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Page 6 of 8 Dai et al. Neuroimmunol Neuroinflammation 2018;5:28 I http://dx.doi.org/10.20517/2347-8659.2018.09

Now, Streptococcus gallolyticus performed as a member of S. bovis, which has three hypotypes. Before then,
S. bovis strains were divided into biotypes based on their ability to decompose the mannitol (biotype I) or
[14]
not (biotype II) . Biotype II was further subdivided into biotypes II.1 and II.2. Depending on the ability to
produce acid from trehalose, to exhibit frequently b-glucuronidase, to degrade starch and b-galactosidase
[15]
activity, Biotype II. 2 strains are distinguished from biotype II.1 strains. In 1990, Osawa suggested a new
species, S. gallolyticus, isolated from fecal excretion of a koala, for those organisms able to decarboxylate
gallic acid. Subsequently, the further studies suggested that the S. gallolyticus species comprised S. bovis
[16]
biotypes I and II/2 . Later studies about the sequencing of soda and DNA-DNA hybridization confirmed
[6]
the need for the taxonomic change [17,18] . Therefore, Abdulamir et al. suggested that the S. gallolyticus
species includes three subspecies: S. gallolyticus subsp. gallolyticus, S. gallolyticus subsp. pasteurianus,
and S. gallolyticus subsp. macedonicu. Among the three biotypes of Streptococcus gallolyticus, we know
that S. gallolyticus subsp. pasteurianus causes meningitis, bacteremia, peritonitis, and chorioamnionitis
in adults [19-21] . Since this was the first case of Streptococcus gallolyticus among Chinese population, we
didn’t detect the subtype because the technical reasons. We hope that our case report can provide some
information for the detection of the Streptococcus gallolyticus related diseases and to make more precision
diagnosis by the subtype detection.

From the review of the Streptococcus bovis infection of the CNS, we know that most cases of S. bovis
[22]
infection can be treated with penicillin alone . But as is known to all, the cultures plays an important role
[23]
in the course of treatment. Savitch et al. found that patients with S. bovis endocarditis were resistant to
penicillin G. Several researches proposed that the empirical antibiotics should be chosen based on patient
[24]
history, results of CSF gram stain and local community antibiotic resistance patterns . For our patient,
considering the history of the patient as well as the permeability of BBB to antibiotics, we chosen the
[25]
meropenem (2 g ivd q8h) firstly . We added linezolid as soon as the Streptococcus gallolyticus reported.
Considering the results of sputum Gram stain we continued the treatment with meropenem. Eventually, our
patient recovered very well as we follow up by telephone two weeks after the discharge.

The studies suggested that the mortality rate of the Streptococcus gallolyticus meningitis patients is
[11]
about 24% , but we cannot ignore the fact that the total number of reported patients with Streptococcus
gallolyticus meningitis was small. So, it is of great significance to form a standardized and effective diagnosis
and treatment program for Streptococcus gallolyticus meningitis.

For now, all of the reports are from European and American countries. There are no reports from China.
We hope our case report can give some references for the diagnosis and treatment of the Streptococcus
gallolyticus meningocephalitis in China.

DECLARATIONS
Authors’ contributions
Drafting the manuscript, and literature review: Dai YM, Zhao M, Lu HJ
Revising the manuscript: Wang LX

Availability of data and materials
The data and material used in the study could be open upon request.

Financial support and sponsorship
The study was supported by China Postdoctoral Science Foundation (grant No. 2016M592513).

Conflicts of interest
All authors declared that there are no conflicts of interest relevant to this article.