Mount Sinai School of Medicine of the City University of New York, New York, New York. Requests for reprints should be addressed to Dr. Henry S. Sacks, Clinical Trials Unit, Mount Sinai Medical Center, 1 Gustave L. Levy Place, New York, New York 10029. Manuscript accepted November 19, 1984. An 82-year-old woman was admitted in August 1982 to Mount Sinai Hospi- tal after falling at home. She had had several days of right upper quadrant and right anterior chest discomfort but denied headache, dizziness, chills, sweats, cough, sputum production, or shortness of breath. On examination, she was weak and lethargic but oriented. Her tempera- ture was 103.4OF, pulse 100 beats per minute, respiratory rate 22 per minute, and blood pressure loo/50 mm Hg. Skin, head, eyes, ears, nose, and throat were unremarkable. The neck was supple. There were de- creased breath sounds and dullness at the right base. A grade I/VI soft systolic murmur was noted at the left sternal border. The abdomen was soft with a palpable spleen tip. Results of neurologic examination were normal. Admission laboratory values included hemoglobin 9.8 g/dl, hematocrit 29 percent, and white blood cell count 5,100/mm3 with 55 percent polymor- phonuclear leukocytes, 34 percent band forms, 6 percent lymphocytes, and 5 percent monocytes. The sedimentation rate was 90 mm per hour. Admission chemical values were normal except for a blood urea nitrogen of 32 mg/dl. Arterial blood gas values with the patient breathing room air were pH 7.45, oxygen tension 75 mm Hg, and carbon dioxide tension 22 mm Hg. Chest radiography showed a calcified tortuous aorta, enlarged heart, and right lower lobe infiltrate with effusion. Thoracentesis yielded turbid pleural fluid with pH 7.45, glucose level 32 mg/dl, lactic dehydrogenase level 1,162 units/ml, protein level 4.2 g/dl, white cell count 49,800/mm3 (96 percent polymorphonuclear leukocytes), and red cell count 135,000/mm3. Initial Gram stain of the pleural fluid revealed numerous polymorphonuclear leukocytes and what were interpreted as gram-positive diplococci. The patient began to receive penicillin, 600,000 units every six hours. She remained lethargic and intermittently febrile. On the third day of hospitaliza- tion, blood and pleural fluid culture specimens were reported to be growing 290 February 1986 The American Journal of Medicine Volume 80