Case presentation
A 53-year-old diabetic woman, was admitted to the emergency department with a three days history of fever and altered consciousness. One week before hospitalization, the patient had left flank pain. She was a known case of ITP and had been receiving prednisolone 5mg/d. Upon admission, the patient was febrile (38.5 °C) and hemody- namic status was stable. She showed no localized motor or sensory deficits, but was aphasic and opens the eyes just with painful stimulation. No other physical abnormality was found.
Initial laboratory evaluation are shown in table 1. Brain computed tomography scan was normal and lumbar puncture was performed. Cerebrospinal fluid (CSF) examination showed white blood cells of 9600 cells/mm3 (80% neutrophil), glucose level of 20 mg/dl with corresponding blood sugar of 130 mg/dl and elevated protein of 80 mg/dl. Blood, CSF and urine cultures were sent. The patient was started on Meropenem 2gr IV every 8 hr and Vancomycin 1gr IV every 12 hr as empiric therapy for acute meningitis. Dexamethasone 8 mg IV every 6 hr for 4 days was started before the initiation of antibiotics.
According to the previous history of flank pain and the pyuria in urine analysis, initial kidneys ultrasound was performed and it revealed air focus in the parenchyma of the left kidney, which confirmed in abdominopelvic CT scan and was consistent with emphysematous pyelonephritis. In consultation with urologist, surgery was not recommended and antibiotic therapy was continued with close monitoring. After three days of treatment, the patient became afebrile. The results of cultures of urine, blood and CSF yielded Extended Spectrum β-Lactamase (ESBL) E. coli . Hence she was diagnosed as acute meningitis and emphysematous pyelonephritis due to E. coli . ELISA test for HIV antibody reported a negative result. Brain magnetic resonance imaging was performed and revealed no brain abscess. Transthoracic echocardiography was normal and no evidence of endocarditis was reported. Despite antimicrobial therapy, the neurological condition of the patient only minimally improved. Repeated blood cultures and also urine culture were sterile after initiation of antibiotic therapy. On day 20 of hospitalization, the patient died from sudden decrease in O2 saturation and respiratory failure followed by cardiopulmonary arrest.