February 28, 2015

Clinical Vignette 23

An elderly man was knocked down by a taxi while riding on his bicycle. He developed a right subarachnoid hemorrhage and became progressively drowsy, requiring emergent evacuation of the clot and insertion of an external ventricular drain (EVD).

He got progressively better in the hospital, and the EVD was removed 12 days later. At that time, he had no fever nor suggestion of any inflammation or infection. The EVD tip was (mistakenly?) sent off for culture. Two days later, the culture report returned as: Aspergillus spp.

Question: How should one react to the culture report?

[Updated 7th March 2015]

As he remained well with a clean ex-EVD exit site on repeat examination, the patient continued to be closely monitored but nothing further was done with regards to the culture report. However, one week later, he spiked a new fever with leukocytosis. A CT head showed inflammation along the tract of the former EVD (figure below), while CSF obtained via lumbar puncture showed an elevated CSF white cell count (307 cells per cubic millimetre of CSF), with elevated CSF protein and low CSF glucose. CSF galactomannan index was also high at >5.0.

CT head showing inflammation along the tract of the former EVD.

CT head showing inflammation along the tract of the former EVD.

He was treated with voriconazole – an antifungal drug with high activity against Aspergillus spp. and also with excellent CSF penetration – and fortunately survived the infection.

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