To describe an unusual case of transverse myelitis (TM) presenting as a manifestation of Epstein-Barr virus infection superimposed on streptococcal meningitis. 

Transverse myelitis is an inflammatory disorder of the spinal cord characterized by rapidly progressive weakness, sensory deficits, and potential bowel and bladder deficits. Infections account for 6% of possible etiologies. Amongst those, streptococcus and Epstein-Barr virus (EBV) remain possible but rare causative agents. We report a challenging case of partial longitudinally-extensive TM in an immunocompetent patient who developed EBV reactivation during active streptococcal meningitis.

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A 39-year-old male presented with headache and altered mental status. Initial lumbar puncture revealed hypoglycorrhachia (<5 mg/dL), elevated protein (791 mg/dL), and pleocytosis (98% neutrophils). CSF and blood cultures returned positive for streptococcus pneumoniae and treatment with IV ceftriaxone was initiated. He developed urinary retention, flaccid quadriplegia, and areflexia. Spinal MRI with and without contrast demonstrated longitudinal multilevel intramedullary T2 hyperintensities throughout the cervical spine with extension to the upper thoracic spine without evidence of vascular insult. Repeat LP depicted positive EBV PCR and IgG antibody. Initiation of intravenous ganciclovir, along with daily dosage of 1g methylprednisolone, and five plasmapheresis sessions resulted in minimal clinical improvement.  A repeat MRI three weeks later demonstrated significant interval resolution of T2 hyperintensities throughout the spinal cord compared to the prior study. However, the patient remained paralyzed and was discharged to a long-term care facility. 

Although EBV and streptococcal meningitis have both been individually reported as rare causes of acute transverse myelitis, it is challenging in this case to definitively identify one parainfectious source. This peculiar case of pneumococcal meningitis and bacteremia in an immunocompetent young adult who developed longitudinally extensive TM shortly after being initiated on antibacterial treatment and had simultaneous EBV reactivation highlights the importance of considering rare pathogens and viral reactivation in critically ill patients.