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Staphylococcus aureus Meningitis in a Patient With Acquired Immunodeficiency Syndrome
Staphylococcus aureus Meningitis in a Patient With Acquired Immunodeficiency Syndrome LOREN G. MILLER, M.D., GLENN
E. MATHISEN, M.D., AND SUSAN CHANG, M.D. procedure, head trauma, or overwhelming bacteremia. Treatment of this infection was successful. S. aureus should be added to the list of potential pathogens that can cause spontaneous meningitis in people with AIDS. Mayo Clin Proc 1998;73:1083-1084
Meningitis due to Staphylococcus aureus is well described but uncommon. Most cases arise as a complication of neurosurgical interventions or head trauma, although some arise spontaneously. To our knowledge, no case of S. aureus meningitis has been previously reported in a person with the acquired immunodeficiency syndrome (AIDS). Herein we describe a case of S. aureus meningitis in a person with AIDS who had no history of a neurosurgical
= acquired immunodeficiency syndrome; CSF brospinalfluid
AIDS
M
eningitis due to Staphylococcus aureus is well described but uncommon. S. aureus is responsible for 1 to 9% of cases of bacterial meningitis.' Most cases result from complications of neurosurgical procedures, trauma, or indwelling devices in the central nervous system; other cases arise spontaneously. In patients in whom S. aureus meningitis occurs spontaneously, the usual characteristics are advanced age, overwhelming bacteremia, a history of intravenous drug use, or immunosuppression due to chronic diseases. \-6 A few cases have been described in which no underlying condition was found.':" To our knowledge, this is the first reported case of S. aureus meningitis spontaneously occurring in a patient with acquired immunodeficiency syndrome (AIDS).
his back; no stigmas of intravenous drug use were evident. Results of cardiovascular, pulmonary, and abdominal examinations were normal. Other than the patient's confusion, findings on the neurologic examination were within normal limits. The patient's previous opportunistic infections included oral candidiasis, chronic diarrhea of unknown cause, and an outbreak of herpes zoster 1 week before hospitalization. In addition, he had chronic neutropenia and had undergone a bone marrow biopsy several months previously, findings of which were nondiagnostic. His prescribed medications from a clinic elsewhere were acyclovir, fluconazole, saquinavir, clotrimazole troches, and aerosolized pentamidine. On admission, laboratory values included a leukocyte count of 2.7 x 109jL with 55% neutrophils and 15% bands. The hemoglobin concentration and platelet count were slightly decreased. Chemistry panel was within normal limits. Urinalysis revealed moderate proteinuria, pyuria, and hematuria. Analysis of the cerebrospinal fluid (CSF) disclosed a leukocyte count of 518/mm3 with 98% neutrophils, protein level of 112 mg/dL, and glucose value of 33 mg/dL. The patient was initially treated with intravenously administered ampicillin and cefotaxime, but CSF and urine cultures grew methicillin-sensitive S. aureus. Thus, therapy was changed to intravenously administered nafcillin (2 g every 4 hours) and orally administered rifampin (600 mg daily). Two sets of blood cultures were sterile. A further evaluation to localize the source of staphylococcal infection included two two-dimensional transthoracic echocardiograms, which revealed no vegetation. "'In scintigraphy showed asymmetric activity in the right maxillary sinus, a finding compatible with sinusitis. Computed
REPORT OF CASE
A 49-year-old bisexual man with AIDS and a CD4 cell count of 15/mm3 was brought to the hospital by paramedics because of altered mental status and fever. One week before admission, the patient had fevers but no other systemic symptoms. On the day of admission, he had become disoriented while performing his usual job as a delivery person. On admission to the hospital, he was alert but confused and oriented only to person. His temperature was 40°C; his blood pressure and pulse were normal. Physical examination revealed no acute distress. Nuchal rigidity was present. An examination of the skin revealed a healing zoster scar involving the right T8 and T9 dermatomes on From the Division of Infectious Diseases (L.G.M.), UCLA Medical Center, Los Angeles, California; and Division of Infectious Diseases (G.E.M.) and Department of Medicine (S.C.), Olive View-UCLA Medical Center, Sylmar, California. Individual reprints of this article are not available. Mayo Clin Proc 1998;73: 1083-1084
= cere-
1083
© 1998 M.c:yo Foundation for Medical Education and Research
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
1084 Staphylococcus aureus Meningitis and AIDS
tomography of the head and sinuses revealed only minimal mucosal thickening of the sinuses. After both nafcillin and rifampin therapy were initiated, the patient's fever rapidly diminished, and his mental status normalized. He received intravenously administered antibiotic therapy for 2 weeks. Because the pyuria and bacteriuria with S. au reus raised the suggestion of endocarditis or occult bacteremia, he was given an additional 28 days of ciprofloxacin (750 mg twice daily) and rifampin (600 mg twice daily) orally, a regimen that has demonstrated efficacy in selected cases of endocarditis.' The patient remained in good health throughout the course of his antimicrobial therapy. DISCUSSION
In a review of the literature from 1980 to the present, we found no case of S. aureus meningitis in a patient with AIDS. The factors that allow seeding of the CSF with S. aureus have not been well defined; investigators have noted the rarity of CSF seeding despite the common occurrence of S. aureus bacteremia.P The source of infection and portal of entry in our patient are unclear. The patient's sinuses may have been the source of the infection in light of the fact that radiologic studies suggested sinusitis. Weinke and associates" showed that patients with AIDS have a high incidence of S. aureus nasopharyngeal carriage. Clinically, however, our patient had no signs or symptoms of sinus disease. Alternatively, his skin may have been the source of infection. Previous series of S. aureus meningitis in nonneurosurgical patients have identified the skin as the most common portal of entry when entry can be identified.':" Our patient's episode of herpes zoster before admission may have provided a direct entry point to the central nervous system from a skin source. Alternatively, pyuria and bacteriuria with S. aureus raise the possibility of endocarditis or at least occult bacteremia," but the repeatedly normal findings on cardiac examinations and transthoracic echocardiograms and the sterile blood cultures make either diagnosis unlikely. Finally, neutropenia may have been a factor in our patient's meningitis, although previous
Mayo Clin Proc, November 1998, Vol 73
studies have not recognized it as a risk factor for S. aureus meningitis. 1-6 SUMMARY
Our case is unique in that a patient with AIDS had development of spontaneous S. aureus meningitis, but he had no concomitant history of a neurosurgical procedure, trauma, or overwhelming bacteremia. Jacobson and colleagues'? described a series of patients with AIDS and S. aureus infection at San Francisco General Hospital. They found that patients with AIDS have an increased rate of S. aureus infections even when the high incidence of indwelling catheter devices is not considered. Therefore, we conclude that, although rare, S. aureus meningitis should be considered in the patient with AIDS who has a syndrome compatible with acute bacterial meningitis.
REFERENCES 1. 2. 3. 4. 5. 6. 7.
8.
9. 10.
Jensen AG, Espersen F, Shlnhoj P, Rosdahl VT, Frimodt-Moller N. Staphylococcus aureus meningitis: a review of 104 nationwide, consecutive cases. Arch Intern Med 1993;153:1902-1908 Kim JH, van der Horst C, Murlow CD, Corey GR. Staphylococcus aureus meningitis: review of 28 cases. Rev Infect Dis 1989;11:698706 Schlesinger LS, Ross SC, Schaberg DR. Staphylococcus aureus meningitis: a broad-based epidemiologic study. Medicine 1987;66:148lli6 . Gordon JJ, Harter DH, Phair JP. Meningitis due to Staphylococcus aureus. Am J Med 1985;78:965-970 Fong IW, Ranalli P. Staphylococcus aureus meningitis. Q J Med 1984;53:289-299 Roberts FJ, Smith JA, Wagner KR. Staphylococcus aureus meningitis: 26 years' experience at VancouverGeneral Hospital. Can Med Assoc J 1983;128:1418-1420 Heldman AW, Hartert TV, Ray SC, Daoud EG, Kowalski TE, Pompili VJ, et al. Oral antibiotic treatment of right-sided staphylococcal endocarditis in injection drug users: prospective randomized comparison with parenteral therapy. Am J Med 1996;101:68-76 Weinke T, Schiller R, Fehrenback FJ, Pohle HD. Association between Staphylococcus aureus nasopharyngeal colonization and septicemia in patients infected with the human immunodeficiency virus. Eur J Clin Microbiollnfect Dis 1992;11:985-989 Lee BK, Crossley K, Gerding DN. The association between Staphylococcus aureus bacteremia and bacteriuria. Am J Med 1978;65:303306 Jacobson MA, Gellerman H, Chambers H. Staphylococcus aureus bacteremia and recurrent staphylococcal infection in patients with acquired immunodeficiency syndrome and AIDS-relatedcomplex. Am J Med 1988;85:172-176
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
E. MATHISEN, M.D., AND SUSAN CHANG, M.D. procedure, head trauma, or overwhelming bacteremia. Treatment of this infection was successful. S. aureus should be added to the list of potential pathogens that can cause spontaneous meningitis in people with AIDS. Mayo Clin Proc 1998;73:1083-1084
Meningitis due to Staphylococcus aureus is well described but uncommon. Most cases arise as a complication of neurosurgical interventions or head trauma, although some arise spontaneously. To our knowledge, no case of S. aureus meningitis has been previously reported in a person with the acquired immunodeficiency syndrome (AIDS). Herein we describe a case of S. aureus meningitis in a person with AIDS who had no history of a neurosurgical
= acquired immunodeficiency syndrome; CSF brospinalfluid
AIDS
M
eningitis due to Staphylococcus aureus is well described but uncommon. S. aureus is responsible for 1 to 9% of cases of bacterial meningitis.' Most cases result from complications of neurosurgical procedures, trauma, or indwelling devices in the central nervous system; other cases arise spontaneously. In patients in whom S. aureus meningitis occurs spontaneously, the usual characteristics are advanced age, overwhelming bacteremia, a history of intravenous drug use, or immunosuppression due to chronic diseases. \-6 A few cases have been described in which no underlying condition was found.':" To our knowledge, this is the first reported case of S. aureus meningitis spontaneously occurring in a patient with acquired immunodeficiency syndrome (AIDS).
his back; no stigmas of intravenous drug use were evident. Results of cardiovascular, pulmonary, and abdominal examinations were normal. Other than the patient's confusion, findings on the neurologic examination were within normal limits. The patient's previous opportunistic infections included oral candidiasis, chronic diarrhea of unknown cause, and an outbreak of herpes zoster 1 week before hospitalization. In addition, he had chronic neutropenia and had undergone a bone marrow biopsy several months previously, findings of which were nondiagnostic. His prescribed medications from a clinic elsewhere were acyclovir, fluconazole, saquinavir, clotrimazole troches, and aerosolized pentamidine. On admission, laboratory values included a leukocyte count of 2.7 x 109jL with 55% neutrophils and 15% bands. The hemoglobin concentration and platelet count were slightly decreased. Chemistry panel was within normal limits. Urinalysis revealed moderate proteinuria, pyuria, and hematuria. Analysis of the cerebrospinal fluid (CSF) disclosed a leukocyte count of 518/mm3 with 98% neutrophils, protein level of 112 mg/dL, and glucose value of 33 mg/dL. The patient was initially treated with intravenously administered ampicillin and cefotaxime, but CSF and urine cultures grew methicillin-sensitive S. aureus. Thus, therapy was changed to intravenously administered nafcillin (2 g every 4 hours) and orally administered rifampin (600 mg daily). Two sets of blood cultures were sterile. A further evaluation to localize the source of staphylococcal infection included two two-dimensional transthoracic echocardiograms, which revealed no vegetation. "'In scintigraphy showed asymmetric activity in the right maxillary sinus, a finding compatible with sinusitis. Computed
REPORT OF CASE
A 49-year-old bisexual man with AIDS and a CD4 cell count of 15/mm3 was brought to the hospital by paramedics because of altered mental status and fever. One week before admission, the patient had fevers but no other systemic symptoms. On the day of admission, he had become disoriented while performing his usual job as a delivery person. On admission to the hospital, he was alert but confused and oriented only to person. His temperature was 40°C; his blood pressure and pulse were normal. Physical examination revealed no acute distress. Nuchal rigidity was present. An examination of the skin revealed a healing zoster scar involving the right T8 and T9 dermatomes on From the Division of Infectious Diseases (L.G.M.), UCLA Medical Center, Los Angeles, California; and Division of Infectious Diseases (G.E.M.) and Department of Medicine (S.C.), Olive View-UCLA Medical Center, Sylmar, California. Individual reprints of this article are not available. Mayo Clin Proc 1998;73: 1083-1084
= cere-
1083
© 1998 M.c:yo Foundation for Medical Education and Research
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
1084 Staphylococcus aureus Meningitis and AIDS
tomography of the head and sinuses revealed only minimal mucosal thickening of the sinuses. After both nafcillin and rifampin therapy were initiated, the patient's fever rapidly diminished, and his mental status normalized. He received intravenously administered antibiotic therapy for 2 weeks. Because the pyuria and bacteriuria with S. au reus raised the suggestion of endocarditis or occult bacteremia, he was given an additional 28 days of ciprofloxacin (750 mg twice daily) and rifampin (600 mg twice daily) orally, a regimen that has demonstrated efficacy in selected cases of endocarditis.' The patient remained in good health throughout the course of his antimicrobial therapy. DISCUSSION
In a review of the literature from 1980 to the present, we found no case of S. aureus meningitis in a patient with AIDS. The factors that allow seeding of the CSF with S. aureus have not been well defined; investigators have noted the rarity of CSF seeding despite the common occurrence of S. aureus bacteremia.P The source of infection and portal of entry in our patient are unclear. The patient's sinuses may have been the source of the infection in light of the fact that radiologic studies suggested sinusitis. Weinke and associates" showed that patients with AIDS have a high incidence of S. aureus nasopharyngeal carriage. Clinically, however, our patient had no signs or symptoms of sinus disease. Alternatively, his skin may have been the source of infection. Previous series of S. aureus meningitis in nonneurosurgical patients have identified the skin as the most common portal of entry when entry can be identified.':" Our patient's episode of herpes zoster before admission may have provided a direct entry point to the central nervous system from a skin source. Alternatively, pyuria and bacteriuria with S. aureus raise the possibility of endocarditis or at least occult bacteremia," but the repeatedly normal findings on cardiac examinations and transthoracic echocardiograms and the sterile blood cultures make either diagnosis unlikely. Finally, neutropenia may have been a factor in our patient's meningitis, although previous
Mayo Clin Proc, November 1998, Vol 73
studies have not recognized it as a risk factor for S. aureus meningitis. 1-6 SUMMARY
Our case is unique in that a patient with AIDS had development of spontaneous S. aureus meningitis, but he had no concomitant history of a neurosurgical procedure, trauma, or overwhelming bacteremia. Jacobson and colleagues'? described a series of patients with AIDS and S. aureus infection at San Francisco General Hospital. They found that patients with AIDS have an increased rate of S. aureus infections even when the high incidence of indwelling catheter devices is not considered. Therefore, we conclude that, although rare, S. aureus meningitis should be considered in the patient with AIDS who has a syndrome compatible with acute bacterial meningitis.
REFERENCES 1. 2. 3. 4. 5. 6. 7.
8.
9. 10.
Jensen AG, Espersen F, Shlnhoj P, Rosdahl VT, Frimodt-Moller N. Staphylococcus aureus meningitis: a review of 104 nationwide, consecutive cases. Arch Intern Med 1993;153:1902-1908 Kim JH, van der Horst C, Murlow CD, Corey GR. Staphylococcus aureus meningitis: review of 28 cases. Rev Infect Dis 1989;11:698706 Schlesinger LS, Ross SC, Schaberg DR. Staphylococcus aureus meningitis: a broad-based epidemiologic study. Medicine 1987;66:148lli6 . Gordon JJ, Harter DH, Phair JP. Meningitis due to Staphylococcus aureus. Am J Med 1985;78:965-970 Fong IW, Ranalli P. Staphylococcus aureus meningitis. Q J Med 1984;53:289-299 Roberts FJ, Smith JA, Wagner KR. Staphylococcus aureus meningitis: 26 years' experience at VancouverGeneral Hospital. Can Med Assoc J 1983;128:1418-1420 Heldman AW, Hartert TV, Ray SC, Daoud EG, Kowalski TE, Pompili VJ, et al. Oral antibiotic treatment of right-sided staphylococcal endocarditis in injection drug users: prospective randomized comparison with parenteral therapy. Am J Med 1996;101:68-76 Weinke T, Schiller R, Fehrenback FJ, Pohle HD. Association between Staphylococcus aureus nasopharyngeal colonization and septicemia in patients infected with the human immunodeficiency virus. Eur J Clin Microbiollnfect Dis 1992;11:985-989 Lee BK, Crossley K, Gerding DN. The association between Staphylococcus aureus bacteremia and bacteriuria. Am J Med 1978;65:303306 Jacobson MA, Gellerman H, Chambers H. Staphylococcus aureus bacteremia and recurrent staphylococcal infection in patients with acquired immunodeficiency syndrome and AIDS-relatedcomplex. Am J Med 1988;85:172-176
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.