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A man in his 40s who takes adalimumab for Crohn’s disease presented with a 1-day history of fever, headache and rapid onset of agitation with reduced consciousness. He was intubated, and a subsequent lumbar puncture revealed severe Streptococcus pneumoniae meningitis. He was started on antibiotics and steroids; however, on sedation hold, he demonstrated abnormal posturing. Neurological imaging revealed extensive cerebral venous sinus thromboses (CVSTs). He was started on a heparin infusion and transferred to a tertiary neurological centre, where he was managed with a split treatment dose of enoxaparin and a 2-week course of IV ceftriaxone. He was extubated on day 4 of admission and made rapid improvements in cognition and function. This case highlights the importance of considering rare neurological complications in cases of severe meningitis in patients who are immunocompromised, as well as recognising CVSTs as a rare but potentially fatal complication in those with pneumococcal meningitis.