Dados do Trabalho

Título

Acute bacterial meningitis due to an abnormal pathogen – it is always important to examine the patient’s skin

Apresentação do caso

A 17-year-old male patient was admitted with high fever associated with vomiting, prostration and sleepiness that had started one day earlier. He reported an insect bite in the left buttock 7 days before, which evolved to an ulcerated lesion suggestive of a suppurative abscess. At the presentation, the only altered vital sign was his body temperature (39.4ºC). Neurological examination revealed neck stiffness and a Glasgow Coma Scale of 14. Empirical treatment with ceftriaxone and dexamethasone was started. The analysis of the CSF was consistent with acute bacterial meningitis and a Magnetic Resonance Imaging (MRI) of the brain suggested possible hemorrhagic cerebritis in the left temporo-occipital subcortical area. On the same day, the antibiotic scheme was changed to vancomycin and ampicillin/sulbactam. After 24 hours of hospitalization, the patient complained about pain on the right shoulder and MRI confirmed septic arthritis and osteomyelitis, which was treated with surgery. There was also evidence of septic embolism on thorax scans. After 48h the cultures were available and confirmed a community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). Despite increasing the dose of vancomycin up to 60mg/kg/day, the patient was not able to reach appropriate serum levels of the drug and the treatment was switched to linezolid and daptomycin. The patient underwent an echocardiogram which showed no intracardiac vegetations. Subsequent brain MRIs documented the formation of a brain abscess in the left temporo-occipital area and the treatment was maintained for 8 weeks with good clinical and imaging response. Patient was discharged to follow outpatient treatment.

Discussão

Acute bacterial meningitis is a serious infection characterized as a medical emergency due to its elevated mortality. In this case report, we observed a case of meningitis caused by a local skin and bloodstream infection caused by CA-MRSA, which is a pathogen associated with more invasive and difficult to treat infections.

Comentários finais

In this case report, our patient did not attain adequate serum levels of vancomycin and it was necessary to change the antibiotics to linezolid and daptomycin. Also, the patient had several complications due to a bloodstream infection by CA-MRSA, which is a rare pathogen to cause meningitis, and thus the clinician should keep a high index of suspicion for these cases due to its potential bad outcome if left untreated.

Palavras-Chave

CA-MRSA, Acute bacterial meningitis, Bloodstream infection