Abstract Introduction We present a case of Streptococcus dysgalactiae subspecies equisimilis (Group C Streptococcus, GCS) ventriculitis presumed to have arisen via hematogenous spread from a severe soft-tissue infection. Although traditionally considered a zoonotic organism, GCS is increasingly recognized as an invasive human pathogen, particularly in older adults and those with comorbidities. Reported manifestations include cellulitis, bacteremia, and endocarditis, while central nervous system (CNS) infection is exceedingly rare, with fewer than five published cases of ventriculitis to date. Ventriculitis carries a mortality rate of up to 30% despite appropriate treatment. Case Report A 70-year-old morbidly obese man with no known medical history was brought to the emergency department after being found obtunded at home. The family reported a reclusive lifestyle complicated by hoarding disorder and poor living conditions. On arrival Glasgow Coma Score was 12, he developed septic shock with fever, hypotension requiring norepinephrine, and hypoxemia. Laboratory studies showed leukocytosis (25.2 × 10³/μL), 19.7% bands, and lactic acidosis. Broad-spectrum antibiotics (vancomycin + piperacillin-tazobactam) were initiated, and he was admitted to the medical intensive care unit (MICU) for septic shock secondary to extensive right-leg cellulitis. His neurological status worsened despite therapy to Glasgow Coma Score 6. Ampicillin and acyclovir were added empirically for suspected meningitis. Electroencephalography on day 2 showed posterior slowing, prompting brain MRI on day 3, which demonstrated pus in the ventricles and subarachnoid space consistent with ventriculitis. Blood cultures grew β-hemolytic GCS. Lumbar puncture, delayed by body habitus, ultimately yielded cerebrospinal fluid consistent with bacterial meningitis (WBC 1360/μL 90% neutrophils, protein 600 mg/dL, glucose 9 mg/dL). Antibiotics were narrowed to ceftriaxone per susceptibilities. In the absence of neurosurgical instrumentation and with extensive soft-tissue infection, the ventriculitis was presumed to result from hematogenous dissemination. Despite appropriate therapy, he remained obtunded and later died after transition to comfort care on hospital day 22. Discussion This case highlights the invasive potential of Group C Streptococcus to cause life-threatening CNS infection. Only isolated cases of GCS ventriculitis have been described, following a similar pattern of hematogenous spread. MRI played a pivotal role in establishing the diagnosis when lumbar puncture was delayed, emphasizing its value in sepsis-associated encephalopathy. Clinicians should include GCS in the differential diagnosis for ventriculitis even in the absence of animal exposure. Awareness of its virulence in humans may guide empiric antimicrobial therapy and encourage early imaging in critically ill patients with unexplained altered mental status. This abstract is funded by: None
Jimenez et al. (Fri,) studied this question.