Extensive Pneumocephalus Caused by Multidrug-Resistant Klebsiella pneumoniae

Pneumocephalus is a life-threatening event associated with different infectious diseases and trauma. Klebsiella pneumoniae is a gas-forming organism that can cause pneumocephalus. A woman aged 56 years presented with a history of septic shock and community-acquired pneumonia. She was supported by mechanical ventilation in intensive care unit. Multidrug-resistant K. pneumoniae was detected in her blood and tracheal aspirate. Her level of consciousness reduced, and clinical condition was deteriorating. The computed tomography scan of the brain revealed abundant pneumocephalus entities. Multidrug-resistant K. pneumoniae was found in her cerebrospinal fluid while on appropriate antibiotic therapy. She died from acute stroke during her treatment.

Pneumocephalus in Child Following Bilateral Otomastoiditis and Nasal Septum Infection

Pneumocephalus is collection of gas or air within the cranial cavity, commonly associated with trauma, cranial surgery, air embolism, open meningomyelocele; and rarely as a result of central nervous system infections. Asymptomatic pneumocephalus usually recovers spontaneously within few days. Untreated pneumocephalus can progress to tension pneumocephalus, manifesting as severe headache, dizziness, cranial nerve palsy, mental changes, seizure and disorientation. Herein, we report a rare case of pneumocephalus in a 9-month infant with subdural effusion following infection of nasal septum and otomastoiditis. There was no sign of meningitis but CThead showed communication of intracranial dura mater across widened foramen caecum with pre-nasal space, and bilateral otomastoiditis with erosion of anterior and lateral wall of right mastoid bone. The patient was treated successfully and discharged without sequelae.

What is hiding behind bubbles of air? An unusual Streptococcus pyogenes meningitis

Streptococcus pyogenes is a rare but aggressive cause of meningitis, which often evolves in a poor outcome with fatal consequences. Although lumbar puncture and CT scan of the brain are the gold standard of diagnosis of cerebral infections, they can have some limitations. We report and describe the clinical history and neuroimaging of a 36-year-old woman admitted to the emergency department of our hospital three days after the onset of earache and otorrhoea. When the patient developed an emergent refractory status epilepticus, the CT scan of the brain showed an unusual pneumocephalus. However, the MRI study of the brain revealed a pachymeningitis with partial thrombosis of the right transverse sinus and subdural empyema due to a S. pyogenes otitis media. Prompt diagnosis and the specific findings of the MRI allowed rapid correct treatment and thus led to a good outcome for the patient.

A 2-year-old boy with hemolytic uremic syndrome and pneumocephalus

Clostridium septicum infection following hemolytic uremic syndrome is rare and carries a poor prognosis, especially when the brain is involved. We report a case of a previously healthy 2-year-old boy who presented with two days of anuria and bloody diarrhea. He was admitted to the local children's hospital with a diagnosis of hemolytic uremic syndrome, presumably secondary to E. coli O157. He soon required intubation and was noted to have fixed and dilated pupils. Head CT revealed left frontal subcortical white matter vasogenic edema and scattered pockets of pneumocephalus. The patient expired 14 hours after admission. Antemortem blood cultures grew C. septicum. Gross pathologic examination of the brain revealed a large intraparenchymal cerebral hemorrhage in the left frontal and parietal lobes. There was extensive cystic changes as well. Microscopic examination revealed vacuolization and diffuse colonization with rod-shaped bacteria, but without the expected tissue response. There have been only six previously reported cases of C. septicum infection following hemolytic uremic syndrome, four of which had brain involvement. Mortality rate is high, with the only known survivor among those with brain involvement having a brain abscess rather than diffuse pneumocephalus.

[Meningitis can resemble subarachnoid haemorrhage]

A 70 year-old man was admitted under the diagnosis of subarachnoid haemorrhage and presented with a history of ear pain, followed by acute onset of severe headache, nausea, vomiting, impaired consciousness, and fever. However, a computed tomography (CT) showed an acute mastoiditis and pneumocephalus, and a lumbar puncture confirmed the diagnosis meningitis. The increased middle ear pressure relative to the intracranial pressure had caused air and bacteria to penetrate intracerebrally. This case illustrates the importance of a rapid diagnostic workup in acute onset headache including a careful anamnesis, CT and lumbar puncture.

Acute group A streptococcal mastoiditis complicated by pneumocephaly in a previously healthy adult

Streptococcus pyogenes is a rare cause of mastoiditis in adults. We report a previously healthy adult patient who had acute bacteraemic S. pyogenes mastoiditis complicated by intra-cranial air. This novel report adds pneumocephaly to the currently recognized list of complications of acute mastoiditis.

[Pneumocephalus caused by neonatal Enterobacter cloacae infection in a case]

OBJECTIVE

Gas-containing encephalo-meningitis is very rare. There have only been a few cases reported in the literature. The majority of neonatal cases reported in literature died. We report a case of a 5-day-old neonate who developed diffuse pneumocephalus from Enterobacter cloacae septicemia and intracranial infection.

METHOD

This neonate was initially treated with penicillin and mezlocillin. He also received phototherapy, intravenous infusion, correction of acidosis and other supportive therapy. Complete blood count, C-Reactive protein, cranial CT scan, blood culture, cerebrospinal fluid culture and biochemistry were tested repeatedly.

RESULTS

This neonate's condition deteriorated after admission. He developed respiratory distress, increased muscle tone and decreased level of consciousness. His WBC and C-reactive protein were elevated, while blood gas, electrolytes, liver enzymes and renal function were within normal range initially. Cranial CT scan was done which demonstrated diffuse pneumocephalus. He was transferred to a higher level hospital for further management at the request of the family. Blood culture done in our hospital subsequently showed growth of Enterobacter cloacae. The infant developed seizures and further deterioration in level of consciousness after transfer. Antibiotics were switched to penicillin and ceftizoxime. Cranial CT scan repeated 2 days after transfer showed hydrocephalus and some resolution of pneumocephalus. Cerebrospinal fluid (CSF) was aspirated from the lateral ventricles two weeks after admission. CSF culture also showed growth of Enterobacter cloacae. Antibiotic was switched to imipenem according to antibiotic sensitivity. His general condition was improved. Blood and CSF cultures were negative 1 month after admission. His head circumference at discharge was 34.6 cm. Repeat cranial CT scan at 4 month of age demonstrated severe hydrocephalus, diffuse leukomalacia and calcification. This infant suffered significant neurodevelopmental deficit. Muscle tone was diffusely increased. Head circumference at 9 month of age was 48.4 cm.

CONCLUSION

This case suggests the importance of Enterobacter cloacae infection in the newborns. Our analysis of 34 cases of Enterobacter cloacae infection showed that 93.75% - 100% were sensitive to quinolones, 94.12% were sensitive to imipenem, 73.33% were sensitive to gentamicin, 50% were sensitive to piperacillin-tazobactam. Enterobacter cloacae is generally not sensitive to penicillin, first and second generation cephalosporins (0 - 21.4%). Enterobacter cloacae septicemia and intracranial infection in neonates have a high mortality rate and can result in severe neurodevelopmental deficit in survivors.

Pneumocephalus as a complication of multidrug-resistant Klebsiella pneumoniae meningitis

Pneumocephalus implies air inside the cranial vault, which usually results from cranio-facial trauma. Occasionally, meningitis caused by gas-forming organisms can result in pneumocephalus. Klebsiella pneumoniae meningitis can, on rare occasions, cause pneumocephalus as a complication. The drug of choice for K. pneumoniae meningitis is a third-generation cephalosporin, and resistance to these drugs is unusual. We report a case of multidrug-resistant K. pneumoniae meningitis resulting from chronic suppurative otitis media, which was later complicated by pneumocephalus. The patient was successfully managed with meropenam and amikacin, the only antibiotics to which these bacilli showed no resistance.

Infected pneumatocele following anaerobic pneumonia in adult

We report a case of an infected pneumatocele in the course of anaerobic pneumonia in an adult. To the best of our knowledge, anaerobic pneumonia complicated by a pneumatocele in an adult has not previously been described. The pneumatocele occurred on the fifth day of hospitalization, and rapidly increased in size, with the development of a subsequent mixed anaerobe infection. A pig-tail catheter was inserted and the pus drained. The bacterial culture from the pus was positive for three anaerobes: Bacteroid species, Peptostreptococcus asaccharolyticus and Fusobacterium species. Intravenous antibiotics and percutaneous catheter drainage resulted in a successful treatment.

Pneumocephalus associated with Bacteroides fragilis meningitis

Gas within the intracranial cavity (pneumocephalus) commonly results from trauma or after surgery and rarely from infection by gas-forming organisms. The presence of pneumocephalus in the absence of injury or surgery should raise the suspicion of anaerobic infection of the central nervous system. I present a case of pneumocephalus associated with Bacteroides fragilis meningitis where the diagnosis was suspected after CT findings become available. Bacteroides fragilis meningitis is rare and often occurs in premature infants and neonates; only few cases are reported in adults. Pneumocephalus associated with Bacteroides fragilis meningitis is not described in the literature. This case also illustrates the absence of classic findings of meningeal irritation in the elderly. The literature is reviewed.

Pneumoencephalomeningitis secondary to infected lumbar arthrodesis with a fistula: a case report

Pneumocephalus associated with spinal problems is very rare. Association with encephalomeningitis secondary to a fistula after an infected elective lumbar spine fusion has not been previously reported. The authors report a case in which the clinical onset of pneumoencephalomeningitis occurred after an airplane flight. CT-scan and lumbar puncture were used to make diagnosis; the treatment was based on parenteral antibiotics. The symptoms and signs of infection and neurological deficit resolved but the fistula remained. Diagnosis in such cases must be based upon CT-scan and lumbar puncture. Treatment should consist of systemic antibiotic therapy. Surgical management of infection and fistula is desirable, should the status of the patient allow such a treatment. In any case, as airplane flights in such cases may predispose to pneumocephalus, patients with an infected CSF fistula should avoid airplane flights until the problem is solved.

Localized pneumocephalus caused by Clostridium perfringens meningitis

Clostridium meningitis is a rare complication of elective surgery, but the presence of pneumocephalus on CT in the absence of penetrating injuries, should raise the possibility of anaerobic infections. We report a case of fatal Clostridium perfringens meningitis which occurred 4 months after a craniotomy for glioblastoma multiforme. The diagnosis was suspected based on the CT findings. The literature of this rare condition is reviewed.

Diffuse pneumocephalus due to Clostridium septicum cerebritis in haemolytic uraemic syndrome: CT demonstration

The computed tomography finding of diffuse pneumocephalus due to infection by gas-forming organisms is very unusual. We report such a case due to secondary infection by Clostridium septicum in a child with diarrhoea-associated haemolytic uraemic syndrome.