Rampant spread of infection in an afebrile immune-competent patient presenting with young-onset ischaemic stroke.

A 27-year-old healthy woman developed spontaneous right-sided orbital cellulitis, followed by left hemiparesis and cranial nerve palsies. MRI revealed underlying basal exudates and vasculitic infarction involving the pons and cerebellar peduncles, following which a cerebrospinal fluid examination confirmed acute bacterial meningitis. Although the patient remained afebrile, imaging revealed asymptomatic septic foci in bilateral lungs, empyema and pyelonephritis. Blood culture grew drug-resistant Klebsiella pneumoniae The case highlights the absence of fever in an immune-competent patient presenting with young-onset stroke secondary to meningitis. © BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.