SESSION TITLE: Critical Care Student/Resident Case Report Posters I
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Bacterial meningitis is a leading infectious cause of morbidity and mortality. The availability of newer antibiotics has led to a significant decrease in mortality. However, complications including seizures, renal failure and hearing deficit still occur. Dural venous sinus thrombosis is a rare and life-threatening complication of bacterial meningitis. We present a patient with streptococcal meningitis and bacteremia who showed marked clinical deterioration, including mental status changes, requiring intubation despite appropriate antibiotic therapy. Imaging studies showed the cause to be sagittal sinus thrombosis. Timely recognition and treatment of this potential complication is necessary to avoid further morbidity and mortality.
CASE PRESENTATION: A 60-year-old male with no significant medical history was admitted with lethargy and headache for one day. On admission the patient was obtunded and febrile (102 F). Neurologic exam showed nuchal rigidity and signs of meningeal irritation. The patient was started on appropriate treatment for meningitis (ceftriaxone, ampicillin and vancomycin). The results of the lumbar puncture favored bacterial meningitis (WBC-25 K/microL with 98% neutrophils; protein-480 mg/dl; glucose < 20 mg/dl). Blood and cerebral fluid cultures subsequently grew S. pneumonia susceptible to current antibiotic regimen. The patient was continued on appropriate antibiotics. After 4 days the patient had continued mental status deterioration requiring intubation for airway protection. Imaging studies revealed sagittal sinus thrombosis and thrombophlebitis (Fig. 1 and 2) associated with venous infarction and mild hemorrhage along the left pre- and post-central gyri. Anticoagulation was added to the patient’s treatment regimen. His clinical status improved and he was discharged home after 14 days. He was advised to continue anticoagulation therapy for 3 months.
DISCUSSION: Dural venous sinus thrombosis secondary to infectious causes like meningitis and bacteremia is potentially fatal, especially if left unrecognized and not appropriately treated in a timely manner. It is more likely to occur in elderly, immunocompromised patients with a previous history of meningitis or head trauma. In addition to appropriate antibiotics, anticoagulation is indicated if dural venous thrombosis is associated with venous infarction and/or hemorrhage.
CONCLUSIONS: It is important to recognize this rare complication of bacterial meningitis. Failure to promptly administer appropriate treatment including antibiotics and anticoagulation, when indicated, is associated with significant morbidity and mortality.
Reference #1: Dery MA, Hasbun R. Changing epidemiology of bacterial meningitis. Curr Infect Dis Rep 2007; 9:301.
Reference #2: Kastenbauer S, Pfister HW. Pneumococcal meningitis in adults: spectrum of complications and prognostic factors in a series of 87 cases. Brain. 2003 May;126 (Pt. 5):1015-1025
DISCLOSURE: The following authors have nothing to disclose: Hineshkumar Upadhyay, Khalid Sherani, Abhay Vakil, Kelly Cervellione, Mohammad Babury
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