Spontaneous Escherichia coli meningitis with subdural empyema in an adult.

To the Editor: Spontaneous or nontraumatic Escherichia coli meningitis is rare in adults. We report a case of spontaneous E coli meningitis associated with a bilateral frontal subdural empyema in an adult.

A 55-year-old man was admitted to the hospital for a 2-day history of confusion and fever. Two years before, he had been diagnosed with squamous cell esophageal carcinoma (stage T2, N0, M0) treated with concomitant radiochemotherapy. Two months before admission, the patient had relapsed and was treated with high intensity ultrasound. At admission, his temperature was 38.5[degrees]C, and no signs of meningeal irritation or focal neurologic deficits were found. White cell count was 19,330/[mm.sup.3] with 92% neutrophils and 4% lymphocytes. C-reactive protein was 73 mg/L (normal < 8). Blood and urine cultures were negative. Analysis of cerebrospinal fluid disclosed cloudy cerebrospinal fluid, 9,500 leukocytes/[mm.sup.3] with 95% polymorphonuclear cells, protein of 2.69 g/L, and glucose of 0.2 mmol/L (blood glucose 5.9 mmol/L). Gram negative bacilli were found. Treatment with ceftriaxone and amikacin was given. Subsequently, spinal fluid and blood cultures grew E coli susceptible to both antibiotics. Due to a rapidly-decreasing level of consciousness, a noncontrast CT scan of the head and sinus was done, disclosing a bilateral frontal subdural empyema with an air fluid level (Fig.). The patient died before neurosurgical drainage was performed. A post-mortem examination was refused by the family.

E coli meningitis is rare in adults, developing mainly after accidental or neurosurgical trauma of the head or spine. (1,2) Spontaneous cases are extremely rare, are usually associated with debilitating disease, and result from bacteremia of intestinal origin. (3) Of note, E coli meningitis is infrequent in patients with E coli septicemia. Its course is often fulminant with a mortality rate from 50 to 90%, especially in patients in a coma or with bacteremia. (2,3) Interestingly, our patient had no evidence of meningitis, and blood and urine cultures were negative, contrary to most cases. The role of treatment with high intensity ultrasound is possible in the genesis of the infection. Moreover, E coli meningitis is associated with subdural empyema, due to extension from paranasal sinusitis and otitis media, head trauma and neurosurgery, but rarely from septicemia or meningitis. (4) To our knowledge, subdural empyema has only been reported in adults as hematogenous dissemination to a pre-existing chronic subdural hematoma, (5) but not with spontaneous E coli meningitis. Our patient had no history of head trauma, and no otorhinolaryngologic infections or skull fractures were found. Therefore, spreading from septicemia or meningitis is likely.

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Claude Bachmeyer, MD

Service de Medecine Interne 

CHU Tenon

Paris, France

Michel Logak, MD

Service de Neurologic

Centre Hospitalier Laennec

Creil, France

Wafa Ammouri, MD

Service de Medecine Interne

CHU Tenon

Paris, France

Anne-Sophie Blanc, MD

Departement de Medecine Interne

Centre Hospitalier Laennec

Creil, France

References

1. Gower DJ, Barrows AA, Kelly DL, et al. Gram-negative bacillary meningitis in the adult: review of 39 cases. SouthMed J 1986;79:1499-1502.

2. Lu CH, Wang WN, Chuang YC, et al. The prognostic factors of adult gram-negative bacillary meningitis. J Hosp Infect 1998;40:27-34.

3. Mofredj A, Guerin JM, Leibinger F, et al. Spontaneous Escherichia coli meningitis in an adult. Scand J Infect Dis 2000;32:699-700.

4. Greenlee JE. Subdural empyema. Curr Treat Options Neurol 2003;5:13-22.

5. Kaminogo M, Kurihara M, Kawano T, et al. A case of infected subdural hematoma (subdural empyema) secondary to septicemia caused by agranulocytosis. No Shinkei Geka 1984;12:353-357.