(750) A Rare Case of Community-Acquired Pyogenic Ventriculitis in an Elderly Afro-Caribbean Male

Introduction: Ventriculitis is a Central Nervous System infection characterized by inflammation of the ependymal cells and purulent exudate. Ventriculitis is well documented in literature as a complication of neurosurgical intervention and instrumentation, however, primary/community-acquired ventriculitis is highly uncommon with less than 10 cases being reported as of 2024.

Description: A 65-year-old male subway worker with hypertension and diabetes mellitus type 2 was admitted with encephalopathy, generalized body aches, headache, lower back and neck pain, and unsteady gait, 5 days after initial evaluation for similar symptoms. Covid test resulted as positive, and patient was admitted to isolation on the Neuroscience unit. His examination subsequently declined with acute encephalopathy, depressed level of consciousness, and fixed upward gaze prompting head CT. Results showed isodense material in bilateral lateral ventricles concerning for ventriculitis. Broad spectrum antibiotics were started, and he required intubation for airway protection and impending respiratory failure. An external ventricular drain (EVD) was placed due to hydrocephalus, and he was transferred to the Intensive Care Unit. Cerebrospinal (CSF) fluid findings were suggestive of bacterial infection however no causative organism was identified. During his hospital stay he required bilateral ventriculoperitoneal shunt (VPS) placement and was eventually discharged to a rehabilitation center. Up to 18 months after diagnosis, he was known to be ambulatory with assistive devices and dementia.

Discussion: The classic triad of encephalopathy, meningismus and fever is only present in 44-67% of patients with meningitis. In patients who have immunosuppression this triad is even less common. With ventriculitis, an even higher index of suspicion must be maintained. Head CT prior to lumbar puncture is commonly necessary, and phlegmon present in the subarachnoid space or ventricular system can be demonstrated. Once identified, cerebrospinal fluid collection via EVD may be required to clear phlegmon. Identification of the causative organism and tailoring of antibiotic treatment should be the next step in management. Our experience shows that favorable outcomes are possible with appropriate multidisplinary care.