Community-Acquired Pneumococcal Ventriculitis as a Complication of Otogenic Pneumococcal Meningitis: A Case Report

Pyogenic ventriculitis is a rare and potentially fatal infection of the ventricular system. While most reported cases are nosocomial and catheter-associated, ventriculitis as a complication of community-acquired bacterial meningitis is uncommon, particularly in adults, and carries a poor prognosis. We report the case of an 82-year-old previously healthy and unvaccinated woman who presented with a one-day history of fever, confusion, and purulent left-sided otorrhea on a 2-week background of flu-like symptoms. Cranial computed tomography was consistent with otogenic meningitis complicated by pneumocephalus, and lumbar puncture confirmed purulent meningitis. Empirical therapy for meningitis with ceftriaxone, amoxicillin, metronidazole, and dexamethasone was initiated, and surgical source control of the otogenic focus was performed. Both blood and cerebrospinal fluid cultures grew Streptococcus pneumoniae with a penicillin minimum inhibitory concentration of < 0.03 mg/L. Serotyping by multiplex PCR with confirmatory Quellung reaction, performed at the Swiss National Reference Center for Invasive Pneumococci, identified Serotype 3. Despite penicillin G monotherapy, fever and impaired consciousness persisted, and repeat imaging revealed meningitis-associated pyogenic ventriculitis with intraventricular debris. Adjunctive rifampicin and a series of cerebrospinal fluid drainage interventions (lumbar drain followed by external ventricular drain) failed to substantially improve neurological outcome. Antibiotic therapy was continued for 9 weeks, after which the patient was transferred to long-term institutional care with severe residual neurological impairment. This case illustrates the diagnostic and therapeutic challenges of meningitis-associated pyogenic ventriculitis in adults and the disproportionate severity of disease caused by Serotype 3 S. pneumoniae, whose unusually thick mucoid capsule promotes immune evasion and the formation of viscous purulent debris that hampers source control. The case is consistent with Swiss surveillance data showing that Serotype 3 remains a leading cause of invasive pneumococcal disease in older adults and serves as a sentinel event highlighting persistent gaps in adult pneumococcal immunization.