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A 29-year-old soldier had a two-day history of headache and fever. He reported having had an intermittent, clear nasal discharge from the left nostril since his involvement in a minor motor vehicle accident two years earlier. Lumbar puncture revealed a white-cell count of 4100 per cubic millimeter, with 98 percent neutrophils — a finding indicative of bacterial meningitis, even though the microbiologic culture grew no organisms. Coronal computed tomography showed absence of the left ethmoidal plate and a focal brain herniation (Panel A, arrow). Incidental maxillary-sinus retention cysts were seen bilaterally. Endoscopic rhinoscopy revealed a small, pulsating mass consistent with the presence of an encephalocele (Panel B, arrow). The asterisks indicate the mid-septum. A fistulous defect in the nasal cavity resulted in the leakage of cerebrospinal fluid and subsequent meningitis. Corrective surgery consisted of resection of the encephalocele, followed by closure of the bony defect. At two years, the patient was doing well, with no further episodes of meningitis.
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