Introduction: This case study explores an uncommon triad of encephalitis, ventriculitis, and meningitis complicated by ischemic strokes and seizures in a COVID-19-positive patient. Prior studies suggest that bacterial meningitis and encephalitis can lead to cerebral infarctions due to inflammation and vascular injury.1,2,5 Ventriculitis, in particular, is rarely observed and typically is seen as a severe complication of meningitis, and can be managed with neurosurgical interventions such as CSF shunt placement, ventricular drains, or other intracranial devices.3,4 The simultaneous presentation of all three conditions in a single patient is rare and poses significant challenges from a diagnostic and management standpoint.
Case Presentation: We present a 73-year-old male with a history of hypertension, hyperlipidemia, and alcohol use disorder who was airlifted from a cruise ship for acute encephalopathy and respiratory distress from COVID-19. On arrival, treatment was initiated for alcohol withdrawal and community acquired pneumonia. At that time, he was septic with leukocytosis, hypertensive with an SBP > 200 mmHg, and initial head CT was negative for any acute abnormality. Several days later, a stroke alert was called for sustained left-sided weakness and worsening encephalopathy, prompting transfer to the ICU and intubation for airway protection. A lumbar puncture revealed findings suggestive of meningitis with purulent CSF and an opening pressure of 24 mmHg prompting immediate escalation of antibiotics. His MRI Brain revealed simultaneous ventriculitis, meningitis, and encephalitis. A repeat CT brain days later revealed ischemic infarcts in the right middle and anterior cerebral artery territories. Following progressive neurologic decline and no improvement over the next week, his spouse opted to transition him for hospice and palliative extubation.
Deviation from the Expected: The patient’s initial neurological state was attributed to alcohol withdrawal. Later CSF analysis and imaging revealed an uncommon infectious triad with significant infarcts.
Conclusion: The simultaneous presence of meningitis, encephalitis, and ventriculitis with stroke is infrequent, emphasizing the significance of broad differentials and importance of implementing comprehensive management strategies.