Third Place EMage Winner: Ventriculitis and Pronounced Hydrocephalus from Neisseria meningitidis

Charles Hwang, MD, PGY-3

Carolyn Holland, MD, MEd

University of Florida Health, Department of Emergency Medicine

A previously healthy, unvaccinated 10-month-old boy presented to the emergency department with a 3-day history of fatigue and somnolence.  Examination revealed an obtunded infant with sluggish pupils, bulging anterior fontanelle, bradycardia, hypertension, and extensor posturing with no purposeful movement.  His workup revealed a white blood cell count of 50.6 x 103 mm-3, bandemia of 8%, and hyponatremia of 119 mmol L-1.  A computed tomographic (CT) scan (Figure 1) of his brain showed hydrocephalus with fluid levels in bilateral ventricles with debris within the cerebrospinal fluid (CSF).  He was started on broad-spectrum antibiotics, and an external ventricular drain was placed.  CSF studies demonstrated WBC 905 mm-3, RBC 21 mm-3, glucose < 2 mg dL-1, protein 302 mg dL-1.  CSF culture confirmed Neisseria meningitidis.  Magnetic resonance imaging (MRI) (Figure 2) of the brain showed severe, diffuse meningitis and ventriculitis with purulent accumulation in the ventricles, sulci, and cisterna magni.

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Ventriculitis, a severe complication of meningitis, is the inflammation of ventricular fluid and is associated with the obstruction of CSF flow, resulting in elevated intracranial pressures (ICP).1,2  It is frequently associated with the presence of external hardware, such as external ventricular drains or ventriculoperitoneal shunts.3  Although there are no reliable clinical signs for ventriculitis, signs of elevated ICP may be present.  The diagnosis must be suspected when patients fail to improve with appropriate antimicrobial therapy for meningitis.1  The diagnosis is confirmed with neuroimaging.  CT or MRI of the brain can demonstrate intraventricular purulent debris accumulation, hydrocephalus, and enhancement of the lining of the ventricles2,4,5.  Management includes broad-spectrum antibiotics and may include external ventricular drains for elevated ICP and hydrocephalus although these should be undertaken in collaboration with neurosurgery and infectious disease.4  Ventriculitis is associated with a high mortality rate of 30 to 70%.  Long term sequelae include severe cognitive deficits, hydrocephalus, developmental delay, late-onset seizures, cerebral palsy, and hearing loss.6

REFERENCES

  1. Miyairi I, Causey KT, DeVincenzo JP, Buckingham SC. Group B streptococcal ventriculitis: a report of three cases and literature review. Pediatric neurology 2006;34:395-9.
  2. Fukui MB, Williams RL, Mudigonda S. CT and MR imaging features of pyogenic ventriculitis. AJNR American journal of neuroradiology 2001;22:1510-6.
  3. Ziai WC, Lewin JJ, 3rd. Update in the diagnosis and management of central nervous system infections. Neurologic clinics 2008;26:427-68, viii.
  4. Agrawal AM, Cincu RM, PhD, Timothy JM, MD, FRCS. Current Concepts and Approach to Ventriculitis. Infectious Diseases in Clinical Practice 2008;16:100-4.
  5. Fujikawa A, Tsuchiya K, Honya K, Nitatori T. Comparison of MRI sequences to detect ventriculitis. AJR American journal of roentgenology 2006;187:1048-53.
  6. Libster R, Edwards KM, Levent F, et al. Long-term outcomes of group B streptococcal meningitis. Pediatrics 2012;130:e8-15.

 

 

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