A 67-year-old male was admitted to our hospital due to unconsciousness and fever. The patient had fever symptoms 3 days before admission, the highest temperature was 39.6 C, and no special treatment was given. The patient had a history of drunkenness and aspiration 1 week before admission. One day before admission, the patient suddenly lost consciousness with quadriplegia. Physical examination: the patient was in a deep coma; the diameter of the bilateral pupils was 2 mm; the Glasgow score was E1V1M3; and the muscle strength of the limbs was grade 2. Blood analyses revealed evidence of leukocytosis (33.6 x 109/L) and elevated C-reactive protein (CRP) levels (199.80 mg/L), neutrophils percentage (93.80%), and procalcitonin range (1.58 ng/ml). Head computed tomography (CT) showed multiple intracranial space-occupying edema, and chest CT showed a right upper lobe space occupying the cavity. Brain magnetic resonance imaging (MRI) showed multiple divergent intracranial abscesses, which were low signal on the T1 weighted image and high signal on the T2 weighted image and were significantly enhanced. On the day of admission, the patient had difficulty breathing and was given mechanical ventilation with tracheal intubation (Figure 1). On day 3, a tracheotomy was performed. The patient had no history of tuberculosis, sputum tuberculosis and tuberculosis infection T cell detection was negative.
To determine the patient's intracranial infection, we performed a lumbar puncture on the third day after admission. Cerebrospinal fluid (CSF) analyses revealed leukocytosis (10,300 x 106/L), elevated protein levels (140.39 mg/dL), decreased glucose levels (0.27 mmol/L), and normal chloride concentration level (120.2 mmol/L). However, pathogens were not detected in the cultures, and Gram staining assays were prepared from CSF, sputum, and blood samples. We used vancomycin (2 g every 12 h, ivgtt) combined with meropenem (1 g every 8 h, ivgtt) and ornidazole (0.5 g every 12 h, ivgtt) as an empirical anti-infection treatment. We used mNGS to identify pathogens in CSF and alveolar lavage fluid on 5th day after admission (Table 1). We stopped vancomycin and meropenem, then switched to ceftriaxone (2 g every 24 h, ivgtt) combined with amikacin (0.4 g every 12 h, ivgtt) for anti-infection treatment.
The patient's consciousness and limb muscle strength gradually improved during the subsequent treatment. Two weeks after admission, the patient's body temperature was normal, and no more than 39 C. Celsius Routine blood leukocyte count, neutrophil ratio, and procalcitonin levels decreased gradually to normal levels. We performed lumbar puncture during hospitalization at the third week after admission, which showed that the patient's intracranial pressure was 180 mmH2O and the color of the CSF was light blood and clear; CSF analyses showed normal leukocyte count (15 x 106/L), elevated protein levels (72.3 mg/dL), and normal glucose levels (4.37 mmol/L) and chloride concentration level (119 mmol/L). We then sequenced the CSF again at 4 weeks after admission, suggesting that S. intermedia could still be detected, but its relative abundance decreased from 39.34 to 5.62% (Table 2). We continued to use ceftriaxone in the treatment of intracranial infection until the patient's body temperature was normal for 2 weeks, we stopped all antibiotics at 6 weeks after admission (Table 3).
After 8 weeks, the patient's consciousness became clear, and the muscle strength of the limbs recovered to grade 4. CT showed that the size of the lesion and the degree of edema improved significantly, the patient's upper right pneumonia was better than before, and the patient was discharged at the 10 weeks after admission (Table 3). The 3-month follow-up head MRI showed that the brain abscess had basically disappeared (Figure 2).