Rapidly Progressive Pyogenic Ventriculitis Associated With Bacterial Meningitis Caused by Streptococcus intermedius

Ventriculitis commonly arises as a complication of various central nervous system conditions. The causes of ventriculitis include both iatrogenic conditions, such as catheter-related infections, and non-iatrogenic conditions, such as community-acquired bacterial meningitis. The incidence of pyogenic ventriculitis associated with community-acquired bacterial meningitis remains unclear. Additionally, the optimal treatment strategy for pyogenic ventriculitis secondary to community-acquired bacterial meningitis remains uncertain. A 47-year-old man presented with headache, fever, and impaired consciousness. At admission, cerebrospinal fluid analysis five days after the onset (day one) revealed elevated white blood cell count with neutrophilic predominance, increased protein levels, and significantly reduced glucose. Initial brain computed tomography (CT) showed bilateral lateral ventricular enlargement with subtle fluid accumulation in the right lateral ventricle. Despite the initiation of empirical antimicrobial therapy, follow-up CT two days later demonstrated a rapid progression of fluid accumulation in the bilateral lateral ventricles. Diffusion-weighted magnetic resonance imaging (MRI) confirmed high signal intensity within the ventricles, consistent with intraventricular pus. Emergency external ventricular drainage (EVD) was promptly performed, and cultures from the intraventricular pus identified <i>Streptococcus intermedius</i>. These findings led to a diagnosis of pyogenic ventriculitis with secondary hydrocephalus associated with bacterial meningitis. Initial clinical improvement was observed following EVD. The EVD catheter was removed 15 days after the procedure on day 18. However, the patient developed status epilepticus, necessitating a second EVD procedure on day 22. Subsequent intervention and continued antimicrobial therapy from day one until day 52 resulted in a follow-up MRI on day 55 confirming the resolution of intraventricular pus. The ventricular drain was safely removed, and the patient was discharged on day 68 in stable condition with only mild residual cognitive impairment. This case underscores several critical considerations in managing pyogenic ventriculitis with hydrocephalus secondary to bacterial meningitis. First, careful imaging follow-up is crucial for monitoring disease progression and guiding timely interventions. Second, the prompt implementation of EVD can play a pivotal role in improving patient outcomes. Finally, EVD should be maintained until imaging confirms the complete resolution of intraventricular pus. Adhering to these management principles likely helps optimize prognosis in these challenging cases.