A penny for your CSF - An Unexpected consequence of bottle recycling: Meningitis due to Leptospira and Streptococcus – a case report

Background Leptospirosis is a preventable zoonotic infection that can present with a wide spectrum of clinical features, ranging from mild flu-like illness to severe multi-organ dysfunction. Meningitis due to Leptospira is rare, and co-infection with Streptococcus pneumoniae has not been reported. Case Presentation We describe here a case of a 50-year-old male with schizophrenia and hypothyroidism who presented with seizures, jaundice, shock, and respiratory failure. Initial evaluation revealed severe metabolic acidosis, renal failure, transaminitis, and thrombocytopenia. Lumbar puncture showed xanthochromic CSF with lymphocytic predominance. Urine Streptococcus antigen was positive, and serum PCR confirmed Leptospira . The patient was treated with broad-spectrum antibiotics, later narrowed to intravenous penicillin G for optimal CNS penetration. He underwent mechanical ventilation, tracheostomy, gastrostomy, and hemodialysis, ultimately achieving a favorable recovery.Epidemiologic history revealed daily collection of discarded bottles in an area with high rodent exposure. Discussion: Leptospirosis, transmitted through contact with rodent urine, is underdiagnosed in the United States. In New York City, most reported cases occur in the Bronx. Our patient’s occupational exposure from bottle collection likely facilitated Leptospira infection. The concurrent pneumococcal infection may have delayed recognition of leptospiral meningitis. Conclusion: This case highlights the importance of thorough exposure history and broad diagnostic testing in atypical meningitis presentations, particularly when occupational or environmental risk factors exist.