LAUSR

A 73-year-old man presented with expressive dysphasia and disorientation. Multimodal computed tomography (CT) showed no cerebral ischaemia. Cerebral spinal fluid (CSF) on lumbar puncture was consistent with pyogenic meningitis with polymorphic pleocytosis (white cells 216 000 10/L, 96% polymorphonuclear cells), marked elevated protein of 12.96 g/L and undetectable glucose <0.1 mmol/L. Initial Gram stain revealed coccobacilli, suspicious for meningococcal meningitis (Fig. 1). He was empirically treated with intravenous ceftriaxone, amoxicillin and dexamethasone. Within 24 h, Gram-negative bacilli with non-haemolytic colonies were cultured. This was later identified as Escherichia coli on matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry (MALDI-TOF-MS; Bruker Daltonics, Germany). Subsequently, amoxicillin and dexamethasone were ceased. Ceftriaxone monotherapy was continued. Fully sensitive E. coli was simultaneously cultured in the urine but blood cultures collected pre-antibiotics were negative. There was no evidence of an enterothecal fistula or intra-abdominal collection on CT of the abdomen. The urinary tract also appeared structurally normal on both ultrasonography and CT. Endoscopy and colonoscopy were unremarkable. Cerebral magnetic resonance imaging (MRI) was performed and revealed ventriculitis (Figs 2,3). There were no signs of CSF leak, hydrocephalus, empyema or abscess. The patient was screened for diabetes mellitus, multiple myeloma, human immunodeficiency virus, immunoglobulin deficiency, hepatitis and strongyloidiasis, which were unremarkable. There was no history of alcohol dependence or end-organ dysfunction. On Day 19 of admission, he developed Clostridiodes difficile-related diarrhoea and was commenced on oral vancomycin. Three days later he developed fevers. A repeat CSF analysis showed resolution of pleocytosis with no further bacterial growth. Interval MRI of the brain demonstrated resolution of ventriculitis, but revealed a new cerebral abscess. On Day 24 he developed a widespread maculopapular rash accompanied by new thrombocytopenia and hepatitis consistent with a drug reaction with eosinophilia and systemic symptoms. Antibiotics were ceased and oral prednisolone was commenced. He was discharged on Day 28 with no residual neurological deficits or end-organ injury.