Case Presentation: 51-year-old female with a past medical history of end-stage renal disease on intermittent dialysis and a recent vitreous hemorrhage status post pars plana vitrectomy with endo-laser photocoagulation 2 days prior to admission, presented with post-operative severe bilateral eye pain, headaches, and fevers. She was diagnosed with acute angle-closure glaucoma in the left eye and underwent anterior chamber paracentesis, resulting in an improvement in ocular pressures. However, she continued to experience ongoing headaches, fevers, and encephalopathy. As these symptoms seemed disproportionate to her eye exam and were unlikely to be explained solely by acute angle-closure, the patient was empirically started on meningitis coverage with Vancomycin, Ceftriaxone, and Ampicillin. On hospital day 1, lumbar puncture results were consistent with bacterial meningitis, showing cerebral spinal fluid (CSF) with a nucleated cell count of 784 x 10^6/L with 90% neutrophils, protein level of 157 mg/dL, glucose level of 61 mg/dL, and an opening pressure of 20cm H20. Blood cultures returned positive for Klebsiella pneumoniae. Upon further chart review, it was discovered that the patient had a recent history of Klebsiella pyelonephritis in May, which was complicated by Klebsiella bacteremia in September due to incomplete treatment of the pyelonephritis. No repeat blood cultures were performed after treating for bacteremia with a 21-day course of levofloxacin. Although no organism was identified on CSF cultures (lumbar puncture obtained 24 hours after starting antibiotics), she was treated for presumed Klebsiella meningitis with a 14-day course of Ceftriaxone, resulting in complete resolution of symptoms. This case represents an unusual presentation of presumed Klebsiella meningitis in the setting of incompletely treated bacteremia or inadequate source control of the original pyelonephritis. It is theorized that the patient subsequently developed recurrent bacteremia that translocated across the blood-brain barrier after developing vitreous hemorrhage, causing acute bacterial meningitis.
Discussion: Community acquired Klebsiella pneumoniae meningitis is exceedingly rare, especially in the United States, and is often associated with a poor prognosis and high mortality due to rapid clinical and neurological deterioration [1]. A study by Fang e.al describes that patients presenting with community-acquired Klebsiella meningitis often have preceding infections including pyogenic liver abscess, septic endophthalmitis, pneumonia, otitis media, and urinary tract infections [2]. A major determinant of survival and favorable neurological outcome is the early administration of appropriate antibiotic therapy before mental status worsens.
Conclusions: This case illustrates a rare presentation of bacterial meningitis in the context of untreated Klebsiella bacteremia/pyelonephritis with suspected central nervous system translocation after an ophthalmologic procedure, complicated by vitreous hemorrhage. Despite her clinical picture being clouded by recent surgery and acute angle closure, which could also cause severe headaches, significant neurological deterioration was mitigated by early initiation of intravenous antibiotic coverage for meningitis. Clinical suspicion for community acquired Klebsiella meningitis should be raised in patients with prior Klebsiella infections who present with headaches, fevers, and encephalopathy, prompting early initiation of antibiotics.