Concurrent Spontaneous Pneumocephalus and Subarachnoid Hemorrhage Due to Klebsiella Pneumoniae Meningitis

Abstract

Dear Editor, Pneumocephalus is the presence of air or gas within the cranial cavity,1 and is usually caused by craniofacial trauma, neurosurgery, or an invasive procedure. Although rare, bacterial meningitis can lead to pneumocephalus without structural defect of the skull or dura.2 In addition, subarachnoid hemorrhage (SAH) is extremely rare, although there are reports of cerebral infarction due to arteritis, thrombophlebitis, or vasospasm being accompanied with bacterial meningitis.3 Here we report an unusual case—which is the first case to the best of our knowledge—presenting concurrent pneumocephalus and SAH due to Klebsiella pneumoniae meningitis in adults. A 51-year-old female was admitted to our hospital with right ear pain and headache that had first appeared 3 days previously. She had a 10-year history of diabetes mellitus (DM) and liver cirrhosis due to hepatitis C. At admission she had no fever and her consciousness was alert, but on the following day her consciousness deteriorated to stupor with a high fever of 38.9°C. A neurologic examination revealed neck stiffness, although her brainstem reflexes including the corneal reflex and vestibulo-ocular reflex were intact. The initial brain CT (computed tomography) showed right chronic otitis media (COM), but the findings were otherwise unremarkable (Fig. 1A). At 3 hours after the initial brain CT, she showed ocular flutter and absence of brainstem reflexes. Blood tests revealed thrombocytopenia (platelet count: 40,000/μL), but no leukocytosis or elevation of CRP. During the cerebrospinal fluid (CSF) study there was a high opening pressure of 510 mm H2O, with the CSF presenting a greenish yellow color with the following extremely serious inflammatory findings: 14,200 white blood cells/μL (97% polymorphonuclear cells), 3,150 red blood cells/μL, elevated protein (1,740 mg/dL), and severe hypoglycorrhachia (glucose ratio in CSF/serum=0.03). Vancomycin, meropenem, and ampicillin along with high doses of steroids were applied immediately after obtaining the CSF findings. Despite the combined antibiotic treatment, the patient deteriorated rapidly to a coma state with anisocoric pupils and no self-respiration. On the 3rd day of hospitalization, SAH in both cerebral sulci and the suprasellar cistern was observed on brain CT (Fig. 1B). Brain magnetic resonance angiography only revealed diffuse luminal irregularity in both middle cerebral arteries, with no aneurysm identified. She progressed to septic shock with high fever and decreased blood pressure. Chest and abdomenpelvic CT produced no other infectious findings. However, Klebsiella pneumoniae was identified in blood and CSF cultures. Based on these results, cefepime (which is more effective against Klebsiella pneumoniae) was replaced as the main antibiotic treatment. However, her condition did not improve despite aggressive treatment. Brain CT of the 10th day (Fig. 1C) revealed pneumocephalus (which had not been seen previously) within subdural, intraparenchymal, and intravascular spaces, along with diffuse brain swelling. Unfortunately her condition continued to worsen, and she died on the 12th day. Pneumocephalus is usually associated with craniofacial trauma, neurosurgery, or neoEun Ji Lee Rae On Kim Mina Lee Byung-Euk Joo