Pyogenic ventriculitis is defined as the presence of suppurative fluid in the cerebral ventricular system [1,2]. It is usually a complication of neurosurgical procedures, ruptured brain abscesses, or head injury [1, 2, 3]. Cases of community-acquired ventriculitis are rare, with only a few cases due to
A 58-year old Caucasian British female presented to the emergency department (ED), Colchester General Hospital, Colchester, UK in October 2018, after she was found unresponsive by relatives. She had complained of sudden onset headache the night before admission and had attended the same ED days previously with symptoms suggesting a urinary tract infection (UTI), for which she was given unspecified oral treatment and discharged. A mid-stream urine sample obtained at that time was reported later as positive for
Initial findings included a Glasgow Coma Score (GCS) of 6/15 (scores of 2, 1 and 3 for eye, verbal and motor responses, respectively), right-sided weakness and facial droop. She was afebrile, without neck stiffness but myoclonic jerks in both arms were noted. Past medical and social history included anxiety, treated with sertraline. She smoked approximately thirty cigarettes per day and alcohol intake of seven units per day. There was no recent history of travel, trauma or surgery.
She was intubated in the ED and transferred to the Intensive Care Unit (ICU). The initial working diagnosis was of stroke, however considering a possible CNS infection, ceftriaxone 2 grams 12-hourly (Wockhardt UK Ltd, Wrexham, UK) and aciclovir 640 miligrams 12-hourly (Hospira UK Limited, Hurley, UK) were promptly started. Results of blood tests on admission are summarised in Table 1.
Results of relevant blood tests (on admission day)
Test | Result | Normal range |
---|---|---|
White cell count | 9.8 109/L | 4-11 109/L |
Neutrophils | 8.8 109/L | 2-7.5 109/L |
Lymphocytes | 0.2 109/L | 1-4 109/L |
Platelets | 62 109/L | 135-450 109/L |
C-reactive protein | 643mg/L | 0-5 mg/L |
Creatinine | 232 μmol/L | 45-84μmol/L |
Urea | 19.7mmol/L | 2.5-7.8 mmol/L |
At the time of admission, a computerised tomography (CT) of the brain showed signs of a left-sided middle cerebral artery (MCA) infarct, but no hydrocephalus. On the same day, a magnetic resonance imaging (MRI) of the brain showed a right internal capsule acute infarct and debris in the ventricles suggestive of ventriculitis (Figure 1).
Two sets of blood cultures taken on the day of admission to hospital were later reported as having grown
A lumbar puncture (LP) was performed, and cerebrospinal fluid (CSF) results are shown in Table 2.
LP results (admission day)
CSF appearance | CSF results | |
---|---|---|
White cell count | 15 680 106/L | |
Polymorphs | 95% | |
Lymphocytes | 5% | |
Turbid | Red blood cells | 220 106/L |
Protein | 4.26g/L | |
Glucose | 0.4mmol/L | |
Serum glucose | 7.0mmol/L |
CSF gram-stain analysis revealed that gram-negative organisms and culture results were later reported as
A repeat LP, on day 11, post-admission, showed marked improvement (Table 3), with no further bacterial growth.
LP results (day 11)
CSF appearance | CSF results | |
---|---|---|
White cell count | 14 106/L | |
Polymorphs | 30% | |
Lymphocytes | 70% | |
Clear and colourless | Red blood cells | 1 106/L |
Protein | 0.55g/L | |
Glucose | 4.1mmol/L | |
Serum glucose | 6.8mmol/L |
The patient had a prolonged stay in ICU, requiring mechanical ventilation for twenty-seven days. Therefore a reliable neurological examination was only possible after sedation hold. Marked left-sided hemiparesis was evident. Ceftriaxone was continued at the same dose and frequency until day 25 of admission, when dose was reduced to 2 grams daily. Aciclovir was stopped following the CSF microscopy report.
Strongyloides, human immunodeficiency virus (HIV), Hepatitis B and C serologies were reported negative. Renal tract ultrasound showed no evidence of hydronephrosis or collection. A transthoracic echocardiogram was reported as normal.
On day 27 of hospital admission, an MRI brain with contrast, showed persistent features of ventriclitis, a subacute infarct in the right internal capsule and trapped occipital horn of the right lateral ventricle (Figure 5). A tracheostomy was performed due to marked global weakness. The patient was successfully decannulated in ICU and stepped-down to the Stroke ward 29 days after hospital admission, requiring intensive physiotherapy and neuro-rehabilitation. On day forty-one post-admission, an MRI brain showed a mild reduction of a ring-enhancing lesion in the right lateral ventricle, but persistent ventricular debris (Figure 6).
The patient was discharged to a rehabilitation facility after fifty-eight days in the hospital and eight weeks of intravenous antibiotics. Follow-up imaging at four months showed significant regression of the findings previously noted.
Pyogenic ventriculitis is a known complication of meningitis and especially following neurosurgical interventions (e.g. shunts), trauma or CSF leak [3,5]. Spontaneous, community-acquired gram-negative bacilli CNS infections are reported as rare, representing 8.7% of all cases of meningitis.
Three main categories of
Recent case reports and reviews on primary ventriculitis question the true prevalence of the condition [2,6]. As clinical presentation can be non-specific, the diagnosis relies essentially on neuroimaging. The current patient did not present with neck stiffness, which is consistent with findings reported by Gronthoud
A high level of suspicion is needed, and an MRI of the brain is the most sensitive tool for early diagnosis [2]. The presence of irregular debris on MRI is specific for pus, according to Fukui
Cerebral vasculitis has been reported as a complication of both
The different vascular territories affected, left MCA on initial imaging, right internal capsule on subsequent scans, possibly reflected the evolution of the inflammatory response and CNS infection.
There are no specific recommendations for the management of patients with community-acquired ventriculitis [2,5]. An early neurosurgical opinion should be sought; however, the optimal duration for antimicrobial treatment is not well defined [2,3]. Given the potential high mortality and morbidity, longer duration of antibiotics should be considered (6-12 weeks) [2, 5].
Decision-making, during the management of the current patient, was multidisciplinary, and the teams involved included neurosurgery, critical care, microbiology and stroke. Persistent evidence of intra-ventricular debris on imaging was the primary concern and rationale for a long course of antibiotics.
This case report illustrates the unique features of a case of community-acquired
Universal agreement and recommendation regarding the duration of antibiotic treatment in such cases is required.