Rare presentation of Pseudomonas aeruginosa meningitis following intrathecal pump replacement

Rare presentation of Pseudomonas aeruginosa meningitis following intrathecal pump replacementTo the Editor,We report a rare case of Pseudomonas aeruginosa meningitis following intrathecal pump (IP) replacement.A 69-year-old male with a history of spastic diplegia cerebral palsy, T11-S1 spinal fusion, and chronic low back pain presented six weeks after an uneventful IP replacement.His symptoms included the worst headache of his life, neck pain, and chills.The pump, originally implanted in 2006 for spasticity management, had been revised due to battery expiration.On examination, the surgical site appeared normal, and an initial lumbar puncture (LP) was unremarkable.Despite empiric antibiotics, his condition deteriorated with worsening mental status and seizures.Subsequent cerebrospinal fluid (CSF) side port aspiration and pump pocket lavage identified Pseudomonas aeruginosa.Following pump explantation and targeted meropenem therapy, the patient's condition improved significantly.We received patient consent to publish details of their case.This case underscores the importance of early CSF sampling before initiating antibiotics in suspected infections and highlights the potential for meningitis to occur despite a normal-appearing pump pocket.The patient presented to the emergency department six weeks postoperatively with new symptoms.Imaging, including CT and MRI, showed no evidence of abscess or fluid collection.Despite the normal appearance of the pump site, he developed hallucinations and seizures.An LP was completed by interventional radiology due to his extensive spinal fusion.Unfortunately, this LP was delayed by a week due to scheduling issues but was ultimately unremarkable.Empiric antibiotics were started due to the clinical suspicion of infection.An MRI of the brain on hospital day seven showed findings concerning for ventriculitis and borderline leptomeningeal enhancement.Despite a negative initial LP, the patient's mental status continued to worsen.Next, side port and pump pocket aspiration were completed.There was no fluid in the pump pocket to aspirate, so saline was injected into the pocket then aspirated to be sent for culture.The pocket lavage demonstrated a positive Gram stain, while the CSF sample from the side port was concerning for meningitis with ~270 WBCs (69 % neutrophils), low glucose, and slightly elevated protein.Later, the cultures grew Pseudomonas.