A Rare Cause of Extended-Spectrum Beta-Lactamase Positive Escherichia coli Meningitis in a Child: Spinal Canal Cyst

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To the Editors: Acute bacterial meningitis is an important cause of mortality and morbidity. Gram-negative enteric bacillary meningitis is rare beyond the neonatal period and anatomical malformations can be the underlying risk factors after this period.1 Herein, we report a 13-month-old child with extended-spectrum beta-lactamase positive Escherichia coli meningitis who had a rare underlying cause, a spinal canal cyst. A previously healthy 13-month-old male patient was admitted to the emergency room with complaints of vomiting after falling while climbing on a 30-cm high stool. On admission, he had a fever and confusion. Due to the altered level of consciousness and history of falling, brain computed tomography was performed and no pathology was revealed. A lumbar puncture was performed. Ceftriaxone, vancomycin and dexamethasone were initiated empirically. On the 3rd day of the patient’s follow-up, extended-spectrum beta-lactamase positive E. coli growth was detected in the cerebrospinal fluid culture. Treatment was switched to meropenem due to the culture antibiogram. The patient had a sacral dimple, and a spinal magnetic resonance imaging was performed to evaluate an anatomical disorder for predisposition to meningitis. A spinal canal cyst was observed between L4 and S1 and it was thought to be an epidermoid cyst primarily (Fig. 1). No neurological deficit was detected in the patient, whose antibiotic treatment was completed for 21 days. He was referred to the neurosurgery clinic for further treatment.FIGURE 1.: Spinal magnetic resonance imaging (MRI) of the patient. A: Sagittal T2-weighted, (B) T1-weighted and (C) T1-weighted with contrast MRIs showed a cystic mass in the spinal canal between L4 and S1 (white empty arrows). There was no enhancing solid component within the lesion. Also, a fistula tract between the skin and spinal canal was observed at S2 level (black full arrows).The most common bacterial meningitis agents in the age group after the neonatal period are Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae type b.1 Tebruegge et al1 observed that 26% of Gram-negative enteric bacillary meningitis cases had conditions such as neural tube defects and urinary tract anomalies, which lead to meningitis and require surgical repair. Intraspinal epidermoid cysts are extremely rare and may present with different symptoms depending on the compression of neural or vertebral components.2 Symptoms include pain, weakness, ataxia and incontinence.3 Spinal canal tumors also can be acquired. Potgieter et al4 reported that the cause of acquired spinal canal tumors was a lumbar puncture performed in the early neonatal period. Epidermoid cysts are treated by total resection with microsurgery. However, in the literature, total resection cannot be achieved in one-third, and postoperative deterioration occurs in 13%.5 Siller et al5 state that the postoperative recovery rate in children is higher than in the adult group, and they emphasize early treatment. In conclusion, we described a case that presented with bacterial meningitis, in which we detected a rare underlying cause, a spinal canal cyst. The main reasons that led us to advanced imaging were the fact that the case had no known disease, the detection of E. coli, which is an unexpected organism for the age group, and the presence of sacral dimples on physical examination. We recommend that patients who are followed up with a diagnosis of acute bacterial meningitis be investigated for anatomical malformations if a single unexpected organism is detected.

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