Abstract
A 37-y-old male was admitted to the ICU because of meningitis and respiratory failure with epileptic seizures. Spinal fluid grew Streptococcus salivarius. Prior to presentation the patient underwent surgical excision of a chronic toe ulcer, performed under spinal anaesthesia, which raised the suspicion of iatrogenic origin of the disease. The clinical situation deteriorated over the following d and the patient died from multi-organ failure. Careful hygiene measures are needed to prevent such a severe complication.