LAUSR

We wish to draw your attention to a rare complication of meningococcal meningitis in a 2-month-old girl. The patient presented with a 2-day history of fever, vomiting and irritability. On examination, she was lethargic with a full fontanelle. Her white cell count and C-reactive protein were elevated (11.8 × 10 and 153 mg/L, respectively). A lumbar puncture showed a cerebrospinal fluid (CSF) protein level of 8.55 g/L (normal 0.2–0.4 g/L), glucose <0.3 mmol/L (normal 2.8–4 mmol/L), 729 × 10 red blood cells and total white cell count of 5589 × 10/L with 92% neutrophils. She was commenced on dexamethasone, ceftriaxone, aciclovir and vancomycin. CSF Gram stain identified Gram-negative diplococci and after 24 h Neisseria meningitidis was cultured. Ceftriaxone and dexamethasone were continued. The next day she was noted to be hypertensive and bradycardic with an increased head circumference. Cranial magnetic resonance imaging showed large T2 hypointense fluid–fluid levels within the posterior horns of both lateral ventricles suggestive of intraventricular pus layering and extensive septation within the subarachnoid spaces with restricted diffusion in keeping with severe meningitis (Fig. 1). Neurosurgical opinion was sought but no drainage was performed as she improved with medical management. She received 4 days of dexamethasone and 14 days of ceftriaxone. A repeat brain magnetic resonance imaging 7 days later showed a reduction in intraventricular pus. Neisseria meningitidis is an encapsulated Gram-negative diplococcus transmitted via respiratory droplets. Patients with invasive meningococcal disease most commonly present with meningitis, septicaemia or with symptoms of both forms. Meningococcal meningitis typically presents following a brief febrile illness with headaches, vomiting, photophobia and a petechial or purpuric rash. Pyogenic complications of meningococcal disease are rare and predominantly described in case reports. These have included ventriculitis, subdural empyema, septic arthritis, pneumonia, epiglottitis, otitis media and conjunctivitis. Pyogenic ventriculitis refers to the presence of suppurative material within the cerebral ventricular system. The clinical signs of ventriculitis include progressive hydrocephalus and non-resolution of fever despite appropriate antibiotic therapy as seen in our patient. The empiric treatment for meningococcal disease is with intravenous ceftriaxone or penicillin; however, strains with reduced penicillin susceptibility have been reported in Australia, Asia, Europe, South America and less frequently in North America. The recommended duration of treatment is 5–7 days. There are no specific guidelines available to guide treatment duration in patients with ventriculitis, which may be associated with a higher incidence of relapse following antibiotic cessation. The overall mortality risk of invasive meningococcal disease remains 10% despite antibiotic therapy, and 11–19% of surviving children experience long-term disability. Dr Natasha van den Heuvel† Dr Christine O’Leary† Dr Amanda Gwee Department of General Medicine Royal Children’s Hospital Department of Paediatrics University of Melbourne Infectious diseases and Microbiology Group Murdoch Children’s Research Institute Melbourne, Victoria Australia