Infection of Central Nervous System by Motile Enterococcus : First Case Report

Abstract

A 66-year-old man with four indwelling ventriculoperitoneal shunts for multiloculated hydrocephalus from a complicated case of meningitis a year before developed shunt infection based on a syndrome of fever, drowsiness, and cerebrospinal fluid neutrophil pleocytosis in the background of repeated surgical manipulation to relieve successive shunt blockages. The cerebrospinal fluid culture, which yielded a motile Enterococcus species, was believed to originate from the gut. This isolate was lost in storage and could not be characterized further. The patient improved with vancomycin and high-dose ampicillin therapy. He relapsed a month later with Enterococcus gallinarum shunt infection, which responded to high-dose ampicillin and gentamicin therapy. This is probably the first case report of motile Enterococcus infection of the central nervous system. CASE REPORTA 64-year-old man was admitted to a public hospital in early March 1999 for fever for 2 days. He had a background history of listeria meningitis a year ago, which was complicated by multiloculated hydrocephalus requiring four indwelling ventriculoperitoneal (VP) shunts. He also had mild Parkinson's disease for which he was not on any specific treatment and a recent admission, 2 months ago, to another hospital for aspiration pneumonia after which he was on a nasogastric tube for feeding. On examination, he was febrile (temperature, 38.0°C) and lethargic but oriented. His neck was supple, and the 4-VP shunts were palpable. A computed tomography (CT) scan of the brain showed no hydrocephalus, and the 4-VP shunts were in situ. He was empirically treated for presumed aspiration pneumonia with ceftriaxone and metronidazole, although the chest X-ray was unremarkable. As his fever persisted, therapy was changed to ceftazidime and vancomycin. The fever settled after about a week of treatment, and the antibiotics were stopped. Four days later, vancomycin was restarted because he became febrile and drowsy after a shunt revision from which cultures of the shunt and cerebrospinal fluid (CSF) were sterile. Subsequently, he required two further shunt revisions during the first week of April 1999. Cultures from the CSF fluid from these revisions yielded a motile Enterococcus species which correlated with significant neutrophil pleocytosis from the specimens of the CSF on both occasions. The organism was intermediate in its sensitivity to vancomycin (the vancomycin MIC was 8 mg/liter) and was sensitive to ampicillin, penicillin (the MIC of penicillin was 0.38 mg/liter), and gentamicin synergy. Shunt infection was diagnosed based on the preceding features and the ongoing fever and drowsiness in the patient. High-dose ampicillin was added to vancomycin, resulting in marked defervescence after 2 days. The treatment was continued for 3 weeks with good response. The shunts remained indwelling, as the surgeons were not keen to remove them. He underwent another shunt revision 2 weeks later, and this time the CSF culture was sterile. He was discharged after 6 weeks of hospitalization...

Enterococcus gallinarum meningitis in an immunocompetent host: a case report

“…Most cases of enterococcal meningitis occur in patients with anatomic defects of CNS, prior neurosurgery, head trauma or immunosuppression 1,4,5,7 . Two presentations of enterococcal meningitis are usually described: postoperative and spontaneous.…”

“…In a review of the literature, only four cases of meningitis by E. gallinarum were found as shown in Table 1. In all cases, a neurological procedure was performed prior to diagnosis (three with ventriculoperitoneal shunt and one with a lumbar drain) 4,8,9,10 . We describe here a case of E. gallinarum meningitis in a 53-year-old man, with a long history of alcohol abuse.…”

“…The option for ampicillin and aminoglycoside was based on two important facts: the antibiogram and synergy of both antimicrobials, as recommended for CNS infections due to Enterococci, although there is no consensus about the best choice between monotherapy or combination therapy 4,7 . The occurrence of vancomycin resistance in our case was expected, regarding a natural characteristic of motile species of enterococci in expressing Glycopeptide resistant genes.…”

“…The occurrence of vancomycin resistance in our case was expected, regarding a natural characteristic of motile species of enterococci in expressing Glycopeptide resistant genes. The duration of treatment was based on previous reports of treatment of enterococcal meningitis 4,5,7,8,10 .…”

“…Infection by E. gallinarum rarely occurs and has been implicated in a few invasive infections in humans, especially in immunocompromised or chronically ill patients 2,3,5 . There are only four cases of CNS involvement reported in literature due to this unusual germ, all reporting on patients with some degree of immunosuppression who had been previously submitted to a neurological procedure 4,8,9,10 . In this paper we describe one case of meningitis caused by E. gallinarum in an immunocompetent host.…”