A 39-year-old man presented with a bilateral lower limb pruritic and purpuric rash following travel to Chongqing, China. He was initially treated for cellulitis abroad. On arrival, his rash was noted, and the initial workup revealed raised inflammatory markers with a CRP of 252 mg/L and an ESR of 80 mm/hr. Examination of the lower limb reveals symmetrical, non-blanchable purpuric plaques with post-inflammatory hyperpigmentation. He was admitted for further inpatient treatment. Serological workup for autoimmune vasculitis was negative. Urine phase contrast microscopy showed 12% dysmorphic red blood cells, below the threshold typically seen in glomerular bleeding. A punch biopsy revealed minimal, superficial perivascular lymphocytic infiltrate without classic vasculitic features, likely due to timing post-acute inflammation. The clinical workup and examination findings support a diagnosis of post-infectious cutaneous small-vessel vasculitis (CSVV). This case demonstrates the classic distribution and morphology of CSVV. Early recognition of CSVV facilitates prompt systemic evaluation and discontinuation of potential triggers and avoids unnecessary antibiotic use.

Delayed cerebral infarction (DCI) is a rare but devastating complication of bacterial meningitis that is characterized by an initial good recovery followed by sudden deterioration several days after presentation. The potential mechanisms underlying DCI encompass postinfectious vasculitis, vasospasm, and cerebral thrombosis. Sequential magnetic resonance angiography and characteristic high-resolution magnetic resonance patterns are helpful in discerning the cause of DCI. A right-handed 45-year-old man with nasal leakage of cerebrospinal fluid from a car accident was admitted to the local hospital for fever, vomiting, and impaired consciousness. Post-infectious vasculitis. Meropenem (1 g 3 times/day), vancomycin (0.5 g 4 times/day), and dexamethasone (10 mg/day, gradually reduced to withdraw) were administered immediately after the patient was diagnosed with Streptococcus pneumoniae meningitis. After the patient was diagnosed with DCI, we applied nimodipine (10 mg 3 times/day) to prevent vasospasm, clopidogrel (75 mg/day), and heparin to counteract thrombosis, and prednisone (60 mg/day) was applied to reduce the inflammatory reaction. On the 52nd day, the patient's magnetic resonance angiography reexamination indicated a continuous expansion of the cerebral infarction area and a worsening of cerebrovascular occlusion. After the prednisone dose was increased, the consciousness disorder ceased to progress. Early detection and treatment are very important for DCI, the sequential magnetic resonance imaging and high-resolution magnetic resonance imaging are conducive to identify the etiology of DCI and providing guidance for treatment. The delayed tapering of glucocorticoids appears to be beneficial for alleviating the severity of DCI.

We aim to report 3 cases of central nervous system (CNS) vasculitides, in which high-resolution magnetic resonance vessel wall imaging (HR-VWI) findings were instrumental in the diagnosis and management. Case 1: A 41-year-old obese, smoker female with arterial hypertension presented with recurrent transient ischemic attacks. Computed topography angiography demonstrated bilateral middle cerebral artery (MCA) stenosis. HR-VWI revealed uniform enhancement and thickening of the arterial wall, suggestive of MCA vasculitis. The patient reported chronic calf rash that was biopsied and revealed unspecified connective tissue disease. With immunomodulation, patient remained asymptomatic and 6-month surveillance HR-VWI showed improved MCA stenoses.Case 2: A 56-year-old male with herpes simplex virus 1 encephalitis was treated with antiviral therapy and improved clinically. Two months later, the brain magnetic resonance imaging revealed new temporo-parietal edema and distal MCA hyperintense vessels. HR-VWI showed MCA concentric smooth contrast enhancement, that was attributed to postinfectious vasculitis and had resolved on follow-up HR-VWI.Case 3: A 41-year-old male presented with 1-week of headache and encephalopathy. Brain magnetic resonance imaging revealed punctate multifocal acute ischemic infarcts and no contrast-enhancement. HR-VWI showed multifocal diffuse enhancement of distal cerebral vasculature. Patient subsequently developed branch retinal artery occlusion and hearing loss and was diagnosed with Susac syndrome. No recurrent symptoms were noted after immunotherapy initiation. In these 3 cases, HR-VWI identified distinctive vascular inflammatory changes, which were crucial to guide the etiological workup, positive diagnosis, surveillance neuroimaging, and targeted treatment. HR-VWI is an important diagnostic tool in CNS vasculitides, by providing nuanced information about arterial wall integrity and pathology.

Intracranial abscesses, postinfectious vasculitis, and hydrocephalus are rare complications of Streptococcus pneumoniae (S. pneumoniae) meningitis, and to our knowledge, there have been no case reports where all these 3 complications occurred in a single patient with Streptococcus pneumoniae meningitis. Here, we report a case of a 48-year-old male who developed postinfectious vasculitis, abscess, hydrocephalus, and hearing loss after S. pneumoniae meningitis. Clinicians ought to be aware of the possible adverse outcomes of S. pneumoniae meningitis and the limitations of current treatment options.