Case of the Week
Section Editors: Matylda Machnowska1 and Anvita Pauranik2
1University of Toronto, Toronto, Ontario, Canada
2BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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September 10, 2015
Meningitis, Ventriculitis, and Liquefaction of Periventricular White Matter (Citrobacter koseri)
- Background:
- Bacteria of the genus Citrobacter are uncommon neonatal infection agents. Neonates may become infected horizontally (nosocomial infection) or vertically from the mother during delivery.
- A study by Li et al found that 79% of strains of C. diversus (C. koseri) from cerebrospinal fluid (CSF) had a unique 32-kD outer membrane protein, found in only 9% of non-CSF isolates. C. koseri accounted for only 1.3% of cases of neonatal meningitis reported to the CDC’s Bacterial Meningitis and Meningococcemia Surveillance System.
- Clinical Information: Classic signs and symptoms include fluctuating fever, seizures, vomiting, lethargy, hypotonia, and bulging fontanelle.
- Key Diagnostic Features:
- Hemorrhagic necrosis and liquefaction may occur with or without abscess formation. Brain imaging studies may demonstrate signs of meningitis and cerebritis.
- There may be debris within the ventricular system, which has a higher T1-weighted signal and lower T2-weighted signal compared to CSF. The debris may show restricted diffusion because of the high protein content and, possibly, necrotic material.
- Hydrocephalus, periventricular edema, and ependymal enhancement are additional findings that may be seen.
- DDx:
- Other bacterial meningoencephalitis with intraventricular pus
- Viral meningitis
- Periventricular leukomalacia
- Peroxisomal disorders
- Treatment Options: Antibiotics are usually preferred, except for cases with subdural infected collections. However, most authors recommend surgery for accessible cerebral abscesses and ventriculitis evolving with acute hydrocephalus.
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