Case of the Week

Editor: Dr Danielle Coleman

An unsuspected deadly diagnosis of cerebral pyogenic ventriculitis
A Rare case of severe headache: cerebral pyogenic ventriculitis.
Author: C Lojo Rial

A 40yr old Caucasian man presented to A&E with a 2 weeks history of malaise and back pain radiating down the left leg. He had a background of intravenous drug abuse and chronic back pain following a road traffic accident 10 years ago. Collateral history revealed that he had been self-medicating for back pain (eight weeks) and severe headache (four days) with a cocktail of painkillers, crack cocaine and heroine. His GCS was 8 and was admitted via ambulance for a suspected overdose.

On arrival, he was apyrexial (35.1), agitated and disorientated. General examination revealed a 2cm liver edge, a small right groin abscess, no focal neurological deficits or signs of meningism. His gait was unsteady and he had sluggish but equal pupillary reflexes bilaterally (3+). He was treated as a suspected overdose in view of his recent substance abuse and fluctuant GCS, but rapidly became unwell and progressively unresponsive despite Naloxone. His bloods suggested unknown source of sepsis (WCC 17.7; Plat 939; CRP 338; otherwise normal).

An urgent CT-Head was performed showing hydrocephalus and generalised oedema. A high-density fluid level was noted suggesting frank pus within the ventricles (White arrow). Spine imaging demonstrated an L5-S1 spinal abscess. He was started on Vancomycin, Ceftriaxone and Metronidazole and referred to neurosurgery for insertion of an external ventricular drain.

Although rare, ventriculitis is associated with a very high mortality requiring long periods of intensive treatment. The importance of accurate information in making the diagnosis is critical, particularly where signs and symptoms do not fit.

Reference: Kiyan S, et al. A rare diagnosis in ED: cerebral pyogenic ventriculitis due to infective endocarditis. American Journal of Emergency Medicine (2007);25:120-122.