It is a rare but serious intracranial infection.
The commonest organisms causing pyogenic ventriculitis are Staphylococcus aureus, other Gram-positive cocci, Enterobacter and Klebsiella species, in association with nosocomial infection or immunosuppression 3) 4).
In the series of Wang et al., the most frequently isolated pathogen from cerebrospinal fluid (CSF) was Acinetobacter baumannii, followed by Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, and Serratia marcescens 5).
The clinical course of ventriculitis is typically indolent and non-specific, and early diagnosis and treatment are important to improve prognosis.
In a febrile patient with a ventriculostomy, diagnosing or excluding bacterial or microbial ventriculitis is difficult, as conventional markers in analysis of cerebrospinal fluid (CSF) are not applicable due to presence of blood and inflammation.
Data from a large sample of CSF studies in patients with ventriculostomy indicate that no single value of cerebrospinal fluid lactate provided both sensitivity and specificity high enough to be regarded as reliable test 7).
Characteristic findings include: ventricular debris, periventricular hyperintensity, and diffusion restriction in the debris. However, in patients who are unstable to undergo MR scans, CT scans can still be informative. The irregular debris morphology is highly specific for purulent material 11).
The ventricular debris sinks towards the occipital horns with the patient supine in the scanner. The surface of the viscous debris is often round or irregular, in contrast to the straight level of acute intraventricular blood.
The ‘lodge sign’ is observed, a radiological phenomenon not previously described: in the right lateral ventricle, where the debris diameter exceeds the occipital horn, the debris is ‘lodged’, separating the CSF anteroposteriorly. On the left, CSF is also seen isolated at the tip of the occipital horn, by the overlying debris. The ‘lodge sign’ is likely to be underreported previously, as the shape of the small purulent material was not studied in details.
In patients whose clinical history is unclear and who are unsafe to undergo MRI scan, such as this case, the ‘lodge sign’ can differenitate pyogenic ventriculitis from acute intraventricular hemorrhage, both of which require prompt and specific investigations and treatments 12).
The cure rate was 73.3%. Of note, the mean period to sterilize the CSF after appropriate IVT antibiotic treatment was 6.6 days. There were no incidents of seizure or chemical ventriculitis during this IVT therapy.
The findings of this study suggest that IVT antibiotic therapy is a useful option in the treatment of postneurosurgical GNBM or ventriculitis, especially for those with a treatment-refractory state 13).
Srihawan et al performed a retrospective study of adults and children with the diagnosis of healthcare associated meningitis or ventriculitis, as defined by the 2015 Centers of Disease Control and Prevention case definition, at 2 large tertiary care hospitals in Houston, Texas from July 2003 to November 2014. Patients were identified by infection control practitioners and by screening cerebrospinal fluid samples sent to the central laboratory. We collected data on demographics, clinical presentations, laboratory results, imaging studies, treatments, and outcomes. Results. A total of 215 patients were included (166 adults and 49 children). A positive cerebrospinal fluid culture was seen in 106 (49%) patients, with the majority of the etiologies being Staphylococcus and Gram-negative rods. An adverse clinical outcome was seen in 167 patients (77.7%) and was defined as death in 20 patients (9.3%), persistent vegetative state in 31 patients (14.4%), severe disability in 77 patients (35.8%), or moderate disability in 39 patients (18.1%). On logistic regression analysis, age >45 years (adjusted odds ratio [OR], 6.47; 95% confidence interval [CI], 2.31-18.11; P ≤ .001), abnormal neurological exam (adjusted OR, 3.04; 95% CI, 1.27-7.29; P = .013), and mechanical ventilation (adjusted OR, 5.34; 95% CI, 1.51-18.92; P = .01) were associated with an adverse outcome. Conclusions. Healthcare-associated meningitis or ventriculitis is associated with significant morbidity and mortality 14).
A 53-year-old previously well man who presented with a collapse after a 4-day history of severe non-specific headache and vomiting. His initial Glasgow Coma Score (GCS) was 7/15 (E1V1M5), temperature was 38.2 °C, and he was intubated. Empirical ceftriaxone and acyclovir were commenced for suspected encephalitis. Cranial CT revealed intraventricular hyperdense areas in bilateral occipital horns and hydrocephalus, suggestive of spontaneous hemorrhage (39–48 Hounsfield units) (Fig. 1). He was transferred to our Neurosurgery Unit. CT angiogram excluded intracranial vascular abnormalities. Blood tests showed neutrophilia (26.5 × 109 /l) and raised C-reactive protein (260.5 mg/l). Following extubation 4 h later, the patient’s GCS improved to E4V1M6. Cerebrospinal fluid (CSF) from a lumbar puncture was turbid; opening pressure was low; glucose was 2.2 mmol (serum glucose 5.9 mmol); microscopy showed pleocytosis (4105 × 106 /l, polymorphs 92 %), and presence of Gram-negative diplococci. Nuclei acid test and polymerase chain reaction test confirmed Neisseria meningitides serogroup B. In retrospect, the intraventricular materials were suppurative substance. On day 2, the patient’s GCS returned to 15. Tests for immunodeficiency, including HIV test, were negative. He completed a 10-day course of ceftriaxone. On day 10, a repeat scan showed complete resolution of the intraventricular purulent material. On day 12, his inflammatory markers normalized, and he was discharged with a full neurological recovery and returned to work 6 weeks later 15).