Pneumococcal meningitis has a high case-fatality rate. It can be fulminant and occurs with bacteremia but not necessarily with any other focus, although there may be otitis media or mastoiditis. Onset is usually sudden with high fever, lethargy or coma, and signs of meningeal irritation. It is a sporadic disease in young infants, the elderly and other high-risk groups, including asplenic and hypogammaglobulinemic patients. Receipt of a cochlear implant and basilar fracture causing persistent communication with the nasopharynx are predisposing factors (see Pneumonia, pneumococcal). Diagnosis may be made by isolation of organisms from blood or CSF. Pneumococcal capsular polysaccharide may be identified by CIE or LA techniques.