MULTIFACTORIAL MENINGITIS IN A PATIENT WITH PREVIOUS EPSTEIN BARR VIRUS ENCEPHALITIS

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Gram negative bacillary meningitis is rare and mostly occurs in patients with recent neurosurgery. We present such a case of bacterial meningitis combined with other etiologies in a patient with previous Epstein Barr Virus (EBV) encephalitis. CASE PRESENTATION: 62-year-old male with history of diabetes, stroke and EBV encephalitis (1 month ago) presented with altered mentation. Lumbar puncture (LP) showed neutrophil predominant leukocytosis but cerebrospinal fluid (CSF) culture was negative. Brain imaging showed developing hydrocephalus. He was started on empiric meningitis coverage with antibacterial, antifungal and antitubercular regimen (due to basilar changes on imaging and mildly elevated adenosine deaminase in the CSF). He underwent right craniotomy with ventriculo-peritoneal (VP) shunt placement. Course complicated by worsening mentation requiring intubation for airway protection. Due to concern of hospital acquired pneumonia (HAP), piperacillin-tazobactam was added. Repeat LP showed improved leukocyte count but culture was again negative. He had persistent fevers after finishing piperacillin-tazobactam course; subsequent sputum culture and 3rd CSF culture now grew pseudomonas aeruginosa. He finished 21 days of systemic cefepime and 7 days of intrathecal tobramycin for pseudomonas; and 14 days of empiric amphotericin B (although fungal CSF culture was negative). He remains on empiric antitubercular regimen (isoniazid/rifampin/pyrazinamide/ethambutol) - culture negative. Mentation remains poor and family is currently deciding on aggressive care with tracheostomy or palliative care approach. DISCUSSION: In our case, meningitis on admission was likely some bacterial superinfection after viral encephalitis. After neurosurgery, 2nd CSF culture was negative likely due to ongoing antibiotics for HAP. 3rd CSF culture grew pseudomonas as patient was now off of piperacillin-tazobactam. Pseudomonas meningitis is rare and can occur as complication of neurosurgery, chronic cranial osteomyelitis, mastoiditis or trauma. The mortality rate ranges from 40 to 80%. Complications include hydrocephalus, brain abscesses, seizures, ventriculitis etc. The CSF gram stain is positive in 50% of cases with a positive culture result. Bacteremia is also present in about 50% of the cases. The usual empiric meningitis regimen does not cover pseudomonas and antipseudomonal agents can be added in patients with above risk factors. Cefepime/ceftazidime are empiric therapy and should be adjusted based on sensitivities. Dual therapy with intrathecal/intraventricular regimens can be started in resistant cases. Adjuvant steroids have shown no benefit. CONCLUSIONS: Timely recognition of risk factors for gram negative bacillary meningitis and starting empiric treatment regimen can improve the prognosis of such patients. REFERENCE #1: Berk SL, McCabe WR. Meningitis caused by gram-negative bacilli. Ann Intern Med. 1980;93(2):253. REFERENCE #2: Rahal JJ, Simberkoff MS. Host defense and antimicrobial therapy in adult gram-negative bacillary meningitis. Ann Intern Med. 1982;96(4):468. REFERENCE #3: S. Pai, L. Bedford et al. Pseudomonas aeruginosa meningitis/ventriculitis in a UK tertiary referral hospital. An International Journal of Medicine, Volume 109, Issue 2, February 2016, Pages 85–89, https://doi.org/10.1093/qjmed/hcv094 DISCLOSURES: No relevant relationships by Sahib Singh, source. Web Response no disclosure on file for Parth Jamindar