Supplementary Material for: Successful management of Acute Streptococcal Meningoencephalitis complicated by bilateral third nerve palsies, Wall-Eyed Bilateral Internuclear Ophthalmoplegia (WEBINO), blindness and deafness: Case Report

Introduction Streptococcal meningoencephalitis (SME) is a rare, and frequently lethal, acute infection and inflammation of the central nervous system parenchyma, with associated meningeal involvement. Bacterial meningoencephalitis (BME) is generally associated with high rates of morbidity and mortality, despite available antimicrobial and corticosteroid treatments. While Streptococcus pneumoniae is well recognised to cause bacterial meningitis, direct extension into the CNS parenchyma is rare. Case Presentation A previously well 49-year-old man presented with sudden onset severe headache, fevers, neck stiffness, and reduced consciousness. The manifestations of SME in this patient were bilateral pupil-involving third nerve palsies, Wall-Eyed Bilateral Internuclear Ophthalmoplegia (WEBINO), bilateral blindness, bilateral deafness, a right lower motor neuron facial palsy, and upper motor neuron signs in his limbs. Initially, a partial response to high dose intravenous antibiotics occurred, but with administration of intravenous corticosteroids, further substantial resolution of the patient’s neurological and neuro-ophthalmological deficits occurred. Conclusion This case highlights the benefit of Multidisciplinary diagnostic and therapeutic interventions in a case of SME complicated by bilateral pupil-involving third nerve palsies, WEBINO, bilateral blindness, bilateral deafness, a right lower motor neuron facial palsy, and upper motor neuron signs. It appears to be the first reported case of SME with this rare collection of neuro-ophthalmological abnormalities.