Klebsiella pneumoniae meningitis associated with acute vasculitis and stroke

Details

• Personal Author:
  Kwon S ; Luk A ; Mahmoudi M ; Murthy V ; Nolan A ; Phillips M ; Rastogi N
• Description:
  Introduction: Klebsiella pneumoniae is an uncommon cause of meningitis - most cases are associated with nosocomial infection. In the United States and Europe, an estimated 8% of nosocomial bacterial infections can be attributed to K. pneumoniae, and predominantly manifest as urinary and respiratory tract infections. From past reports, gram negative bacilli made up only 3% of community acquired meningitis cases, although higher rates are described in Southeast Asia. We report a case of meningitis due to community-acquired Klebsiella with a rare stroke-like presentation secondary to meningitis-associated vasculitis. Case Report: A 57 year-old man with diabetes mellitus and hypertension presented with confusion, fever, and left-sided hemiplegia for the preceding four days. He was obtunded and intubated. Lumbar puncture yielded cerebrospinal fluid (CSF) with a white blood cell count of 53,600cells/mm3 with 95% neutrophils, glucose <1mg/dL and protein of 474.3mg/dL. The patient was started on vancomycin, ceftriaxone and dexamethasone. CSF gram stain was significant for gram negative bacilli that speciated to Klebsiella pneumoniae and dexamethasone was discontinued. Magnetic resonance imaging was performed, which showed arteritis of the right middle cerebral artery, bilateral ventriculitis and acute infarction of the right cerebellar hemisphere. By hospital day (HD) two, the patient demonstrated improved strength in his left upper and lower extremities. On HD 3 patient's left sided weakness returned and his mental status worsened. Steroids were restarted-again with improvement within 12 hours. Extensive evaluation for a source of Klebsiella, including abdominal imaging, cultures of urine and blood and echocardiography yielded no findings outside the central nervous system. In addition, other causes of vasculitis were not found. Treatment included a 21-day course of ceftriaxone and a tapered 14-day course of steroids. Minimal residual left-sided motor deficit remained and patient was transferred to the rehabilitation service. Discussion: Review of the literature confirmed the rarity of community acquired Klebsiella meningitis with no significant prior healthcare exposure. Age and underlying diabetes mellitus are predisposing factors in this patient. Steroid-responsive neurological findings consistent with vasculitis further added to the novelty of our patient's presentation. Klebsiella meningitis animal models have demonstrated increased synthesis of pro-inflammatory markers such as, TNF-alpha, IL-1 and IL-6 with subsequent neurological and cognitive deficits. This patient's Klebsiella isolate had hypermucoviscous characteristics similar to those described in case series from Southeast Asia, mainly Taiwan. Steroids in the management of Klebsiella meningitis has not been previously described given the rarity of this clinical syndrome. [Description provided by NIOSH]
• Subjects:
  Anti-Bacterial Agents Blood Cardiovascular Diseases Cardiovascular System Communicable Diseases Drug Therapy Health Care Facilities Workforce And Services Hematologic Diseases Immune System Men Microbiology Nervous System Occupational Health Respiratory System Respiratory Tract Diseases Safety Steroids

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• Keywords:
  Antibacterial Agents Antibiotics Bacteria Bacterial Infections Bacterial Meningitis Blood Sugar Disorders Blood Vessels Cardiac Function Cardiopulmonary Function Cardiovascular Function Case Reports Cerebrospinal Fluid Cerebrovascular System Cognitive Function Drug Therapy Health Care Health Care Facilities Heart Hypertension Immune Reaction Infectious Diseases Ischemic Stroke Medicinal Chemicals Microorganisms Neurological Reactions Nosocomial Infections Respiratory Infections Urogenital System Vasoactive Agents

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• ISSN:
  1073-449X
• Document Type:
  Text
• Funding:
  Cooperative Agreement
• Genre:
  Abstract or Summary
• Place as Subject:
  New York ; OSHA Region 2
• CIO:
  National Institute for Occupational Safety and Health (NIOSH)
• Topic:
  Workplace Safety & Health
• Location:
  North America
• Volume:
  191
• NIOSHTIC Number:
  nn:20048578
• Citation:
  Am J Respir Crit Care Med 2015 May; 191(Abstract Issue):A1681
• Contact Point Address:
  V. Murthy, New York University School of Medicine, New York, NY
• Email:
  murthv01@nyumc.org
• Federal Fiscal Year:
  2015
• Performing Organization:
  New York University School of Medicine
• Peer Reviewed:
  False
• Start Date:
  20140701
• Source Full Name:
  American Journal of Respiratory and Critical Care Medicine
• Supplement:
  Abstract Issue
• End Date:
  20170630
• Collection(s):
  National Institute for Occupational Safety and Health
• Main Document Checksum:
  urn:sha-512:0b5471babe470ebce1e791892035450abe8d0ac314c7464d104c26550b6c6cc4bb59b400bc465e900714d5845ba4f12d391fd4c558ca61f154de332ed0f9b704
• Download URL:
  https://stacks.cdc.gov/view/cdc/203301/cdc_203301_DS1.pdf
• File Type:
  [PDF - 46.11 KB ]