Intraventricular Bleed Secondary to Intraventricular Antibiotics: A Case Report.

In case of multidrug resistant CNS infection use of intraventricular antibiotics are considered which have their own undesirable effects1 An adult male patient who presented with multidrug resistant infection secondary to procedures done to facilitate to drain cerebrospinal fluid. Secondary to intraventricular antibiotic administration patient developed an intraparenchymal bleed with intraventricular extension; as a result of the bleed there was persistently raised intracranial pressure (ICP). The harmful effects of intraventricular antibiotics have to always be considered before taking a decision to start it. Appropriate precaution and low threshold of suspicion is required to rule out complications. HOW TO CITE THIS ARTICLE: Sultana N, Reddy KS, Alam MI. Intraventricular Bleed Secondary to Intraventricular Antibiotics: A Case Report. Indian J Crit Care Med 2019;23(10):484-485.

BACKGROUND

Intraventricular therapy of antibiotic is reserved for multidrug resistant organisms causing central nervous infection (CNS) secondary to procedures done to facilitate cerebrospinal fluid (CSF) drainage.

CASE DESCRIPTION

A 52-year-old hypertensive male who previously underwent decompressive craniectomy for spontaneous right frontal haemorrhage followed by ventricular-peritoneal shunt (vp shunt) 10 months presented with fever and vomiting, blood investigation were within normal limit (Figs 1 and 2). CT brain plain showed postoperative communicating hydrocephalus with periventricular seepage of CSF and cerebral edema (Fig. 3). CSF culture showed pansensitive Pseudomonas. VP shunt was removed, culture showed Pseudomonas. Antibiotics ceftazidime 2 g 8th hourly based on the sensitivity was added.

Fig 1

Chest X-ray on admission

Fig 2

Chest x-ray after starting treatment

Fig. 3

Computerized tomography (CT) of brain after removal of VP shunt

In view of persistent drop in sensorium external ventricular drain (EVD) inserted. Persistent fever spikes for 9 days (leukocyte count 28900 which decreased to 11100 in 2 days) Intraventricular gentamicin 5 mg daily with 80 mg IV thrice daily was added. Persistent fever in view of which EVD was changed. Repeat CSF culture showed multidrug resistant Pseudomonas sensitive to colistin. Started on Colistin (4.5 million IV BD along with intraventricular 1.2 lakh units OD). Repeat CSF culture showed no growth and was afebrile for next 6 days, on 7th day there was persistent hypertension followed seizure leading to acute circulatory collapse. CT brain showed intraventricular bleed in lateral ventricles, 3rd and 4th ventricles, dilated lateral and third ventricle (Fig. 4). Electroencephalography (EEG) showed on going seizure activity from right hemisphere intraventricular colistin stopped. Persistent status epilepticus inspite of multiple antiepileptics.

Fig. 4

CT brain showing intraventricular hemorrhage

Electroencephalography showed diffuse nonspecific electrophysiological dysfunction followed by electrical silence after few hours. Pupils were bilaterally dilated and fixed. CT brain showed increase in size of intraventricular bleed with pressure on the brainstem. Patient declared brain dead after 26 days of hospitalization

DISCUSSION

EVDs and other CNS shunts are a mainstay in the management of hydrocephalus secondary to neurological injury; unfortunately, they may become infected.[1,2] While skin flora predominates, infection with gram-negative bacilli can occur as well, possibly by introduction during surgery or via retrograde infection in the case of ventriculoperitoneal shunts[3] Ventriculitis might be caused due to infection, intrathecal injection of antibiotics. Intraventricular hemorrhage could be due to ventriculitis leading to fragile vasculature[4] There is evidence that colistin itself can cause neovascularization and these under developed vessels are fragile[5] The above factors under even a slightly stressful condition may lead to vascular disruption. Hence, advantage and disadvantage need to be weighed adequately.

Ethical Consideration

Waiver of consent was obtained from patient's wife.