First Initial community-acquired meningitis due to extended-spectrum beta-lactamase producing Escherichia coli complicated with multiple aortic mycotic aneurysms
© Weyrich et al; licensee BioMed Central Ltd. 2012
Received: 15 September 2011
Accepted: 9 February 2012
Published: 9 February 2012
We report the first case of extended-spectrum beta-lactamase producing E. coli community-acquired meningitis complicated with multiple aortic mycotic aneurysms. Because of the acute aneurysm expansion with possible impending rupture on 2 abdominal CT scan, the patient underwent prompt vascular surgery and broad spectrum antibiotic therapy but he died of a hemorrhagic shock. Extended-spectrum beta-lactamase producing E. coli was identified from both blood and cerebrospinal fluid culture before vascular treatment. The present case report does not however change the guidelines of Gram negative bacteria meningitis in adults.
Adult community-acquired meningitis due to E. coli is a rare entity. It generally occurs in patients with compromised immune status or cirrhosis. When direct examination of the cerebrospinal fluid (CSF) shows the presence of Gram negative bacilli (GNB), current guidelines recommend the use of a 3rd generation cephalosporin (cefotaxime or ceftriaxone) [1, 2]. We herein report the first case of extended-spectrum beta-lactamase (ESBL) producing E. coli community-acquired meningitis complicated with multiple aortic mycotic aneurysms.
In September 2010, a 59-year-old patient with a history of chronic alcohol and tobacco consumption was admitted to the emergency unit for consciousness disorders and fever. Two days before his admission, the patient had presented headache and nausea.
Community-acquired meningitis in adults due to E. coli is a rare entity. The main risk factors are alcoholism, cirrhosis, neoplasic diseases, diabetes mellitus, and treatment with immunosuppressive agents [3–7]. Others cases occur frequently in neurosurgery and are usually associated with multi-drug resistant strains [8–11]. In our observation, the patient had no risk factors except a chronic alcoholism and perhaps his dog as animal pet.
In Europe, there is an increasing in 3rd generation cephalosporin resistant E. coli isolates in both hospital setting and the community. CTX-M ESBL is the most common genetic support of resistance in these strains . In our case report, we suspected this mechanism. The spread of E. coli producing ESBL is now well- identified .
Blood stream infections due to E. coli in adults are often related to underlying urinary or bilary tract or other intra-abdominal infections. Vascular infections and meningitis due to E. coli are exceedingly rare and few cases isolated have been reported [14–16]. Diabetes mellitus, previous fluoroquinolone use, recurrent urinary tract infection, previous hospital admission and older age in male patients have been identified as risk factors for infection of ESBL-producing E. coli . Recently, Ewers and al. suggested the possibility of inter-species transmission of multiresistant strains of E. coli from human to animal and vice versa .
The current guidelines for the management of gram negative bacilli (GNB) related meningitis are well codified and recommend the use of a 3rd generation cephalosporins ± gentamicin. Alternative therapies are Cefepime, meropenem, aztreonam, fluoroquinolone, and trimethoprim-sulfamethoxazole [1, 2]. In our case report, meropenem (in association with ciprofloxacin) was used because of the lower risk of seizures compared to imipenem [19, 20]. Mortality associated with GNB related meningitis varied from 25 to 100% [7, 21]. Lu et al. identified several risk factors for mortality associated to GNB related meningitis: inappropriate initial treatment, septic shock, initial level of consciousness, hyperosmolar hyperglycemic coma, disseminated intravascular coagulation, high CSF lactate levels and leucocytosis. In the multiple logistic regression analysis, only appropriate antimicrobial therapy and septic shock were strongly associated with mortality even after adjusting for other potentially confounding factors . Inappropriate treatment and septic shock were initially present in our patient. The presence of a concomitant aortic mycotic aneurysm was an additional factor of mortality.
Only two cases of mycotic aneurysm in patient presenting initially bacterial meningitis have been reported [22, 23]. The first case is a 65-year old woman with ruptured mycotic aneurysm in a patient with pneumococcal meningitis, who died on week later. The second case is a 57 year-old man with a history of CFS fistula and multiple neurosurgical treatment, who developed meningitis complicated with endocarditis and thoracic aortic infection. No bacteria were identified in this second case. The patient was successfully treated with endovascular prosthesis. In the present case report, multiple mycotic aneurysms were suspected because of the sustained bacteremia, the atypical and multiple foci of vascular infection, the normality of the first abdominal CT scan and the rapid evolution of aneurysm. the aortic involvement may be the result of infection of the aortic wall.
The present case report highlights the risk of meningitis due to ESBL producing E. coli in a patient with apparently no risk factor for this infection with this type of resistant bacilli. This unique observation does not provide, however to modify the current guidelines for the treatment of community acquired meningitis in adults.
Written informed consent was obtained from the patient's family for publication of this case report and accompanying images.
Thanks to J Bram for her English assistance.
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