Neurological examination revealed disorientation with no focal findings. The patient scored a 9 on the Glasgow coma scale. His temperature was 37.5℃, blood pressure was 160/98 mm Hg, pulse rate was 96 beats per min, respiratory rate was 22 breaths per min and oxygen saturation was 95% at room air. Lung auscultation revealed coarse crackles in the right whole lung fields.

Complete blood cell count showed a white blood cell count of 11.97×10³/µL (normal, 3.9~11.0×10³/µL), a hemoglobin concentration of 12.8 g/dL (normal, 13~18 g/dL), and a platelet count 155×10³/µL (normal, 140~440×10³/µL). The differential count showed neutrophils at 96.4%, lymphocytes at 2.7%. The C-reactive protein level was 38.5 mg/dL (normal, ≤0.3 mg/dL). His blood urea nitrogen was 51 mg/dL (normal, 8~20 mg/dL), creatinine was 1.31 mg/dL (normal, 0.6~1.2 mg/dL), albumin was 2.6 g/dL (normal, 3.8~5.1 g/dL), alkaline phosphatase was 200 U/L (normal, 3~120 U/L), aspartate aminotransferase was 43 IU/L (normal, 7~38 IU/L) and alanine aminotransferase was 21 IU/L (normal, 4~43 IU/L). In the arterial blood gas analysis, PaO₂ was 72.2 mm Hg, PaCO₂ was 24.6 mm Hg and oxygen saturation was 95%.

Pleural fluid examination showed pH 7.0, glucose 2 mg/dL, protein 4.0 g/dL, white blood cell 137,000/mm³ (polymorphonuclear leukocyte 95%, lymphocyte 5%).

Both blood and pleural fluid cultures grew S. suis which was identified by using the automated Vitek2 system. Antimicrobial susceptibility testing using disc diffusion method showed that the isolate was sensitive to penicillin, erythromycin, clindamycin, cefepime and vancomycin but resistant to tetracycline (Table 1).

The initial chest X-ray showed diffuse hazy opacity on the right upper and lower portion (Figure 1). Chest computed tomography scan demonstrated moderate consolidation in the right lung with pleural effusion (Figure 2). Brain computed tomography showed moderate diffuse brain atrophy without meningeal enhancement (Figure 3).

Empirical antibiotics with piperacillin-tazobactam and ciprofloxacin were administered. Because the patient's irritability was thought to be due to delirum of alcohol withdrawal, spinal tap was not performed. On the 3rd day of admission, blood cultures showed Gram-positive cocci in pairs and chains, which suggested streptococcus species. We used disc diffusion method while not utilizing automated system for antimicobial susceptiblity testing because brush dilution method was not available in our laboratory. The isolate was sensitive to penicillin, erythromycin and vancomycin. Empyema was drained through a percutaneous catheter. On hospital day 4, he had a grand mal seizure which was treated by anti-epileptic drugs. On hospital day 7, the isolated organism was identified as S. suis. Pleural fluid also grew the same organisms. A week later, the patient showed improvement with his fever and pneumonia. However, his mental status did not improve, the patient's Glasgow coma score was only was only 4 to 5 and electroencephalographic findings showed moderate cerebral dysfunction. Brain magnetic resonance imaging scans was similar with initial brain computed tomographic findings showing diffuse brain atrophy but many white blood cells were seen in cerebrospinal fluid from the patient. Cereobrospinal fluid (CSF) culture grew no organism. Those results suggested that he had meningitis and explained the reason why he did not regained consciousness. On hospital day 12, the patient acquired nosocomial pneumonia which required intubation and mechanical ventilation. On hospital day 14, multi-drug resistant Acinetobacter baumannii grew in the sputum of the patient and we switched antibiotics to intravenous colistin. On hospital day 30, pneumonia was improved so much (Figure 4) and the weaning from mechanical ventilation was done successfully. He was discharged without regaining consciousness.