A. Chirianc, Giorgiana Ion, Z. Faiyad, I. Poeata DOI: 10.33962/roneuro -2020-001 Management of a patient with acute internal hydrocephalus, ventriculitis and bronchopneumonia. Case report Balasa Daniel, Tunas Alexandru Romanian Neurosurgery (2020) XXXIV (1): pp. 17-19 DOI: 10.33962/roneuro-2020-002 www.journals.lapub.co.uk/index.php/roneurosurgery Management of a patient with acute internal hydrocephalus, ventriculitis and bronchopneumonia. Case report Balasa Daniel, MD, PhD; Tunas Alexandru, MD Department of Neurosurgery, Clinical County Hospital, Constanta, ROMANIA ABSTRACT A 69-year-old patient, with a long history of lung tuberculosis, with lymphopenia was emergently admitted in our hospital for bronchopneumonia, ventriculitis, acute internal hydrocephalic. He was aggressively treated with iv Meropenem and Vancomycin, intraventricular high doses of Vancomycin, aerosols, Dexametazone with healing of internal hydrocephalus, ventriculitis and improvement of bronchopneumonia. OBJECT The international data in the literature regarding the treatment of ventriculitis is limited. The authors aimed to share their experience in the treatment of ventriculitis and using intraventricular (IVT) and intravenous antibiotherapy. CASE REPORT The patient was a 69 year-old man, with a previous history of lung tuberculosis. He was adressed to the emergency department for 2 days of fever (39 degrees C), 4 days of productive cough with purulent expectoration, dyspnea with tachypnea, respiratory failure (SPO2 87%), altered mental status (stupor, GCS 10 ), neck stifness. The patient was treated by his family doctor with oral cefuroxyme , 4 grams daily . The patient was imunodepressed (lymphocytes 470/microliter) Chest X-rays and CT scan revealed bronchopneumonia (Fig. 1) Head CT Scann: Acute hidrocephalus, ventriculitis, parafluid purulent deposits in occipital horns, bilateral. (Fig 2 - blue arrows) The lumbar puncture revealed a purulent CSF with 4690 white cells/mm3, 92% of neutrophils. The patient underwent emergency surgery, extraventricular drainage (EVD) with double purpose: treatment of acute hydrocephalus and treatment of ventriculitis. The ventricular CSF samples were purulent. For this reason we considered unnecesarry a Keywords bronchopneumonia, intraventricular vancomycin, limphopenia, ventriculitis Corresponding author: Balasa Daniel University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania balasadaniel100@yahoo.com Copyright and usage. This is an Open Access article, distributed under the terms of the Creative Commons Attribution Non–Commercial No Derivatives License (https://creativecommons .org/licenses/by-nc-nd/4.0/) which permits non- commercial re-use, distribution, and reproduction in any medium, provided the original work is unaltered and is properly cited. The written permission of the Romanian Society of Neurosurgery must be obtained for commercial re-use or in order to create a derivative work. ISSN online 2344-4959 © Romanian Society of Neurosurgery First published March 2020 by London Academic Publishing www.lapub.co.uk http://www.lapub.co.uk/ 18 Aurelia Mihaela Sandu, Adrian Mircea Fürtös, Radu Mircea Gorgan complementary head MRI scan. Bacteriologic examination of the CSF revealed: Streptococcus pneumoniae. Intravenous antibiotherapy with Meropenem 6 grams/day and Vancomycin 2 grams /day, intraventricular antibiotics (Vancomycin 50 mg/day in the first postoperative day and 100 mg/day in the following days), iv Dexametasone (6 mg q 6 hours), aerosols with salbutamol 5mg/ml, 1 ml. After 22 days of treatment, control CT Scann revealed disappearance of the acute hydrocephalus and the occipital purulent debris (Fig 3). Figure 1. Bronchopneumonia. Multiple perihilar opacities, bilateral. Figure 2. Figure 3. Postoperative contrast CT Scann. No internal hidrocephalus, no ventriculitis. Moderate ventriculomegaly. The neurological status of the patient progressively improved and the neck stiffness dissapeared, also the respiratory status improved. Follow time period: 5 months DISCUSSION Ventriculitis is defined by high fever, clinical signs of meningitis (nuchal rigidity, photophobia, decreased mental status, seizures), a positive CSF culture, positive Gram stain, decreased CSF glucose, increased CSF proteins, CSF pleocytosis (at least 11 leukocytisis/mL with 50% or more polymorphonuclear neutrophils) 1,2 In the pre- antibiotic era, the great majority of patients died from bacterial meningitis/ventriculitis at the end of the first week of ventriculitis3. Nowadays, the incidence of this complication lowered. Central nervous system infections requiring treatment with intraventricular (IVT) vancomycin are becoming increasingly common with advent of intracranial devices and increasing prevalence of multi-drug resistant and nosocomial organisms4. Administering vancomycin via IVT route bypasses the blood-brain barrier and allows controlled delivery directly to the desired site of action, achieving higher concentrations for a more reliable bactericidal action4. Indications for IVT vancomycin include meningitis unresponsive to intravenous antibiotics, ventriculitis, and intracranial device infections4. Recommended dosages of antimicrobial agents 19 Overview of patients with vascular pathology and cost analysis administered by the intraventricular route are vancomycin (5–20 mg/d). Dosages reported in literature ranged from 0.075-50 mg/day, with the most evidence for dosages of 5 to 20 mg/day. Duration of therapy most commonly ranged from 7 to 21 days4. For this patient, considering the imunodepression, bronchopneumonia, ventriculitis our option was to administer a higher dose of IVT Vancomycine.The patient received aditional dexamethasone according to current guidelines, as soon as possible when the lumbar puncture reveals a purulent CSF 6. Such a treatment has been proven to be beneficial in preventing hearing loss and neurological sequelae in adult purulent bacterial meningitis, particularly those due to Streptococcus pneumoniae6,7 The mean time to obtain CSF sterilisation in medical literature was 24hours. This time was achieved in this case too. The fever disapeared in the first postoperative day. There were no adverse effect of antibiotics administered IVT. CONCLUSION Intraventricular and intravenous antibiotics lead very quickly to CSF sterilisation in this critical ill patient. THE IVT vancomicyne administration appears to be safe and have high efficacy together with IV administration of Vancomicyn and Meropenem. The IVT Vancomycin dose , higher than the literature data, dramaticaly hastened the healing of ventriculitis and shortened the hospitalisation period of the patient. FINANCIAL SUPPORT AND SPONSORSHIP Nil. CONFLICTS OF INTEREST There are no conflicts of interest REFERENCES 1. Sundbarg G, Kjallquest A, Lundberg N, et al. Complications due to prolonged ventricular fluid pressure recording in clinical practice. In: Brock M, Dietz H, eds. Intracranial Pressure I: Experimental and Clinical Aspects—International Symposium on Intracranial Pressure, Hannover, 1972. Berlin: Springer-Verlag:348– 35, 1972. 2. Sundbarg G, Nordstrom CH, Soderstrom S. Complications due to prolonged ventricular fluid pressure recording.Br J Neurosurg;2:485–495, 1988. 3. Adams RD, Kubik CS, Bonner FJ. The clinical and pathological aspects ofinfluenzal meningitis. Arch Pediatr;65:354–76, 1948. 4. Ng K, Mabasa VH, Chow I, Ensom MH. 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