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From Presentation to Prognosis: A Challenging Case of Multifocal Cerebral Micro Abscesses Due to Citrobacter Freundii
Varsha Nandwana1, Liam M Cleary1, Thomas V Kodankandath1
1Department of Internal Medicine, Section of Neurology, Carilion Clinic-Virginia Tech Carilion School of Medicine, Roanoke, USA.
Introduction:
Citrobacter freundii is a rare cause of central nervous system (CNS) infections, primarily affecting neonates. In adults, cases are uncommon and often associated with high mortality rates.
Case Description:
We describe the case of an adult male with multiple comorbidities who presented with constipation, nausea and vomiting, which rapidly progressed to altered mental status and seizures. Neuroimaging revealed gas densities within intracranial veins and evolving encephalitic changes. Cerebrospinal fluid (CSF) findings were non-specific, but blood and wound cultures identified C. freundii. Targeted antibiotic therapy with cefepime and ampicillin-sulbactam was initiated, but the patient's condition deteriorated leading to withdrawal of care, and death. Autopsy confirmed multiple cerebral micro abscesses, consistent with septic embolization.
Conclusion:
This case highlights C. freundii as a rare but fatal cause of septic encephalopathy. Diagnostic challenges arose from the atypical neurological presentation and non-specific CSF findings. The transition to cefepime was guided by concerns over C. freundii's AmpC β-lactamase production. Despite appropriate antimicrobial therapy, the patient's poor outcome underscored the challenges of managing CNS infections in relatively immunocompromised hosts. Early recognition of C. freundii CNS infections is crucial, particularly in high-risk patients. A high index of suspicion, serial imaging and tailored antimicrobial therapy are essential for optimising outcomes. Further research is needed to enhance diagnostic methods and treatment strategies.
Learning Points:
Septic embolization due to C. freundii can present with atypical neurological symptoms.Antibiotic selection should consider C. freundii's resistance mechanisms.
Insights
Citrobacter freundii central nervous system (CNS) infections are rare in adults but highly fatal. This case highlights diagnostic challenges and the need for early recognition and tailored treatment in high-risk patients.
Area of Science:
- Neurology
- Infectious Diseases
- Microbiology
Background:
- Citrobacter freundii is an uncommon cause of central nervous system (CNS) infections, predominantly seen in neonates.
- In adults, CNS infections by C. freundii are rare and associated with significant mortality.
- Patients with comorbidities are at higher risk for severe outcomes.
Purpose of the Study:
- To report a rare case of fatal septic encephalopathy caused by Citrobacter freundii in an adult with multiple comorbidities.
- To discuss the diagnostic challenges and management strategies for C. freundii CNS infections.
- To emphasize the importance of early recognition and appropriate antimicrobial therapy.
Main Methods:
- Case report of an adult male with atypical neurological presentation.
- Diagnostic workup included neuroimaging, cerebrospinal fluid (CSF) analysis, and blood/wound cultures.
- Treatment involved targeted antibiotic therapy based on identified pathogen and resistance mechanisms.
Main Results:
- The patient presented with gastrointestinal symptoms rapidly progressing to altered mental status and seizures.
- Neuroimaging showed intracranial venous gas and encephalitic changes.
- C. freundii was identified in blood and wound cultures; CSF findings were non-specific.
- Despite appropriate antibiotics, the patient experienced clinical deterioration and death, confirmed by autopsy with cerebral microabscesses.
Conclusions:
- Citrobacter freundii can cause severe septic encephalopathy with atypical neurological manifestations.
- Diagnostic difficulties arise from non-specific CSF findings and unusual presentations.
- Effective management requires considering C. freundii's resistance mechanisms, such as AmpC beta-lactamase production, and prompt, tailored antimicrobial therapy.
- Early detection and intervention are critical for improving outcomes in high-risk individuals.
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