Isolation of Proteus mirabilis from severe neonatal sepsis and central nervous system infection with extensive pneumocephalus

Abstract

A fatal case of pure Proteus mirabilis meningitis complicated by extensive pneumocephalus demonstrated on brain CT is reported. We suggest that early institution of third generation cephalosporin combined with an aminoglycoside and a brain CT scan are warranted in neonates with neurological sepsis caused by this organism.In neonates and infants, Proteus mirabilis is encountered world-wide as an uncommon aetiological agent in sepsis and infections of the central nervous system (CNS), often as a mixed infection.A 5-day-old term baby girl was admitted to our neonatal intensive care unit with a 1-day history of jaundice and 3-day history of poor feeding and lethargy. There was no history of injury. Her mother was a 28-year-old hepatitis B carrier primigravida who was otherwise well. Antenatal, intrapartum and immediate postnatal periods were uneventful. On admission, the baby was poorly hydrated, jaundiced, lethargic and hypotonic. Her sucking reflex was poor. Her anterior fontanelle was soft and normotensive. A full septic screen was done and she was commenced on intravenous penicillin and gentamicin. She was put on nasal continous positive airway pressure which was later changed to ventilation when she became apnoiec and desaturated.Immediate investigations showed unconjugated hyperbilirubinaemia and hypoglycaemia (<1.0 mmol/l) but otherwise normal full blood count and serum electrolytes. Cerebrospinal fluid (CSF) microscopy showed a white cell count of >200 (70% polymorphs, 30% leukocytes), a CSF glucose of <1.0 mmol/l, and a CSF protein of 6.8 g/l, globulin positive but a latex test (for Neisseria meningitidis, Streptococcus pneumoniae, Escherichia coli, Streptococcus group B and Haemophilus influenzae type B) was negative. Penicillin was discontinued and cefotaxime was added to her antibiotic regime when she deteriorated on ventilator.The next day, she became hypotensive needing inotropic support and developed generalised convulsions which responded to phenobarbitone. A brain ultrasound scan revealed multiple areas of echogenicity with cerebral oedema. A brain CT scan was deferred at this stage due to her unstable condition. Later that day, the CSF culture was reported to grow a gram-negative bacillus. On day 3 of admission, she developed generalised hypertonia, hyper-reflexia and a tense anterior fontanelle. Her pupils were dilated and sluggish. Both CSF and blood cultures grew Proteus mirabilis and this was the only organism isolated from both samples. The organism was sensitive to both gentamicin and cefotaxime. Later that day, she had a further convulsion and went into renal failure. Her coagulation profiles were deranged and both platelets and haemoglobin were low. She was transfused with platelets, packed cells, fresh frozen plasma and cryoprecipitate. Her condition remained unchanged the next day. A brain CT scan performed on day 5 of admission showed extensive pneumocephalus replacing the substance of the frontal and temporal lobes. Air density was also present in the subdural space along the falx and in...

Proteus Mirabilis Septicemia and Meningitis in a Neonate

“…Some report it as the causative agent in about 4% of cases of neonatal meningitis [3]. Cerebral abscess formation and pneumocephalus has been described as also being associated with Proteus infections [2][3][4][5]. Our patient had brain findings that were most likely caused by the overwhelming sepsis.…”

“…Route of infection has not been established but presumed to be ascending infection during delivery due to its early presentation. In most of the cases reported in literature, the course of the infection appears to be fatal involving severe neurological complication with cerebral abscess and pneumocephalus formation despite institution of appropriate antibiotics [2][3][4][5].…”

Case Report of Neonatal Proteus mirabilis Meningitis and Brain Abscess with Negative Initial Image Finding: Consideration of Serial Imaging Studies

“…The patient showed slight tonic movements suggestive of seizure activity and phenobarbital loading was started. A second CSF analysis showed a markedly decreased , hydrocephalus 2) , extensive pneumocephalus 5) , global anoxic injury 6) , or hemorrhagic meningoencephalitis 7) . In our patient, brain CT was performed on day 3 of admission, which was 2 days after symptom onset, and showed normal findings.…”

“…The initial choices of antibiotics are mainly ampicillin or penicillin with a combination of aminoglycosides [2][3][4][5][6][7] . Antibiotics can be changed to chloramphenicol, cefotaxime, and meropenem if the patient's condition deteriorates 5) , fever persists despite…”

“…Antibiotics can be changed to chloramphenicol, cefotaxime, and meropenem if the patient's condition deteriorates 5) , fever persists despite…”