Infections due to Pseudomonas fulva remain a rare but emerging concern. A case of ventriculitis due to Enterobacter cloacae and Pseudomonas fulva following placement of an external ventricular drain is described. Similar to other reports, the organism was initially misidentified as Pseudomonas putida. The infection was successfully treated with levofloxacin.
CASE REPORTA 55-year-old woman with a history of chronic migraines and hypertension was transferred to Emory University Hospital for management of a spontaneous subarachnoid hemorrhage. The patient complained of 1 week of worsening migraine headaches but denied nausea, vomiting, and neurologic disturbances until the day of admission, when she developed generalized paresthesia and progressive decline in the level of consciousness. On initial examination, she was lethargic and confused but her motor, sensory, and cranial nerves were intact. A computed tomography (CT) scan of the head showed a large subarachnoid hemorrhage in the basilar cisterns, bilateral sylvian fissures, and the interhemispheric fissure with hydrocephalus. Subsequently, an external ventricular drain (EVD) was placed. A saccular anterior communicating aneurysm was identified on a CT angiogram of the head, and the patient underwent coil embolization. On day 3 of hospitalization, the patient developed a temperature of 38.1°C and was diagnosed with an Escherichia coli urinary tract infection for which she was given levofloxacin (750 mg daily) during hospital days 4 to 8. Fevers persisted, however, and on day 5 of hospitalization, a grossly bloody cerebrospinal fluid (CSF) specimen from the EVD showed a white blood cell (WBC) count of 350 ϫ 10 6 cells/liter. CSF Gram stain and culture at that time were negative. Over the next several days, the CSF cell count progressively increased and on the day 9 of hospitalization was 14,000 ϫ 10 6 cells/liter with 80% neutrophils. During the same time period, the CSF glucose level ranged between 59 and 68 mg/dl (with corresponding plasma glucose levels of 112 to 131 mg/dl) and protein levels ranged between 159 and 270 mg/dl. Three CSF cultures obtained with each EVD aspiration during concurrent levofloxacin treatment for urinary tract infection were negative.Given worsening fever, three CSF specimens were sent for culture on hospital days 12 to 14. Each culture was positive for two different Gram-negative rods, which were detected on blood agar, chocolate agar, and MacConkey agar and in thioglycolate broth (Remel, Lenexa, KS) after overnight incubation at 35°C in 5% CO 2 . The first organism was present in a lower quantity than the second (2ϩ [moderate] in the first two cultures and 1ϩ [few] in the third) and was identified as Enterobacter cloacae. The other organism was present in high quantity (4ϩ [many]) in all three cultures, was a lactose nonfermenter, and formed smooth, wet colonies with a yellow nondiffusible pigment (Fig. 1). The oxidase reaction was inconclusive but was ultimately determined to be weakly positive after repeat testing. Biochemical ...
