We present a rare case of pneumocephalus in an 11 day old 32 week infant. She presented with signs of fulminant sepsis with no predisposing factors. Despite appropriate broad spectrum antibiotics and supportive treatment, her condition worsened. Care was withdrawn after discussion with parents.
Cranial ultrasound (figure 1) suggested the presence of intracranial air filled spaces, and computed tomographic images confirmed pneumocephalus (multiple air filled spaces in the brain) as well as a large posterior fossa haemorrhage. Citrobacter koseri was identified in cerebrospinal fluid culture.
Pneumocephalus is often due to brain trauma and iatrogenic causes, but is also an extremely rare complication of neonatal meningitis. Citrobacter species are facultative anaerobic gram-negative enteric bacilli. C koseri is most commonly associated with brain abscesses, but this gas forming organism has also been associated with pneumocephalus.
This case emphasizes the importance of Citrobacter as an important neonatal pathogen in late preterm infants. If a late preterm baby has signs of late-onset sepsis with no antenatal or postnatal risk factors it should be considered. If Citrobacter is isolated in cultures, prompt initiation of appropriate broad spectrum antibiotic with effective central nervous system penetration and close monitoring is needed. CT is the imaging modality of choice.
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