Title : Abrupt and lethal rare complication: A case report of a 32 year-old male who suffered from pyogenic ventriculitis
Abstract:
Introduction: Pyogenic ventriculitis is characterized by ependymal lining inflammation of the cerebral ventricular system and presence of suppurative fluid in the ventricles. Risk factors include a compromised immunity such as human immunodeficiency virus, diabetes, and cancer. This infection could arise as a complication from deep-seated cerebral abscesses, carrying a higher mortality rate, ranging from 30% to 85%, and leaving 60% of survivors with lasting neurological sequelae. Early recognition is crucial but data on clinical and neuroimaging features are scarce. Our case report sheds light on specific clinical and neuroimaging aspects for pyogenic ventriculitis in a young male adult, at in-hospital setting and, as a complication of extensive multiloculated cerebral abscesses involving atypical locations.
Case Presentation: We present a case of a 32-year-old male with a history of intravenous drug abuse and homelessness who arrived at the Emergency Department for muscle aches, sore throat, and multiple infected ulcers. Participating in a methadone rehabilitation program, they were concerned for noticing episodes of hypoactivity. Initial examination revealed a mildly hypoactive, afebrile patient with a Glasgow Coma Scale (GCS) of 14/15, stable vital signs, and no meningeal irritation or focal neurological findings. Multiple infected ulcers were noted on his upper extremities. General laboratories were mostly unremarkable, except for mild elevated erythrocyte sedimentation rate. Head computer tomography (CT) reported no intracranial abnormalities. Therefore, the patient was admitted for infected ulcers management and further workup investigations. On day ten, the patient experienced a sudden clinical deterioration that was remarkable for peaks fever, decreased alertness, apathy, withdrawal, and a reduced GCS of 10/15. Focal neurological deficits were noted, including horizontal nystagmus, leftward eyes deviation, vertical gaze palsy, and right nasolabial fold flattening. A new head CT with and without contrast revealed ill-defined lesions in the right frontal and occipital lobes surrounded by edema and communicating hydrocephalus. A subsequent magnetic resonance imaging (MRI) diagnosed multiple intraparenchymal brain abscesses and ventriculitis. Unusual features included abnormally enhancing patterns involving the fourth ventricle and left frontal periventricular region. Lesions were identified in both infra and supratentorial regions, including the midbrain and prepontine cistern. The largest lesion was located at the right side of the genu and splenium affecting the corpus callosum. Moreover, serial blood culture results remained negative, and transthoracic and transesophageal echocardiogram reported no vegetations. The patient’s cognitive decline abruptly got worsened by the third week of admission leading to comma.
Conclusion: Pyogenic ventriculitis might present lethally as a severe complication of extensive multiloculated abscesses and it requires early recognition and timely intervention. Additionally, it can present with diverse infectious origins or unknow primary sources. MRI of the brain is essential for a comprehensive evaluation of this complication and known as the most reliable neuroimaging study for establishing diagnosis, management guidance, and prognosis. Furthermore, this life-threatening infection often requires prolonged antibiotic treatment combined with external ventricular drainage and intraventricular antibiotics for the most favorable outcomes.
