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.