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Título

Community-acquired Pseudomonas aeruginosa meningoencephalitis: a case report

RESUMO

Case Presentation: A 66-year old woman with type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD) and chronic sinusitis was admitted to our institution presenting with a 8-day history of continuous holocranial headache, nauseas and vomiting, without fever. She evolved with disorientation and seizures. Computed tomography of the brain was normal and cerebrospinal fluid (CSF) showed pleocitosis with a lymphocytic predominance. Ceftriaxone, ampicillin and acyclovir were started empirically promptly. Pseudomonas aeruginosa was identified in CSF culture, and the antibiotic regimen was modified for cefepime, oxacillin and metronidazole. Cranial magnetic resonance showed bilateral frontal and sphenoidal sinusopathy, discontinuity of the sphenoid roof, without cerebrospinal fluid insinuation, purulent collections in posterior ventricles, empyema in the left temporal and occipital regions. A new CSF three days later maintained culture with Pseudomonas aeruginosa, so meropenem and ciprofloxacin were started. Antibiotic treatment lasted eight weeks, with a control lumbar puncture without bacteria growth. Sphenoid and ethmoid sinusotomy was performed by the otorhinolaryngology team. She was discharged after one month with mild paresthesia on the left hemiface, for outpatient follow-up.

Discussion: Gram-negative bacilli are an uncommon etiology of community-acquired meningitis in adults, with the majority of the cases occurring in neonates or infants. Escherichia coli accounts for the most cases, but there are less frequent pathogens described, such as Pseudomonas aeruginosa, Acinetobacter and Enterobacter. Non-hematogenous bacterial invasion of CSF occurs in situations of compromised integrity of the blood-brain barrier, such as neurosurgery, mastoiditis, sinusitis and malformations. We described a rare case of an elderly patient who has been diagnosed with community-acquired Pseudomonas aeruginosa meningoencephalitis and a medical history of chronic sinusitis and COPD. This patient presented with headache and confusional state, the last may be the only clinical feature in the elderly.

Conclusions: Pseudomonas aeruginosa is a rare cause of meningoencephalitis and has a significant morbidity and mortality. Further studies are needed to investigate if it is more common in patients with COPD and chronic sinusitis than in the general population due to the bacterial colonization in this profile of patients.

Palavras Chave

Meningoencephalitis; Pseudomonas aeruginosa Infection; Community-Acquired Infections; Sinusitis