A 50-year-old woman presented with headache, fever, lethargy and confusion. She had been taking amoxicillin for several days prior to presentation for worsening headache and presumed sinusitis. Her background history included hypertension, poorly controlled type 2 diabetes and a pineal tumour for which she was followed with regular brain imaging. In the emergency department, lumbar puncture showed a raised opening pressure of 52 cm H₂O, white blood cell count of 1200/mm³ and protein 600 mg/dl. Gram stain revealed gram positive cocci in chains and culture subsequently grew Streptococcus pneumonia.

Shortly after the diagnosis of meningitis was established, the patient provided additional history of a road traffic accident with head trauma two decades earlier. Seventeen years after the road traffic accident—that …