NONTYPEABLE HAEMOPHILUS INFLUENZAE VENTRICULITIS COMPLICATED BY HYDROCEPHALUS IN A PATIENT WITH SICKLE CELL DISEASE

Abstract

SESSION TITLE: Fellows Critical Care Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Community-acquired purulent ventriculitis is very rare. We present a case of community-acquired purulent nontypeable Haemophilus influenzae meningitis with ventriculitis requiring cerebrospinal fluid diversion. CASE PRESENTATION: 46-year-old female with sickle cell disease presented in late fall with two days of headache, fever, and confusion. On arrival, she was febrile to 103F. On exam, she was agitated and unable to follow commands. Laboratory studies showed a white blood cell count of 23,000 (94% neutrophils), and procalcitonin 36 mg/dL. Blood and urine cultures were collected. The patient was given dexamethasone, vancomycin, meropenem (anaphylactic to penicillin), acyclovir, and doxycycline for community-acquired meningoencephalitis. CT Brain was consistent with cerebral edema. The patient required intubation for airway protection. Lumbar puncture showed purulent cerebrospinal fluid with opening pressure 21. CSF protein was 900, glucose 1, and 24,000 neutrophils. Gram stain showed numerous gram negative coccobacilli. MRI Brain showed layering debris within the ventricles and hydrocephalus. Due to intracranial hypertension, mannitol was given and an external ventricular drain placed. Blood and CSF cultures grew non-type B Haemophilus influenzae. The patient completed 14 days of ceftriaxone and was eventually extubated and ventriculostomy removed. DISCUSSION: Anatomical and functional asplenia poses high risk for invasive infections with encapsulated organisms such as S. pneumoniae, N. meningitidis, and H. influenzae. However, we present a case of community-acquired nontypeable H influenza meningitis with associated ventriculitis requiring CSF diversion. Nontypeable Haemophilus species lack a polysaccharide capsule for which splenic function provides less immunity. Serotype B was a common invasive pathogen prior to the institution of Hib vaccination in 1987. Nontypeable H influenzae is a common pathogen in otitis media in children and exacerbations of COPD in adults. Invasive diseases such as bacteremia and pneumonia are mostly seen at the extremes of age. Our patient is also unique in that she developed purulent ventriculitis complicated by hydrocephalus. Hydrocephalus complicates community-acquired bacterial meningitis in about 5% of cases and is associated with high mortality. H influenza ventriculitis is a rare condition and is mostly described in children and patient’s after neurosurgical CNS manipulation. CONCLUSIONS: We present a case of community-acquired nontypeable Haemophilus influenzae meningitis with ventriculitis. This case is unique in that the patient had purulent ventriculitis required CSF diversion. Community-acquired purulent ventriculitis is very rare without neurosurgical manipulation or indwelling CSF drainage catheters. Also, nontypeable H flu is an uncommon pathogen in the central nervous system and usually affects the respiratory tract. Reference #1: Eldere, J.V., Slack, M, Ladhani,Shamez, Cripps, A. Non-typeable Haemophilus infl uenzae, an under-recognised pathogen.Lancet Infect Dis 2014; 14: 1281–92. Reference #2: Bakaletz, L, Novotny, L. NontypeableHaemophilusinfluenzae(NTHi). Trends in Microbiology, August 2018,Vol. 26,No.8. Reference #3: Langereis, J, Jonge, M. Invasive Disease Caused by Nontypeable Haemophilus influenzae. Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 21, No. 10, October 2015. DISCLOSURES: No relevant relationships by Andrew Holt, source=Web Response No relevant relationships by Scott Sinclair, source=Web Response