Reply to Gilchrist et al. and to Musher

To the Editor—We read with interest Gilchrist and colleagues' report of an adult case of recurrent bacterial meningitis, presenting with both an immunodeficiency and a local promoting factor. The patient first presented with a history of 2 episodes of pneumococcal meningitis in 3 years and then an episode of meningococcal meningitis 6 years later, despite antibiotic prophylaxis (the details of which were not provided) and protein-conjugate vaccination (probably against Streptococcus pneumoniae). After the first 2 episodes, immunological evaluation detected an IgG2 subclass deficiency and associated poor anti-pneumococcal antibody responses. Surprisingly, an initial computed tomography (CT) scan did not find any skull base abnormalities after the 2 episodes of pneumococcal meningitis. However, dehiscence of the right tegmen tympani was observed after the episode of meningococcal meningitis—suggesting a cerebrospinal fluid leak. When directly questioned in this respect, the patient reported watery rhinorrhea.