Mannitol Anaphylaxis in the Setting of Septic Emboli-Induced Intracranial Hemorrhage

Abstract

Neurological complications are a significant problem in bacterial endocarditis. Cerebral embolism is the most frequent concern. Acute embolic disease may trigger focal seizures or mycotic aneurysms. Miliary infection is also common, and lumbar puncture can guide in determining the infective organism. Purulent cerebrospinal fluid (CSF) consists often of Staphylococcus aureus, a virulent organism, whereas non-virulent organisms (i.e., viridans streptococci) have normal CSF formulae. Microscopic abscesses suggest the potential for aneurysm from bacterial endocarditis amplifying the risk of intracranial hemorrhage. Mannitol and hypertonic (3%) saline are intravenous medications used as a rescue treatment for brain hemorrhage. A patient diagnosed with mycoplasma pneumonia and septic shock secondary to tricuspid endocarditis with extensive pulmonary emboli and metastatic infection to his spine was initiated on antibiotics. He developed a massive intracranial bleed from the rupture of mycotic septic emboli and was given mannitol to decrease intracranial pressure, which caused anaphylaxis.

Keywords: allergic reaction; allergy and anaphylaxis; bacterial endocarditis; septic emboli; spontaneous intracranial hemorrhage.

Figure 1. Chest X-ray showing diffuse scattered infiltrates suggesting multilobar pneumonia (arrow)

Figure 2. Ventilation/perfusion (VQ) scan showing perfusion defects (arrows)

Figure 3. Computed tomography (CT) of the chest with widespread cavitary nodular parenchymal densities consistent with septic emboli (arrows)

Figure 4. MRI of the spine with lumbar involvement of septic emboli (arrows)

Figure 5. CT of the head showing left frontal intraparenchymal intracranial bleed (arrow)