Oral sequential therapy in the treatment of post-surgical epidural abscess and subdural empyema.

PURPOSE: The management of post-surgical subdural empyema and subdural abscess is not standardised. The objective was to analyse the efficacy and safety of oral sequential therapy (OST). METHODS: Retrospective observational study in a tertiary hospital in Vigo (Spain). We included adult patients with subdural abscess or epidural empyema with microbiological isolation. Clinical and demographic variables, isolated microorganisms and treatment regimens were included, as well as mortality and adverse effects during the follow-up period. RESULTS: Thirty patients were reviewed, two died due to causes other than infection. Six-month recurrence rate was 2/28 and all other patients (26/28) had clinical cure at the end of the treatment. The commonest isolated microorganisms were Gram-positive, especially Staphylococcus aureus. The most widely used oral antibiotic was trimethoprim-sulfamethoxazole (80%). No side effects related to oral treatment were observed. CONCLUSION: After adequate source control, OST can be a safe practice in the management of post-surgical epidural abscess and subdural empyema.

The Case for Early Antibiotic Commencement and Source Control in Paediatric Subdural Empyema: A Single-Centre Retrospective Case Series.

BACKGROUND: Subdural empyema is a neurosurgical emergency requiring prompt diagnosis and treatment. There is a debate between the benefits and risks of starting early antibiotics prior to surgical drainage as this is purported to reduce the rate of microbiological diagnosis. Here, we describe our experience of treating this potentially life-threatening condition, advocating for the early commencement of antibiotics and importance of source control in its treatment. METHODS: Retrospective review of a prospectively collected electronic departmental database included all patients who were admitted to our unit with a diagnosis of subdural empyema over an 11-year period (2008-2018). Basic demographic data were collected. Further data pertaining to mode of presentation, surgical approach, causative organism, post-operative antibiotic regime, anti-seizure medications, length of hospital stay, further surgery, and neurological outcomes were extracted. RESULTS: Thirty-six children underwent 44 operations for subdural empyema at our institution during the study period. Median age was 11.0 (range 0.2-15.8); 47.2% (17/36) were female. Over time, there was decreasing use of burr holes and increasing use of craniectomy as the index surgery. Using a combination of extended culture and polymerase chain reaction, a microbiological diagnosis was achieved in all 36 cases; the commonest causative microorganism was of the Streptococcus anginosus group of bacteria. Seven patients underwent repeat surgery, and 4 patients underwent a concurrent ENT procedure. No risk factors were significant in predicting the likelihood of re-operation (location of subdural empyema, age, index surgery type, inflammatory markers, concurrent ENT procedure, and microorganism) although it was notable that none of the patients undergoing a concurrent ENT procedure underwent repeat surgery (p = 0.29). Median length of stay was 12 days (range 3-74), and there were no inpatient or procedure-related mortalities. Clinical outcomes were good with 94.4% (34/36) categorized as modified Rankin Scale 0-3 at discharge and there were 2 cranioplasty-related complications. CONCLUSIONS: We observed an evolution of practice from limited surgical approaches towards more extensive index surgery over the study period. Given that a microorganism was isolated in all cases using a comprehensive approach, initiation of antibiotic therapy should not be delayed on presentation. Concurrent ENT surgery may be an important factor in providing aggressive source control thereby reducing the need for repeat surgery.

Pediatric subdural empyema as a complication of meningitis: could CSF protein/CSF glucose ratio be used to screen for subdural empyema?

Subdural empyema (SDE) is a rare condition which can appear secondary to meningitis in childhood, especially in infants. This study was planned to evaluate and compare clinical and laboratory features, treatment, and outcome of children with SDE to those with acute bacterial meningitis (ABM) without SDE. The electronic medical files of 266 patients diagnosed with ABM between January 2009 and December 2019 were evaluated. Patients' demographic and clinical features, laboratory results, cranial imaging findings, treatment, and outcomes were recorded. SDE was identified in 10 patients, 3.7% of all diagnosed with meningitis. The etiology of SDE was identified in eight (80%). The most common responsible pathogen was Streptococcus pneumoniae. Cranial imaging was performed between the 2nd and 13th days of admission, and the most common reason of performing cranial imaging was persistence of fever. Two patients were healed with 4-6 weeks of antibiotic treatment without surgery, eight (80%) needed surgical intervention.Conclusion: The clinical signs and symptoms of SDE may be subtle. If the fever persists or focal neurological findings are seen during the treatment of bacterial meningitis, SDE should be suspected. Furthermore, patients with ABM who are determined to have a protein-to-glucose ratio in the cerebrospinal fluid above 4.65 should be carefully monitored for SDE development. What is known: • Subdural empyema may develop subsequently to meningitis, especially in the infant age group in whom very little is known in terms of disease characteristics. • Delay in diagnosis and treatment can cause long-term neurologic sequelae and mortality. What is new: • Persistence or relapse of fever during the treatment of acute meningitis is an important warning sign for SDE even if there are no other symptoms. • Children with subdural empyema secondary to bacterial meningitis have higher protein-to-glucose ratio in the CSF, and a threshold of ˃ 4.65 was determined to demonstrate 100% sensitivity and 50.7% specificity.

Unusual subdural empyema in a homeless patient diagnosed by molecular approach: a case report.

BACKGROUND: We report a case of subdural empyema in a homeless patient caused by Bartonella quintana. B. quintana is a facultative intracellular bacteria for which bacterial growth is fastidious. The molecular biology approach has been a real help in establishing the diagnosis. CASE REPORT: A 59-years old homeless patient, with a history of chronic alcohol abuse, was brought to the emergency department with a massive subdural empyema. Extensive microbiological evaluation didn't reveal any pathogen in the pus collected before antibiotic treatment. B. quintana was detected in the pus from the empyema using a 16S rRNA-based PCR. Histology of intraoperative samples was consistent with the diagnosis and a serological assay was positive. The patient responded well to a treatment that included craniectomy with drainage of the loculated pus, total removal of the infected capsule and a combination of antibiotics. CONCLUSION: This unique case of B. quintana-related empyema illustrates the risk of secondary infection of subdural hematoma with B. quintana since such infections have recently reemerged, predominantly among the homeless populations. Patients with subdural empyema in at-risk populations should be systematically evaluated for B. quintana with an appropriate diagnostic approach involving molecular biology.

A case report of multiple cerebral abscess formation complicating serogroup B Neisseria meningitidis meningitis.

BACKGROUND: Invasive meningococcal disease (IMD) presenting with meningitis causes significant mortality and morbidity. Suppurative complications of serogroup B meningococcal sepsis are rare and necessitate urgent multidisciplinary management to mitigate long-term morbidity or mortality. CASE PRESENTATION: We present a rare case of invasive meningococcal disease in a 28-month old boy complicated by multiple abscess formation within a pre-existing antenatal left middle cerebral artery territory infarct. Past history was also notable for cerebral palsy with right hemiplegia, global developmental delay and West syndrome (infantile spasms). Two craniotomies were performed to achieve source control and prolonged antimicrobial therapy was necessary. The patient was successfully discharged following extensive multidisciplinary rehabilitation. CONCLUSIONS: Longstanding areas of encephalomalacia in the left MCA distribution may have facilitated the development of multiple meningococcal serogroup B abscess cavities in the posterior left frontal, left parietal and left temporal lobes following an initial period of cerebritis and meningitis. A combination of chronic cerebral hypoperfusion and some degree of pre-existing necrosis in these areas, may also have facilitated growth of Neisseria meningitidis, leading ultimately to extensive cerebral abscess formation following haematogenous seeding during meningococcemia. In this case report we review similar cases of cerebral abscess or subdural empyema complicating serogroup B meningococcal meningitis.

Case report of Actinomyces turicensis meningitis as a complication of purulent mastoiditis.

BACKGROUND: Central nervous system (CNS) infections caused by Actinomyces spp. including brain abscess, actinomycoma, subdural empyema and epidural abscess are well described, however reports of Actinomyces-associated meningitis are scarcely reported. CASE REPORT: We present the case of a 43-year-old Hungarian male patient with poor socioeconomic status who developed acute bacterial meningitis caused by Actinomyces turicensis originating from the left side mastoiditis. The bacterial cultures of both cerebrospinal fluid (CSF) and purulent discharge collected during the mastoid surgery showed slow growing Gram-positive rods that were identified by automated systems (API, VITEK) as A. turicensis The bacterial identification was confirmed by 16S rRNA PCR and subsequent nucleic acid sequencing. No bacterial growth was detected in blood culture bottles after 5 days of incubation. Hence, multiple antibacterial treatments and surgical intervention the patient passed away. CONCLUSIONS: Anaerobes are rarely involved in CNS infections therefore anaerobic culture of CSF samples is routinely not performed. However, anaerobic bacteria should be considered as potential pathogens when certain risk factors are present, such as paranasal sinusitis, mastoiditis in patients with poor socioeconomic condition. To the best of our knowledge, our case report is the first description of A. turicensis meningitis that has been diagnosed as consequence of purulent mastoiditis.

Interhemispheric and Infratentorial Subdural Empyema with Preseptal Cellulitis as Complications of Sinusitis: A Case Report.

Intracranial complications of paranasal sinusitis have become rare due to the use of antibiotics nowadays. However, several cases have been reported due the ability of paranasal sinusitis to cause serious complications. Once the infection spreads over the cranial structure, it could infect the orbits, underlying bones, meninges, adjacent veins, and brain. Subdural empyema is a rare but potentially life-threatening complication following paranasal sinusitis and should be considered as a neurological emergency. The location where subdural empyema may appear is a challenge in diagnosis and treatment. We report the case of a 17-year-old boy who presented in a state of somnolence due to interhemispheric and infratentorial subdural empyema with preseptal cellulitis secondary to pansinusitis. Early diagnosis and aggressive antibiotic treatment combined with neurosurgical operation were mandatorily implemented. The case was managed using a multidisciplinary approach including the ENT, eye, and nutrition departments. The boy achieved clinical improvement, with impairment of eye movement as the only persistent symptom before discharge. Daily supervision at the primary health care center with continuous antibiotic treatment was recommended to the patient. Pertinent literature with controversies in the management of subdural empyema will be briefly discussed in this case report.

Unusual manifestation of Helicobacter cinaedi infection: a case report of intracranial subdural empyema and bacteremia.

BACKGROUND: There have been various reports concerning Helicobacter cinaedi infections. However, few reports have examined central nervous system infections. CASE PRESENTATION: A 52-year-old man was transferred from the local hospital because of a persistent headache and suspected intracranial subdural empyema. Neurosurgical drainage was performed via burr holes. Gram staining and results from abscess cultures were negative. The blood culture yielded H. cinaedi. He was given an antibiotic regimen consisting of 2 g of ceftriaxone twice a day, but the size of the abscess was not reduced in size at all after 3 weeks of treatment. Neurosurgical drainage was performed again, and the antimicrobial regimen was switched to 2 g of meropenem 3 times a day. The size of the abscess was reduced after 2 weeks of the second drainage and antimicrobial drug change to meropenem. After 4 weeks treatment with meropenem, the patient was discharged, and his symptoms had completely resolved. CONCLUSIONS: H. cinaedi infection should be considered in the differential diagnosis of subdural empyema cases for which Gram staining and abscess culture results are negative. Meropenem can be a first-line drug of choice or an effective alternative treatment for H. cinaedi central nervous system infections.

[A Case of Bacterial Meningitis in Which Occurrence of Ataxie Optique Led to Detection of a Small Subdural Abscess and Pialitis].

We report the case of a 69-year-old man with bacterial meningitis who presented with ataxie optique in the peripheral part of the left visual field in both hands. A detailed neurological examination with contrast-enhanced brain MRI in the early stage of the clinical course identified a small subdural abscess and pialitis in the right parietal area. A favorable outcome was obtained with antibiotic therapy alone. In a case with higher brain dysfunction of unknown cause in the clinical course of bacterial meningitis, a detailed neurological examination may be helpful to identify the causative site. (Received September 25, 2023; Accepted October 31, 2023; Published March 1, 2024).

Meningitis complicated by subdural empyema and deafness caused by pneumoccoccal serotype 7F in a 17-month-old child: a case report.

Despite the availability of effective antibacterial agents and vaccines, pneumococcal meningitis and sepsis are still associated with high mortality rates and a high risk of neurological sequelae. We describe the case of a 17-month-old boy vaccinated with heptavalent pneumococcal conjugate vaccine (PCV7) who developed bacterial meningitis complicated by subdural empyema and deafness caused by Streptococcus pneumoniae serotype 7F. The 7F strain is not contained in PCV7 (the only vaccine on the market at the time of the onset of meningitis) but is included in the new pediatric 13-valent PCV, which may therefore prevent cases such as this in the future.

Extensive actinomycosis with intracranial and mediastinal involvement: a therapeutic challenge.

Central nervous system (CNS) involvement by actinomycosis is rare, seen in 2%-3% cases. It mostly spreads to CNS by haematogenous route from a distant primary site such as oral cavity, lung, abdomen or pelvis. Direct CNS extension can also occur. It mostly presents as brain abscess, meningoencephalitis, actinomycetoma, subdural empyema and epidural abscess. We report one case of extensive actinomycosis having intra and extraparenchymal CNS, spinal canal, retropharyngeal and mediastinal involvement. Due to such widespread extension and involvement of vital areas, complete surgical debulking was not possible. In addition to therapeutic resistance to conventional antibiotics, repetitive negative cultures posed significant difficulty in the case management.

Obscure manifestations of Salmonella subdural empyema in children: case report and literature review.

PURPOSE: Salmonella intracranial infections, including subdural empyema and brain abscess, are rare clinical manifestations in children. The aim of this study is to investigate the clinical course of Salmonella subdural empyema in infants and children. METHODS: We report a 9-month-old female infant diagnosed as Salmonella subdural empyema with clinical features of prolonged fever for more than 2 months and episodic focal seizures. Literature published between 1986 and 2010 relevant to Salmonella subdural empyema in children were reviewed. The clinical presentations and laboratory findings were analyzed. RESULTS: Seventeen cases with Salmonella subdural empyema, including our index case, has been reported with detailed clinical presentation. Fever (17/17; 100%), symptoms and signs of increased intracranial pressure (8/17; 47%), seizures (8/17; 47%), and limb paralysis (8/17; 47%) were the most frequent clinical features. Among these cases, unknown causative organism prior to surgery (11/17; 65%) and prolonged fever for more than 3 weeks (5/17; 29%) were also noticed. Sixteen out of 17 patients (94%) required surgical intervention for treatment. The morbidity rate and mortality rate were 29% (5/17) and 6% (1/17), respectively. CONCLUSION: Subdural empyema is considered to be a disease with rapid progression. However, the cases caused by Salmonella species may present a slow disease course. Surgical intervention is sometimes the only way to detect the pathogen.

Focal intradural brain infections in children: an analysis of management and outcome.

INTRODUCTION: Focal intradural infections of the brain include empyema and abscess in the supratentorial and infratentorial spaces. These are amenable to surgical management. Various other issues may complicate the course of management, e.g. hydrocephalus with infratentorial lesions or cortical venous thrombosis with supratentorial lesions. Here, we review the management and identify factors affecting outcome in these patients. MATERIALS AND METHODS: This is a retrospective analysis of all children (aged <18 years) treated at the National Institute of Mental Health and Neurosciences, Bangalore, India, between 1988 and 2004. Case records were analyzed to obtain clinical, radiological, bacteriological and follow-up data. RESULTS: There were 231 children who underwent treatment for focal intradural abscess/empyema at our institute. These included 57 children with cerebral abscess, 65 with supratentorial empyema, 82 with cerebellar abscess and 27 with infratentorial empyema. All patients underwent emergency surgery (which was either burr hole and aspiration of the lesion or craniotomy/craniectomy and excision/evacuation), along with antibiotic therapy, typically 2 weeks of intravenous and 4 weeks of oral therapy. The antibiotic regimen was empiric to begin with and was altered if any sensitivity pattern of the causative organism(s) could be established by culture. Hydrocephalus was managed with external ventricular drainage initially and with ventriculoperitoneal shunt if warranted. Mortality rates were 4.8% for cerebral abscess, 9.6% for cerebellar abscess, 10.8% for supratentorial subdural empyema and 3.7% for posterior fossa subdural empyema. The choice of surgery was found to have a strong bearing on the recurrence rates and outcome in most groups, with aggressive surgery with craniotomy leading to excellent outcomes with a low incidence of residual/recurrent lesions. CONCLUSIONS: Antibiotic therapy, emergency surgery and management of associated complications are the mainstays of treatment of these lesions. We strongly advocate early, aggressive surgery with antibiotic therapy in children with focal intradural infections.

[Postoperative recurrence of subdural empyema]. / Recidiva de empiema subdural postquirúrgico.

We present a case of recurrent subdural post-surgical empyema by Proprionibacterium acnes after a first drained empyema in which no microbiological diagnosis was reached. P. acnes is a gram-positive anaerobic organism which is part of the saprophytic flora of the skin and others parts of the body. However, it can cause infections, as in the central nervous system, especially post-surgical infections in which can be the second more frequent organism after Staphylococcus aureus. P. acnes grows slowly and shows better growth in liquid anaerobic media. It is usually resistant to metronidazol and sensitive to penicillin. In postoperative central nervous system infections we must take into account the possibility of this organism, process the sample properly and keep touch with the Microbiology Department.

Multidisciplinary management and outcome in subdural empyema--a case report.

Cranial subdural empyema (SDE), a localized septic intracranial collection, occurs mostly as a complication of sinusitis, otitis or mastoiditis. Although relatively rare, SDE requires an increased attention for early recognition, cerebral imagery being mandatory in any suspected case. Any delay in treatment can lead to coma with a fatal outcome. The authors report the case of a young boy, who developed a severe, important cerebral edema, thin subdural collection with minimal displacement of the median line. Repeated cerebral MRI showed an enlarged subdural collection with higher median line shift and imposed rapid surgical intervention. The collection proved to be empyema. Other findings on MRI are pansinusitis, mild mastoiditis and transverse sinus thromboflebitis. The recovery was accompanied by the need for long course of antibiotherapy, secondary epilepsy treatment and kinetotherapy for hemiparesis. The patient also developed intracerebral cysts expanding the brain through the postoperative cranial defect which later needed surgical intervention, for both neurological and esthetic improvement. The management of the case implied strong interdisciplinary collaboration between infectionist, neurologist, neurosurgeon, microbiologist and imagist.

A novel missense mutation in the nuclear factor-κB essential modulator (NEMO) gene resulting in impaired activation of the NF-κB pathway and a unique clinical phenotype presenting as MRSA subdural empyema.

INTRODUCTION: We describe a previously unreported 437 T→G missense mutation producing a V146G substitution in the first coiled-coil (CC1) domain of nuclear factor-κB essential modulator (NEMO) in a 9-month-old boy with ectodermal dysplasia with immunodeficiency who presented with methicillin-resistant Staphylococcus aureus subdural empyema. We performed in vitro experiments to determine if this novel mutation resulted in impaired NF-κB signaling. METHODS: IκBα phosphorylation experiments were performed using a Jurkat T cell line lacking endogenous NEMO expression that was transfected with vectors containing either the wild type or the patient's V146G mutation. The cells were stimulated with TNF-α to activate the NF-κB pathway. Phosphorylated IκBα was detected by immunoblotting with anti-phospho-IκBα antibodies. Peripheral blood mononuclear cells from the patient were stimulated with TNF-α or anti-CD3 and anti-CD28. Impaired IκBα degradation was detected using antibodies against the IκBα protein. RESULTS: While TNF-α stimulation resulted in IκBα phosphorylation in NEMO-deficient Jurkat cells reconstituted with wild-type NEMO, cell transfected with the V146G mutant exhibited a 75% reduction in phospho-IκBα. Peripheral blood mononuclear cells from the patient showed impaired degradation of IκBα after stimulation when compared with normal controls. CONCLUSIONS: The patient's V146G mutation results in impaired NF-κB activation in vitro. The mutation extends the known N-terminal boundary within the CC1 domain that produces an ectodermal dysplasia phenotype, and defines an infectious susceptibility previously unappreciated in ectodermal dysplasia with immunodeficiency (methicillin-resistant S. aureus subdural empyema), broadening the clinical spectrum associated with the disease.

Multiple intracranial abscesses due to Cryptococcus neoformans: an unusual clinical feature in an immunocompetent patient and a short review of reported cases.

We present a case of multiple intracranial abscesses caused by Cryptococcus neoformans in a patient who presented with no symptoms of immunodeficiency.

Pediatric intracranial subdural empyema caused by Mycobacterium tuberculosis--a case report and review of literature.

INTRODUCTION: Intracranial subdural tubercular empyema is an extremely rare entity. To our knowledge, only one such case has been previously reported in the pediatric population (Cayli et al. J Neurosurg 94(6):988-991, 2001). We report a case of intracranial tubercular subdural empyema in a child, with both convexity and interhemispheric fissure involvement. CASE MATERIAL: A 12-year-old boy with history of exposure to an active case of pulmonary tuberculosis (his father) presented to our institution with features of raised intracranial pressure and fever for 1 month and altered sensorium for 2 days. Computerized tomography (contrast enhanced) revealed a left fronto-parietal and interhemispheric subdural space abscess. A left fronto-parietal craniotomy was performed and the subdural empyema was evacuated, and adjacent calvarium was normal. Ziehl-Neelsen staining revealed acid-fast bacilli and the subsequent polymerase chain reaction test was positive. Histopathological examination showed granulation tissue including scattered multinucleated giant cells and caseation. Mycobacterium tuberculosis bacilli were the sole organisms cultured after 6 weeks. Anti-tuberculous treatment was given in appropriate doses for 18 months at the end of which the patient was doing well with no deficits. CONCLUSION: Intracranial tubercular subdural empyema in the pediatric age group is an extremely rare but curable entity.

Subdural Empyema in an Immunocompetent Active Duty Soldier: A Case Report.

Intracranial subdural empyema is a rare clinical entity with incidence estimates of 0.1 per 100,000 people. The condition is most often the sequela of a primary infection elsewhere and carries a high morbidity and mortality. The authors present the case of a 22-year-old active duty soldier on mission on the southern border of the United States. The patient had been complaining of headaches that became progressively worse over 2 weeks and presented to a civilian hospital where he was diagnosed with intracranial abscess versus sinus thrombosis on radiographic imaging. The patient was promptly transferred to a military tertiary care center where further workup including pivotal imaging confirmed subdural empyema and right transverse sinus thrombosis. Given the rapid patient deterioration associated with subdural empyema, the emergent intravenous antibiotics, neurosurgical consultation, and subsequent collection evacuation performed are likely to credit for saving this soldier's life. This case highlighted an atypical and time-sensitive etiology for a common complaint in the active duty population, which underscores the requirement for evacuation to higher roles of care in those soldiers with a similar diagnosis.