Mycotic aneurysm rupture: a sunken rock of central nervous system infection

Article information

J Neurocrit Care. 2024;17(1):38-39

Publication date (electronic) : 2024 June 25

doi : https://doi.org/10.18700/jnc.240008

Keun Tae Kim, MD

Department of Neurology, Keimyung University School of Medicine, Daegu, Korea

Corresponding author: Keun Tae Kim, MD Department of Neurology, Keimyung University School of Medicine, 1095 Dalgubeol-daero, Dalseo-gu, Daegu 42601, Korea Tel: +82-53-258-4379, Fax: +82-53-258-4380, E-mail: 6k5upa@gmail.com

Received 2024 March 20; Revised 2024 May 28; Accepted 2024 June 11.

An 81-year-old male with a history of diabetes mellitus and consequent retinopathy visited our emergency department. Six months prior, he developed otitis media due to gram-positive cocci and was treated with vancomycin. However, progressive confusion over 2 months prompted his family to bring him to our emergency room. Upon examination, he was drowsy and repeatedly stated “okay” in response to every question. Laboratory tests revealed leukocytosis (12,730/μL), C-reactive protein levels of 10.3 mg/dL, cerebrospinal fluid (CSF) red blood cell levels of 0/μL, CSF pleocytosis (white blood cell levels of 6/μL; a differential count was not provided), and protein elevation (57.0 mg/dL). CSF and serum glucose levels were 62 mg/dL and 122 mg/dL, respectively. Brain magnetic resonance imaging showed no significant abnormalities (Fig. 1). Consequently, combination therapy with vancomycin (1 mg q 12 hr) and ceftriaxone (2 mg q 12 hr) was initiated for bacterial infection of the central nervous system.

Fig. 1.

Normal brain magnetic resonance imaging and magnetic resonance angiography on the first day.

Computed tomography revealed infection of the right inner ear (Fig. 2). On the fifth day of admission, the patient became alert and followed a one-step command. CSF culture identified a Staphylococcus warneri infection. Three days later, the patient was found to be comatose. Brain computed tomography revealed a subarachnoid hemorrhage with an aneurysm in the right posterior communicating artery (Fig. 3). The patient died the following day.

Fig. 2.

Paranasal sinus computed tomography shows middle ear effusion (circle).

Fig. 3.

Brain computed tomography on post-admission day 8 shows a subarachnoid hemorrhage around the basal cistern and newly developed cerebral aneurysm (arrowhead).

In this case, sequential neuroimaging demonstrated the sudden rupture of a mycotic aneurysm within only 8 days. Since mycotic aneurysms can be asymptomatic but fatal, short-term follow-up angiography after central nervous system infection should be considered.