P3C337: A Rare Case of Pasteurella multocida Meningitis Complicated by Empyema in a Newborn

Introduction: Pasteurella multocida is a gram negative non–spore-forming coccobacillus present in the oral flora of 70–90% of cats and 50–66% of dogs. Clinical sequelae of P. multocida most commonly includes soft tissue infection, but may also cause respiratory infections, bacteremia, meningitis, and endocarditis. Severe infections almost exclusively affect neonates, elderly, and immunocompromised patients.

Case Description: A 7-week-old ex 34-week premature infant male presented to ED with new onset irritability and fever (Tmax 38.3 C). On presentation, a full sepsis workup was completed revealing no leukocytosis (72600/uL), elevated CRP (15.41 mg/dL) and CSF significant for pleocytosis (209/cumm), elevated protein (158 mg/dL), hypoglycorrhachia (37 mg/dL). Empiric ceftriaxone and ampicillin was initiated, and baseline MRI brain was completed. Imaging revealed incidental retro cerebellar arachnoid cyst with no evidence of meningitis.

On hospital day 3, both blood and CSF cultures confirmed growth of Pasteurella multocida. Upon further history, the mother stated that the family dog had scratched the infant’s cheek and was found licking the wound several days prior to presentation.

Following diagnosis of Pasteurella bacteremia and meningitis, antibiotic coverage was broadened to include meropenem in addition to ceftriaxone. Fevers continued to persist after 5 days of antibiotics. Blood and CSF cultures were repeated and negative. Patient defervesced on day 7 of antibiotics.

On hospital day 13, course was complicated by 3 subsequent episodes of focal, right-sided tonic-clonic seizures requiring abortive treatment. A loading dose of levetiracetam was administered and patient underwent emergent MRI brain w/wo contrast. Imaging revealed interval development of bilateral convexity meningitis and a multifocal subdural empyema along the interhemispheric falx and frontoparietal temporal convexities. No neurosurgical intervention was warranted. Patient continued on levetiracetam for seizure prophylaxis with no further seizure activity. Blood and CSF cultures were repeated on day 26 of antibiotics and resulted negative.

Patient was discharged after completing 28 days IV antibiotics and passing a hearing screen. A month following discharge, MRI brain was repeated and confirmed complete resolution of the subdural empyema.

Discussion: Most common etiologies of meningitis in infants in this age range include Group B Streptococcus, Escherichia coli, Haemophilus influenzae, and Listeria monocytogenes. Less than 40 cases of neonatal meningitis secondary P. multicoda have been reported in literature since the first documented case in 1976. There have been less than 5 cases complicated by neurological sequela including status epilepticus and empyema. Following complicated, prolonged hospital courses, this patient and prior documented cases have reported return to baseline without documented morbidity or mortality.

Conclusion: This case highlights the importance of anticipatory guidance during wellness visits including proper hand hygiene, supervision of house hold pets around children, and avoidance of transmission of oral flora from pet to child.