Abstract Introduction Altered mental status (AMS) is a frequent cause of ICU admission; however, cases of vertebrobasilar dolichoectasia (VBD) or Weeksella virosa (WV) infections or drug-induced aseptic meningitis (DIAM) are not. The incidence of VBD is 0.05% to 0.1% (1), while WV infections have been rarely reported (2). A 2025 review identified 16 human infections with WV only two involving the urinary tract (4). Only one case of zanubrutinib-DIAM has been reported (3). We present a case where all conditions superimposed confounding the diagnosis. Case Presentation A 84-year-old female with high-risk chronic lymphocytic leukemia (CLL) on zanubrutinib admitted with AMS, slow responsiveness, and unsteady gait for 1 week. Imaging revealed enlarged ventricles consistent with hydrocephalus, VBD, and she underwent emergent ventriculostomy. Intracranial pressure was normal, and no significant neurological improvement occurred, prompting reconsideration of her symptoms as sepsis associated encephalopathy (SAE) and meropenem was initiated. Cultures isolated WV in urine after 46 hours. The organism was resistant to amikacin and fluoroquinolones, but susceptible to cefepime, carbapenems, TMP-SMX, and piperacillin-tazobactam. She was then treated with cefazolin and meropenem was discontinued. Her neurologic symptoms resolved within three days. Subsequently, she underwent V/P shunt placement and discharged home. Discussion The diagnostic process was complicated by overlapping symptoms such as altered mental status, slow responsiveness, and gait instability are also seen in hydrocephalus, DIAM, and SAE. Given the confounding presentation, the multidisciplinary team decided to treat hydrocephalus and sepsis. Although hydrocephalus associated with VBD was radiographically confirmed, normal ICP and rapid improvement with antibiotics supported an infectious etiology of her symptoms. Zanubrutinib which has been associated with altered mental status, mainly “brain fog”, intracranial bleeding, and DIAM (3). However, the patient’s CSF was not consistent with infection or aseptic meningitis.This case adds to the scarce VBD, WV, and DIAM literature, representing only 3rd documented UTI and first in a patient with hematologic malignancy. The isolate’s resistance profile aligns with prior reports, emphasizing the need for susceptibility-guided therapy. Despite diagnostic uncertainty, lack of immediate neurological improvement following the ventricular catheter placement and normal ICP, CSF findings not supporting DIAM, while responding to antimicrobials days later supports the pathogenic potential of WV in an immunocompromised host. Overlapping pathologies may obscure early signs of infection, underscoring the need for a broad differential diagnosis and timely sepsis workup. This case highlights the complex diagnosis and management of cancer patients. References: PMIDs 1. 33980042 2. 21209160 3. 37727390 4. https://doi.org/10.3390/tropicalmed10080210, This abstract is funded by: NA
Manjappachar et al. (Fri,) studied this question.