A 84-year-old woman with a history of Alzheimer’s disease presented to our hospital for evaluation of persistent fever. Because of swallowing dysfunction due to the advanced dementia, she had difficulty in eating and gastrostomy was placed 11 months prior to the admission. Although she had been bedridden, she had stayed home and had received visiting care by a multi-disciplinary team. Over the past 8 months, she had developed pressure ulcer on skin over the sacral region. This pressure ulcer gradually deteriorated despite the treatment of dressings, ointments, and debridement. She had been febrile for three weeks. Although home doctor suspected a pressure ulcer infection and administered intravenous antibiotics for two weeks, her fever did not improve. On physical examination, the patient had altered mental status (Glasgow coma scale, E3V1M3). The temperature was 39.5 degrees Centigrade and blood pressure 154/88 mmHg, pulse rate 75 beats per minute, respiratory rate 20 breaths per minute, and oxygen saturation was 95% while the patient was breathing ambient air. She appeared chronically ill and neck stiffness was present. A decubitus ulcer was noted on the skin over the sacral area and over the left elbow. The size of the sacrum pressure ulcer was 2 x 2 cm. There was no apparent bone exposure, but a large pocket of skin defect was present. Lumbar puncture was performed and the pus was discharged. Cerebrospinal fluid (CSF) analysis showed 167,253 leukocytes/mm3 (95% polymorphonuclear leukocytes and 5% lymphocytes), and glucose of 0 mg/dl. Gram’s staining of the CSF revealed polymicrobial organisms. Meropenem, vancomycin and dexamethasone were administered intravenously. CT scan of the spine revealed the presence of multiple emphysemas inside the spinal canal. Blood cultures grew Pravimonas micra and CSF culture results showed polymicrobial growth with enterobacteriaceae and anaerobic bacteria. Surgical debridement and continuous administration of intravenous antibiotics were performed. However she developed acute respiratory distress syndrome and died on hospital day 11.
Pressure ulcer is a common problem of bedridden elderly patients. Infectious complications of a pressure ulcer can be classified into superficial or deep infection. Deep infection includes cellulitis, osteomyelitis, bacteremia and sepsis. Meningitis is rare but the severest complication of a pressure ulcer. Although it may be challenging to make the accurate diagnosis at an appropriate timing, but we should be aware of this important complication. Our patient had severe cognitive impairment and she could not complain of any symptoms. Physicians should keep high index of suspicion for serious complications in cognitively impaired people. Additionally healthcare providers should have discussion about introducing advanced directives and setting an individual goal of care for the patient.
It is challenging to make a diagnosis of meningitis in elderly people who had bedridden and difficulty in communication. A deep pressure ulcer on the skin over the sacral area can lead to fatal emphysematous meningitis.
To cite this abstract:Yabuki, T; Tokuda, Y . FATAL EMPHYSEMATOUS MENINGITIS. Abstract published at Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev. Abstract 796. Journal of Hospital Medicine. 2017; 12 (suppl 2). https://www.shmabstracts.com/abstract/fatal-emphysematous-meningitis/. Accessed September 23, 2019.