Background: Neonatal meningitis is a critical threat to a child's health, often leading to lasting neurodevelopmental sequelae. Although most of the causative microorganisms are predicted based on the age and location, yet some extremely rare infections carry a higher risk of mortality, relapse, and poor prognosis.Meningitis due to Salmonella species is seldom reported, and simultaneous central nervous system (CNS) infection with cytomegalovirus (CMV) has, to date, not been described in the literature. This report presents the first known case of dual CNS infection from Extended Spectrum Beta Lactamase (ESBL)-producing Salmonella typhi and CMV, highlighting a multidisciplinary approach and complex management, and referencing the most recent literature on both pathogens.Case Presentation: A 2-month-old female infant born at 35+5 weeks of gestation presented with an acute onset of fever, irritability, and a weak cry developing over three days. She was previously healthy with a one-month travel history to Pakistan. Initial physical examination was significant for irritability, bulging anterior fontanelle, and opisthotonus.Laboratory findings showed significantly elevated inflammatory markers (CRP 243mg/L, procalcitonin 15ng/mL) with normal white cell count (8.3×10⁹/L). Blood and CSF cultures grew ESBL-producing Salmonella-typhi, while CSF-PCR detected CMV, confirming dual CNS infection. CMV quantitative PCR revealed high urine viral loads (640,000 copies/mL) and minimal viremia (<250 copies/mL), indicating active infection. Serial neuroimaging via contrast-mediated magnetic-resonance imaging (MRI) demonstrated disease progression from initial diffuse leptomeningeal thickening (Figure1.A) to bilateral subdural collections (Figure1.B).She received comprehensive management directed by a multidisciplinary team of pediatric hospitalists, pediatric infectious disease and pediatric rehabilitation. Her anti-microbial treatment course started with broad-spectrum antibiotics, intravenous meropenem and vancomycin, followed by targeted therapy including intravenous meropenem for six weeks, gentamicin for ten days, and ganciclovir for two weeks. Subdural collections were managed conservatively. Her hospital course was further complicated by meropenem-induced neutropenia requiring granulocyte colony-stimulating factor and localized dermatitis at the central line site requiring topical steroids and emollients.Despite the complexity, the patient remained clinically stable with normalization of inflammatory markers and no neurological deficits on discharge. Prior to discharge, our patient underwent immune deficiency screening, including immunoglobulin levels, immune cell subsets, and complement CH50 levels, all of which were reassuring.Discussion: The case we presented illustrated a rare entity in the scope of CNS infections. Dual CNS infections have been described, but the majority involve Enterovirus concurrences (1,2). Few reports document Salmonella and CMV meningitis as separate infections (3,4,5).This case offers novelty by presenting concurrent CNS infection with two severe pathogenic strains; ESBL Salmonella typhi and CMV. Published survival rates for Salmonella meningitis remain poor (30–50%). Thus, early aggressive combination therapy and close monitoring are crucial as long-term complications and relapses are reported. A literature review comparing this dual infection case with previously reported cases of Salmonella and CMV meningitis is presented in Table1.This case emphasizes the importance of comprehensive microbiological testing (culture+PCR), early serial imaging, and balancing prolonged antimicrobial/antiviral therapy with toxicity monitoring. Travel history to regions with high ESBL/XDR S. Typhi prevalence should prompt clinicians to broaden empiric coverage in infants with suspected meningitis.
