Case Presentation: A 68-year-old gentleman status- post craniotomy for meningioma resection 3 weeks ago was brought to the ER with complaints of 1 episode of fever (101 F) associated with weakness, decreased appetite and a decline in functional capacity. Blood cultures were obtained, a CT brain was ordered which ruled out acute pathology and the patient was sent home with oral antibiotics. However, his blood culture reports came back positive for gram-negative rods and he was called back to the hospital. Upon arrival, his wife informed that he had now developed confusion which was sudden in onset and associated with incoherent speech. She denied fever, chills, changes in vision, slurred speech, headache, vomiting, loss of coordination, loss of consciousness, or seizures. Physical examination revealed Tmax 98.2 F, HR 67 bpm, RR 16/min, BP 103/60mmHg and SpO2 99% on room air. He had a GCS score of 11/15, was restless, agitated and was not able to follow commands. Staples present on the right front-parietal region with a fluctuant swelling of less than 2 cm in size. No neck stiffness, Kernig’s sign was positive, brisk reflexes (3+) of the lower extremities. Blood work revealed an elevated WBC count of 11.9. Blood cultures were positive for gram-negative rods (2/2) sets with a lactic acid level of 1.39. A CT head was obtained which showed post-surgical changes. Subsequently, a lumbar puncture was performed, and fluid sent for analysis.Based on preliminary findings, he was admitted with suspicion of meningoencephalitis and was started on IV Zosyn and Linezolid. CSF cell study was significant for increased protein with low glucose and a WBC of >2000. The following morning, there was a marked improvement in his mentation, he was alert, oriented and coherent with no focal defects. However, later he developed severe vertigo associated with vomiting and vertical nystagmus. An MRI brain with contrast was obtained which revealed a subdural empyema, subcutaneous abscess, and ventriculitis. He was taken to the operating room for an emergent subdural empyema washout during which cultures were obtained. His CSF analysis was negative for Listeria, Neisseria, and Streptococcus. Viral, fungal, AFB and gram stain and culture were negative. The wound cultures obtained during the wash-out procedure as well as the blood cultures were both positive for Providencia rettgeri. Echocardiogram was also obtained which showed vegetation in the aortic valve. Over the course of the next 3 days, he started to improve clinically and was discharged to a rehabilitation facility with long term ( 4 weeks) IV antibiotic therapy.
Discussion: It is imperative that new symptoms of headache, change in mentation, or evidence of meningeal irritation in patients who have undergone recent neurosurgical intervention prompt further investigation to rule out ventriculitis or meningitis. Furthermore, a normal CSF cell count, glucose and protein do not reliably exclude infection in patients who have received prior antibiotic therapy. As per guidelines, prophylactic antibiotic use can also be employed to reduce the risk of ventriculitis. Appropriate empiric antibiotic therapy includes Vancomycin plus an anti-pseudomonal beta-lactam agent such as cefepime, ceftazidime or meropenem for at least a 2-week duration.
Conclusions: Of the family Enterobacteriaceae, Providencia is not widely associated with community and hospital-acquired nervous system infections. There are only a few reported cases describing Providencia as the causative agent of meningitis and subdural empyema.