Pneumocephalus as a complication of multidrug-resistant Klebsiella Pneumoniae bacteremia in patient with acute myeloid leukemia

Abstract

Pneumocephalus indicates air in the cranial cavity and commonly results from craniofacial trauma and neurosurgical procedures. Infections can rarely cause pneumocephalus through formation of brain abscess, or as complication of chronic otitis media, or meningitis. Patients might present with headache, fever, change in mental status and diagnosis is confirmed by Brain CT scan. A 51 years old male diagnosed with acute myeloid leukemia (AML) and admitted for fourth cycle of consolidation chemotherapy. He developed prolonged febrile neutropenia and septic shock and multi-organ failure due to Klebsiella Pneumoniae MDR bacteremia. Patient had persistent bacteremia despite being on Meropenem, Colisten, Levofloxacin, Caspofungin, Tigecycline. Due to profound thrombocytopenia, he had severe pulmonary hemorrhage and bilateral diffuse subarachnoid hemorrhage. Repeated CT brain angiography later showed extensive pneumocephalus with finding suggestive of brain death. Ethical approval for case report obtained. Meningitis associated with pneumocephalus is rare and has been reported in gas-forming organisms such as E. coli, Klebsiella Pneumoniae, Bacteroides, mixed aerobic and anaerobic species and streptococcus infection. Treating the underlying meningitis might results in resolution of pneumocephalus, although fatal outcomes were reported. Pneumocephalus secondary to Klebsiella Pneumoniae meningitis is uncommon and one case reported successful treatment using meropenem and amikacin for MDR Klebsiella Pneumoniae meningitis associated with pneumocephalous resulting from chronic otitis media. Pneumocephalus associated with MDR K. pneumonia bacteremia is very rare and had high mortality rate especially in setting of febrile neutropenia with multi-organ failure. Intracerebral hemorrhage in setting of persistent bacteremia might increase the risk of pneumocephalus.