The first patient was a 41-year-old previously healthy man who presented with 2 day history of fever, headache, vomiting, neck pain and behavioural change. He reared four pigs at home and had daily contact with them. On examination, he was confused and disorientated, with a Glasgow Coma Scale (GCS) 7/15, hypotensive with a blood pressure of 89/57 mmHg, and had meningeal signs, however there was no rash noted. He was intubated for airway protection, started on noradrenaline, ceftriaxone and acyclovir. Blood tests indicated leucocytosis (13.7 × 10
9 white blood cell/L), neutrophilia (12.63 × 10
9 neutrophils/L), lymphopenia (0.72 × 10
9 lymphocytes/L), elevated C-reactive protein (320 mg/L), and hypoalbuminemia (28 g/L). Contrast enhanced computed tomography of the brain and transthoracic echocardiogram were normal. Lumbar puncture done 12 h after admission and initial antibiotic administration showed an opening pressure of 27 cmH
20 and the cerebrospinal fluid (CSF) was noted to be cloudy with a protein level of 2.16 g/L, a glucose level of 1.98 mmol/L (concomitant serum glucose was 7.6 mmol/L), and 95 leukocytes/μL (30% neutrophils and 65% lymphocytes). CSF gram stain and culture did not reveal any organism however blood cultures after 3 h of incubation were positive for gram positive cocci in chains. Culture specimens were plated on blood agar and after 18 h of incubation in 37 °C under aerobic conditions, the growth showed alpha haemolytic colonies which were catalase negative. These colonies were identified using matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) VITEK® MS MALDI-TOF MS (bioMériux) as
Streptococcus suis with a 99.9% probability score. Antibiotic susceptibility testing was carried out according to the Clinical Science Laboratory Institute [
3] testing recommendation using the Kirby-Bauer method. The strain was sensitive to penicillin and ceftriaxone the minimal inhibitory concentration (MIC) of penicillin and ceftriaxone were identified by epsilometer test (E-test bioMériux) with an MIC <0.12 ug/ml and <1.0ug/ml respectively). The patient was extubated after 48 h and continued to make a good clinical recovery with antibiotics and completed a two week course of ceftriaxone. However, in the second week of admission he developed tinnitus with reduced hearing in both ear associated with vertigo, loss of balance and nausea. He was scheduled for a pure tone audiometry on clinic follow up upon discharge however defaulted his appointment and we do not have any record of permanent eighth nerve damage.
The second patient was a 44-year-old man, presented with a 2 day history of fever with chills and rigors associated with headache and vomiting. On examination he was alert and conscious with no signs of meningism. He had no fever on admission, the blood pressure was 124/68 mmHg and heart rate 81 beats per minute. Systemic examination was unremarkable. He worked as a butcher in local market handling pork and had injured his thumb while slaughtering a pig two days prior to onset of symptoms. Blood tests showed leucocytosis (35.4 × 109 white blood cell/L), neutrophilia (33.04 × 109 neutrophils/L), lymphopenia (0.70 × 109 lymphocytes/L), elevated C-reactive protein (226.8 mg/L), and hypoalbuminemia (29 g/L). Blood culture on admission and antibiotic susceptibility testing performed by methods described above was positive for Streptococcus suis which was sensitive to penicillin. Lumbar puncture performed 48 h after admission was normal with no white blood cells and normal glucose and protein. His echocardiogram also did not show any evidence of endocarditis. He completed two weeks of intravenous penicillin G and made complete recovery on discharge without any residual neurological or otological deficits.