De Novo Meningitis Caused by Propionibacterium acnes in a Patient with Metastatic Melanoma

Abstract

Propionibacterium acnes is a known cause of postneurosurgical meningitis; however, it is rarely implicated in de novo meningitis. Herein we report a case of a 49-year-old male with de novo meningitis caused by P. acnes with metastatic melanoma as the only identified risk factor for his infection. CASE REPORTA 49-year-old Caucasian male presented to his primary care physician with an 11-week history of bifrontal headaches associated with nausea and emesis but without other symptoms of meningismus. Symptomatic relief was provided with over-thecounter pain medications and antiemetics. Five weeks prior to arrival at our institution, the patient was admitted to an outside hospital for intractable vomiting and headaches. A computed tomography (CT) scan of the head and abdomen were performed, both of which were normal. Two weeks prior to admission, his headache and nausea worsened with the onset of subjective fevers, low back pain, lethargy, and confusion.Roughly 2 years prior to admission, the patient was diagnosed with stage IIIC melanoma of the right lower extremity, for which he underwent resection and lymphadenectomy. In the intervening period, he was thought to be in remission. Eight weeks prior to admission, a left-lower-extremity skin biopsy specimen demonstrated a melanocytic nevus.At the time of admission, his vital signs were as follows: temperature, 36.7°C; blood pressure, 168/92 mm Hg; heart rate, 87 beats per minute; respiratory rate, 20 breaths per minute; oxygen saturation of 98% on room air; height, 188 cm (74 in.); and weight, 142 kg (312.4 lb). The physical exam showed a well-developed male in no acute distress, alert, and oriented to place, year, self, and situation. Notable findings included right-lower-extremity swelling, a healed scar at the site of his prior melanoma, and ecchymosis surrounding a left-lower-extremity biopsy site. He did not have signs of meningismus.Laboratory findings on admission included a hemoglobin level of 14.1 g/dl, hematocrit of 40.3%, white blood cell count of 10,300/mm 3 , mildly elevated absolute neutrophil count of 7,600/ mm 3 (range, 1,800 to 6,600/mm 3 ), normal chemistry panel, an alanine transaminase level of 89 U/liter (range, 7 to 53 U/liter) but otherwise normal hepatic function panel, and a normal urinalysis.A repeat CT scan of the head was obtained on hospital day 2, 5 weeks after the prior scan, which revealed a communicating hydrocephalus. CT myelography was also performed on day 2, which showed clumping of the nerve roots within the lumbar spine and nodular thickening surrounding L2-L3 nerve roots consistent with arachnoiditis versus metastatic disease.A fluoroscopically guided lumbar puncture (LP) was performed on hospital day 2, which yielded clear, yellow cerebrospinal fluid (CSF) with a glucose concentration of 26 mg/dl (serum glucose, 96 mg/dl), protein concentration of 518 mg/dl, 145 nucleated cells/l (1% neutrophils, 32% macrophages, 10% monocytes, 6% lymphocytes, and 51% unclassified cells due to poor cell viability), 576 red blood cells/l, and an...

High‐throughput sequencing of cerebrospinal fluid for diagnosis of chronic Propionibacterium acnes meningitis in an allogeneic stem cell transplant recipient

“…It is well recognized as a cause of CNS infections in patients with a CSF shunt or other foreign material present , but is often dismissed as a contaminant when it is recovered from CSF cultures from patients who do not have foreign material present. However, cases of P. acnes meningitis in patients without a foreign body have been reported . As in the present case, those cases have tended to be sub‐acute, reflecting the low intrinsic virulence of this organism.…”

De novoPropionibacterium acnesseptic arthritis

“…Burnham et al 11 summarise nine cases of meningitis secondary to this organism without preceding surgery. Acute and indolent presentations were equally represented.…”

Routine Testing for Anaerobic Bacteria in Cerebrospinal Fluid Cultures Improves Recovery of Clinically Significant Pathogens

“…Although anaerobes are often considered contaminants because they are normal flora on human skin and mucosal surfaces, numerous case reports detail the existence and relevance of anaerobic organisms in bacterial meningitis (12)(13)(14)(15)(16)(17)(18)(19)(20)(21). These reports highlight some of the predisposing factors for anaerobic menin- gitis, such as infection (otitis media or upper respiratory infections), trauma, a recent surgical procedure, or the presence of CNS hardware, in particular a ventriculoperitoneal shunt (14).…”

“…As this study shows, the decision to treat a patient with antimicrobials is complex and based only in part on the result of a CSF culture. Clinicians take into account patient history and presenting symptoms, with special emphasis placed on the results of CSF studies, including direct specimen Gram stain, protein and glucose concentrations, nucleated cell count, and the relative percentage of neutrophils identified (12,13).…”