A report on pneumonia-induced ventriculitis with intraventricular abscess
For people with weakened immune systems, even common infections can take unexpected—sometimes life-threatening—turns. A 2021 case study from Tianjin Medical University General Hospital illustrates this risk, detailing how a lung infection progressed to a rare brain condition called ventriculitis (inflammation of the brain’s ventricular lining) with an intraventricular abscess (a pus-filled pocket in the brain’s ventricle).
The patient, a 59-year-old man, had a complex medical history: 15 years of hypertension, gout, chronic kidney disease, 4 years of type 2 diabetes, thyroid cancer (treated with surgery 1 year prior), and ischemic optic neuropathy (managed with oral steroids for 3 months). His symptoms began with a month of fever, chills, and cough. Local doctors initially diagnosed an inflammatory lung nodule and prescribed cefoperazone sulbactam (an antibiotic) for two weeks—but his fever persisted. A follow-up chest CT revealed the nodule had evolved into a thick-walled cavitating lesion (a hollowed-out area in the lung). Fungal markers were elevated (plasma (1-3)-beta-D-glucan >600 ng/L, galactomannan 0.64 mg/L), and his immune function was impaired (CD4+/CD8+ ratio 0.55). He started voriconazole (an antifungal) but still had fevers, prompting a transfer to Tianjin Medical University General Hospital.
At the new hospital, his fever improved with piperacillin-tazobactam (another antibiotic). Three weeks later, however, he had a seizure—his first sign of brain involvement. A brain CT showed no abnormalities, but a magnetic resonance imaging (MRI) scan revealed ventriculitis with an intraventricular abscess. A lumbar puncture (spinal tap) confirmed high cerebrospinal fluid (CSF) pressure (260 mmH2O, normal: ~100–180 mmH2O) and inflammation: 950 white blood cells/µL (normal: <5), 1.84 g/L protein (normal: <0.45), and low glucose (1.3 mmol/L, normal: ~2.2–3.9). Standard CSF culture grew nothing, but high-throughput sequencing (a genetic test that detects pathogen DNA) identified Aspergillus fumigatus—a fungus common in invasive aspergillosis, especially in people with weakened immunity.
The patient restarted voriconazole for a month. His fever resolved, and a repeat lumbar puncture showed normal CSF cell counts and pressure. Brain surgery confirmed the intraventricular abscess (though culture again showed no growth). He continued voriconazole plus ceftriaxone (an antibiotic) and had no further sepsis or lung lesions.
Ventriculitis is typically caused by bacterial infections, often in people with brain surgery or trauma (per guidelines from the Infectious Diseases Society of America). This case was unusual: the infection spread from the lungs (pulmonary aspergillosis) to the brain (encephalic aspergillosis)—a route seen in ~5% of central nervous system (CNS) aspergillosis cases. Aspergillus fumigatus is the top cause of invasive aspergillosis and carries a higher mortality rate than other forms—especially for people on long-term steroids or with chronic illnesses like this patient.
The case also highlights diagnostic hurdles: the patient had no classic brain infection symptoms (headache, vomiting, confusion, stiff neck), so CNS involvement wasn’t suspected until he seized. Brain CTs often miss early fungal infections, but MRI is more sensitive. And while standard cultures failed, high-throughput sequencing was critical to identifying the fungus.
For clinicians, the message is clear: if an immunosuppressed patient’s infection doesn’t improve with standard treatments, consider rare sites like the brain. Early MRI scans, advanced tests like high-throughput sequencing, and multidisciplinary care (emergency medicine, infectious disease, neurosurgery) are key to saving lives.
Original study published in the Chinese Medical Journal (2021;134(2):247–248) by Yong-Gang Gui, Yan-Fen Chai, Song-Tao Shou, and Chen-Guang Zhao from the Department of Emergency Medicine at Tianjin Medical University General Hospital, Tianjin 300052, China.
doi.org/10.1097/CM9.0000000000001203
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