Aseptic meningoventriculitis after spinal anesthesia and Epstein Barr finding as a differential diagnosis of rapidly progressive dementia: case report

Case presentation: A 61-year-old female patient from João Pessoa (Paraíba), with a medical history of hypertension and diabetes, underwent uterine polypectomy under spinal anesthesia. Four days post-procedure, she developed an intense headache associated with nausea and vomiting, progressing subacutely to disorientation, recent memory difficulty, disinhibition, incoherent speech, and gait disturbance, and initiated investigation for rapidly progressive dementia. After 40 days, with progressive worsening, she was admitted in a somnolent state, with neck stiffness, bradykinesia in the upper limbs (worse on the right), and left VI paresis. Initial computed tomography revealed cortical sulci effacement with marked supratentorial ventricular dilatation. Contrast-enhanced magnetic resonance imaging demonstrated signs of inflammatory/infectious leptomeningitis affecting cortical gyri and basal cisterns, changes suggesting ventriculitis with moderate supratentorial ventricular dilatation; FIESTA sequence revealed aqueductal stenosis with thin septations. Cerebrospinal fluid analysis revealed limpid fluid with glucose of 69; proteins 111; leukocytes 20 (80% mononuclear); non-reactive VDRL and negative bacterial, fungal cultures, and malignant cells. Viral panel by RT-PCR detected Epstein-Barr Virus (EBV). Serologies for hepatitis C and B, HIV, and VDRL were negative. Initial empiric treatment included vancomycin 2g/day, meropenem 6g/day, and dexamethasone 16 mg/day for 21 days. After aseptic ventriculitis was confirmed, with serial negative CSF cultures, a ventriculoperitoneal shunt was performed. The patient improved cognitively and in his level of consciousness. At 8-month follow-up, she returned to the neurology outpatient clinic with daily activities maintenance and remission of previous symptoms. Discussion: Post-spinal anesthesia meningitis is extremely rare (< 0.01%) with potentially severe complications. The reported case suggests DIAM, diagnosed based on a high suspicion level. Aseptic cerebrospinal fluid confirms the diagnosis, facilitating antibiotic withdrawal, shorter hospital stay, and reduced costs. Final comments: Serial investigations ruled out infectious causes for the clinical-radiological presentation, suggesting inflammatory process as a cause for aqueductal septations. The presence of EBV in the case is uncertain as to whether it is a concomitant finding or a causative and aggravating agent. The patient had a favorable clinical outcome.