Hepatitis C ventriculitis obscured by concurrent methicillin-resistant Staphylococcus aureus infection after ventriculoperitoneal shunt placement: An illustrative case

Background: Hepatitis C virus (HCV) is the most common blood-borne virus, affecting tens of millions of people worldwide. Neurologic manifestations of chronic HCV are rare and may be overlooked during workup of central nervous system (CNS) infections. We report on a patient who was diagnosed with hepatitis C meningoencephalitis after a protracted treatment course for presumed methicillin-resistant Staphylococcus aureus (MRSA) ventriculitis. Case Description: This was a 34-year-old male with a history of intravenous drug use and ventriculoperitoneal shunt placement for hydrocephalus secondary to post-traumatic intracranial hemorrhage, who presented 1 week following shunt surgery with worsening dizziness, with initial assessment demonstrating shunt infection with positive MRSA on cerebrospinal fluid (CSF) cultures. Over his hospital course, the patient demonstrated worsening ventriculomegaly on imaging, with pleocytosis and hyperproteinosis on CSF analyses despite aggressive antibiotic treatment, ventricular irrigation, and negative bacterial and fungal cultures. His symptoms resolved within 1 week of antiviral therapy for HCV with sofosbuvir-velpatasvir. Conclusion: In patients with chronic HCV, viral reactivation may manifest as protracted ventriculitis in the setting of low-to-normal pressure ventriculomegaly. Providers should be cognizant of serologically covert viral etiologies for post-operative infections and consider preemptive antiviral treatment in patients with aseptic CSF profiles when refractory to empiric antibiotic regimens for more common CNS pathogens.