A Rare Case of Primary Pyogenic Ventriculitis in a Patient with Community-acquired Meningitis

INTRODUCTION

Pyogenic ventriculitis is defined as the inflammation of the ependymal lining of the cerebral ventricular system. It mostly affects neonates and children but rarely can be seen in adult population. Healthcare-associated ventriculitis occurs secondary to ventriculoperitoneal shunt, external ventricular drain, intrathecal drug delivery, brain stimulation devices, and neurosurgical intervention.¹ Only a few case reports are available in the literature on primary pyogenic ventriculitis.^2–5 We present a rare case of primary pyogenic ventriculitis occurring as a complication of community-acquired bacterial meningitis due to Streptococcus pneumoniae in an elderly diabetic male. Our management includes early detection of organism using multiplex PCR, control of blood sugar levels, and prolonged targeted antibiotic therapy for 6 weeks. There should be high index of clinical suspicion in adult patients with preexisting comorbidities who are diagnosed with bacterial meningitis with therapeutic failure.

CASE DESCRIPTION

A 64-year-old diabetic male presented to the emergency room with fever and altered sensorium since 1 day. On arrival, he developed one episode of focal seizure in ER, which was treated with a loading dose of intravenous levetiracetam and was resolved. In view of the low Glasgow Coma Score (GCS), invasive mechanical ventilation was initiated. Magnetic resonance imaging (MRI) of the brain showed features of leptomeningitis with a normal angiogram (Fig. 1). He was admitted to the medical intensive care unit (ICU). Initial laboratory investigations were collected (Table 1).

Diagnostic lumbar puncture was done and treated with an empirical antibiotic which included intravenous ceftriaxone and vancomycin as per the body weight (Table 2). Intravenous dexamethasone was administered with the first dose of antibiotics and continued for 4 days. He developed diabetic ketoacidosis (DKA) on admission to ICU, which was managed according to the DKA protocol. Diabetic ketoacidosis was resolved within the next 2 days. No further seizure episodes and he was maintained on intravenous levetiracetam. Bedside electroencephalogram also did not show electrographic seizures.

In view of new-onset acute kidney injury, vancomycin dose was adjusted accordingly. Renal function improved subsequently. Blood and urine cultures showed no growth. His sensorium did not improve despite normal metabolic parameters. Repeated MRI of the brain with diffusion-weighted imaging was done, which showed the findings in concern for infective collections in sulcal spaces with features of ventriculitis (Figs 2 and 3). Repeated cerebrospinal fluid (CSF) examination showed five cells which were all lymphocytes, glucose 82 mg/dL (corresponding blood sugar 246 mg/dL), protein 89 mg/dL, chloride 129 mmol/L, and culture showed no growth.

As there was no evidence of hydrocephalus, no neurosurgical intervention was done and was decided to manage conservatively using prolonged duration of antibiotics. Tracheostomy was done in view of the need for prolonged mechanical ventilation. In due course, he was successfully weaned from the ventilator and was decannulated once the sensorium was completely improved. He was discharged home after 3 weeks of admission with the advice to continue and complete a total of 6 weeks of systemic antibiotic therapy (intravenous ceftriaxone and vancomycin), control of blood sugar as per endocrinology advice, and undergo regular neurorehabilitation follow-up. On follow-up after 6 weeks, he was afebrile with no signs of recurrent infection and with no neurological sequelae.

DISCUSSION

Pyogenic ventriculitis is characterized by the presence of suppurative fluid in the ventricles and is also referred to as pyocephalus, ventricular empyema, or ependymitis. It mostly affects neonates and children but rarely can be seen in adult population. In adults, it usually affects the elderly population (above 60 years)^2,3 as in our case. It is a recognized complication of nosocomial meningitis secondary to intraventricular surgery and drains, brain abscess, and otological disease. The most common organisms implicated in pathogenesis are S. pneumoniae, Neisseria meningitidis, and Staphylococcus aureus. Other organisms like Enterococcus faecalis, Escherichia coli, and Peptostreptococcus have also been isolated.⁶ Signs of meningeal irritation were reported to be absent in most of the adult cases² as it was absent in our patient. Clinical presentation and CSF analysis may be similar in both meningitis and pyogenic ventriculitis. We were able to identify the organism early using multiplex PCR and start targeted antibiotic therapy despite culture being negative. Whenever symptoms persist despite appropriate antibiotic therapy, pyogenic ventriculitis should be suspected. Only nine adult cases have been reported till date.^2–5 Magnetic resonance imaging is more reliable than CT scan in detecting pus within ventricles. Ventricular debris is seen in 94% of cases.⁷ Our patient had ventricular debris on repeated MRI. Enhanced ventricular lining in bilateral occipital horns (60% cases),⁷ hydrocephalus, and hyperintense periventricular signals are the other MRI findings. Ventriculitis complicating meningitis is difficult to treat with significant morbidity and mortality. No specific guidelines are mentioned in the literature for antibiotic therapy in pyogenic ventriculitis. However, it is advisable to administer antibiotics for a duration of 6–12 weeks.^8,9 Our patient was given 6 weeks of intravenous antibiotic therapy. Ventriculitis carries a poor prognosis with 1-year mortality rate close to 40%¹⁰ versus 10–20% in contemporary cohorts of bacterial meningitis and brain abscess.^11–14 Amongst the survivors, 60% of patients had long-term neurological sequelae.¹⁰ On follow-up at 6 weeks, our patient did not have any neurological sequelae.

CONCLUSION

Primary pyogenic ventriculitis though rare should be considered one of the differential diagnosis in patients who do not improve despite routine meningitis treatment. Utilization of multiplex PCR helps in targeted antibiotic therapy. Repeated brain imaging is essential for the confirmation of diagnosis. Earlier initiation of appropriate antibiotics for a longer duration has better outcomes without the need of neurosurgical intervention.

HIGHLIGHTS

Due to infrequent occurrence, primary pyogenic meningitis is likely to be underseen. This case report elucidates the importance of considering it as a differential diagnosis when a patient with suspected meningitis fails to recover despite appropriate treatment. Early detection of organisms using multiplex PCR, repeat neuroimaging, prolonged course of antibiotics, and control of comorbid conditions results in recovery and survival.

ORCID

Harish Mallapura Maheshwarappa https://orcid.org/0000-0001-9377-3421

Akshatha V Rai https://orcid.org/0000-0003-1629-0244

REFERENCES

1. Kovacevic P, Dragic S, Djajic V. Ventriculitis caused by multidrug-resistant bacteria in a medical intensive care unit with limited resources. Indian J Crit Care Med 2018;22(11):814–816. DOI: 10.4103/ijccm.IJCCM_352_18.

2. Gronthoud F, Hassan I, Newton P. Primary pyogenic ventriculitis caused by Neisseria meningitidis: case report and review of the literature. JMM Case Rep 2017;4(1):e005078. DOI: 10.1099/jmmcr.0.005078.

3. Lesourd A, Magne N, Soares A, Lemaitre C, Taha M-K, Gueit I, et al. Primary bacterial ventriculitis in adults, an emergent diagnosis challenge: report of a meningococcal case and review of the literature. BMC Infect Dis 2018;18:226. DOI: 10.1186/s12879-018-3119-4.

4. Bajaj D, Agrawal A, Gandhi D, Varughese R, Gupta S, Regelmann D. Intraventricular empyema caused by Neisseria meningitidis. IDCases 2019;15:e00503. DOI: 10.1016/j.idcr.2019.e00503.

5. Jayendrakumar CI, Ganesan DB, Thampi SJ, Natarajan V. Primary pyogenic ventriculitis caused by streptococcal pneumoniae in adults. J Family Med Prim Care 2019;8(11):3745–3747. DOI: 10.4103/jfmpc.jfmpc_688_19.

6. Barloon TJ, Yuh WT, Knepper LE, Biller J, Ryals TJ, Sato Y. Cerebral ventriculitis: MR findings. J Comput Assist Tomogr 1990;14(2):272–275. DOI: 10.1097/00004728-199003000-00021.

7. Fukui MB, Williams RL, Mudigonda S. CT and MR imaging features of pyogenic ventriculitis. AJNR Am J Neuro Radiol 2001;22(8):1510–1516. PMID: 11559498.

8. Kasimahanti R, Satish SK, Anand M. Community-acquired Escherichia coli meningitis with ventriculitis in an adult-a rare case report. J Intensive Care 2018;6:63. DOI: 10.1186/s40560-018-0332-6.

9. Kumar R, Singhi P, Dekate P, Singh M, Singhi S. Meningitis related ventriculitis–experience from a tertiary care centre in northern India. Indian J Pediatr 2015;82(4):315–320. DOI: 10.1007/s12098-014-1409-4.

10. Luque-Paz D, Revest M, Euge`ne F, Boukthir S, Dejoies L, Tattevin P, et al. Ventriculitis: a severe complication of central nervous system infections. Open Forum Infect Dis 2021;8(6):ofab216. DOI: 10.1093/ofid/ofab216.

11. Thigpen MC, Whitney CG, Messonnier NE, Zell ER, Lynfield R, Hadler JL, et al. Bacterial meningitis in the United States, 1998–2007. N Engl J Med 2011;364:2016–2025. DOI: 10.1056/NEJMoa1005384.

12. de Gans J, van de Beek D, for the European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators. Dexamethasone in adults with bacterial meningitis. N Engl J Med 2002;347:1549–1556. DOI: 10.1056/NEJMoa021334.

13. Brouwer MC, Coutinho JM, van de Beek D. Clinical characteristics and outcome of brain abscess: systematic review and meta-analysis. Neurology 2014;82(9):806–813. DOI: 10.1212/WNL.0000000000000172.

14. Brouwer MC, Tunkel AR, McKhann GM, van de Beek D. Brain abscess. N Engl J Med 2014;371(5):447–456. DOI: 10.1056/NEJMra1301635.