Lawsonella clevelandensis causing spinal subdural empyema.

Lawsonella clevelandensis is a recently described species and genus of bacterium in the Corynebacterineae suborder which is Gram-stain positive, partially acid-fast and anaerobic. Very few cases of human infection due to this organism are described and here we seek to add to the limited medical literature. We report the case of a 2-year-old girl who presented with an infected spinal dermoid cyst secondary to Lawsonella clevelandensis which required surgical drainage and a long course of antibiotics. We encountered diagnostic and therapeutic difficulties because this is a fastidious organism which was difficult to culture and ultimately required molecular detection and identification. To the best of our knowledge, this is only the seventh reported case of Lawsonella clevelandensis causing human infection worldwide and the first in the UK. This is the first reported case of Lawsonella clevelandensis infection in a child and the second reported case of this organism causing spinal infection.

Towards improved outcome in children treated surgically for spontaneous intracranial suppuration in South Wales.

INTRODUCTION: Spontaneous central nervous system (CNS) infections in children are rare. Treatment involves surgical intervention and antibiotic therapy. We describe a single centre experience of managing this condition in South Wales. METHODS: We performed a retrospective review of surgically managed cases in our unit for patients under 18 years of age between 2008 and 2018. Data were collected regarding aetiology, location, microbiology examination, treatment and outcomes. RESULTS: Twenty-six patients were identified of which 25 case notes were available. Fifteen were male and 10 were female. Median age was 12 years (age range 0.3-17 years). Seven patients (28%) had a burr-hole aspiration and 18 (72%) underwent craniotomy. A second procedure was performed in 10 (40%) and a third procedure in two (8%). Fourteen (56%) had a brain abscess, 10 (40%) had subdural empyema (one was bilateral) and one (4%) had an extradural empyema. Fifteen (60%) had a raised WCC (>11.5 × 109/L) and 22 (88%) had a CRP of >10 mg/L at presentation. Three (12%) patients had a normal WCC and CRP at presentation. Overall, 12 (48%) were secondary to sinus infection, with the most common organism being Streptococcus. Seven (28%) were due to otitis media or mastoiditis, six (24%) had no cause identified. The mean number of CT/MRI scans was 6.7 (range 3-13). The mean follow-up period was 16.7 months (range 1-117 months). At last follow up, 19 (76%) had a GOS of 5, five (20%) had a GOS of 4 and one (12%) had GOS of 3. There were no deaths. CONCLUSIONS: In Wales, outcomes have improved over time in keeping with other paediatric neurosurgical units in England. Increased availability of imaging resources in our hospital and use of neuro-navigation for all cases in our unit as well as earlier identification of sepsis, communication with microbiologists with dedicated ward rounds and, enhanced identification of causative organisms and contemporary anti-microbials have also contributed towards the improved management of this condition.

Hyperbaric oxygen for intracranial abscess.

The term "intracranial abscess" (ICA) includes cerebral abscess, subdural empyema, and epidural empyema, which share many diagnostic and therapeutic similarities and, frequently, very similar etiologies. Infection may occur and spread from a contiguous infection such as sinusitis, otitis, mastoiditis, or dental infection; hematogenous seeding; or cranial trauma. In view of the high morbidity and mortality of ICA and the fact that hyperbaric oxygen therapy (HBO2) is relatively non-invasive and carries a low complication rate, the risk-benefit ratio favors adjunct use of HBO2 therapy in selected patients with intracranial abscess.

Combined microsurgical fluorescence for optimizing resection in refractory empyema and cerebritis.

PURPOSE: Due to the generalization of new microsurgical equipment, intraoperative fluorescence techniques have extended in neurosurgical practice, mainly in neurovascular and neuro-oncology patients. The aim of identifying pathological tissue and also differentiating from the normal brain helps neurosurgeons to approach other kinds of intracranial entities such as infections. METHODS: It is described in the case of an 11-year-old patient who underwent a subdural empyema by performing a craniotomy and evacuation of the purulent collection. After a non-optimal evolution, a frontobasal meningoencephalitis was assessed with cerebral involvement and associated intracranial hypertension. Indocyanine green (ICG) was used in reintervention for demonstrating a great damage of cortical vascularization around the infected area as well as fluorescein (FL), which identified a large area of avascularized tissue. RESULTS: Both techniques allowed a selective excision of the affected brain parenchyma while preserving viable parenchymal areas. Radiological evolution and clinical outcome were good. CONCLUSIONS: The identification of vascular patterns in brain lesions and the recognition of viable or necrotized tissues are suitable for a selective resection of the parenchyma, minimizing morbidity. Clinical outcome is related to a safe and effective management of inflammatory and infectious processes.

New perspectives in the endoscopic treatment of brain purulent collections: targets, techniques, results in a case series, and overview of the literature.

BACKGROUND: Purulent intracranial infections are threatening conditions. Different surgical approaches have been described, respecting the rationale of evacuating the fluid component of the purulent collection. Emerging evidence supports the use of the endoscope for the treatment of cerebral abscesses and subdural empyemas; especially the peculiarities of flexible endoscopes could potentially offer a more effective and conclusive management as compared with the drainage through catheters. We describe our experience in the treatment of intracranial purulent collections with flexible endoscopy, comparing it with the most recent literature. METHODS: Ten patients affected by intracranial suppuration were treated with endoscopy at our institution. The neurosurgical technique is thoroughly described. The related literature is reviewed, providing a comprehensive overview on the endoscopic treatment of intracranial suppuration so far. RESULTS: All the patients had a good clinical outcome, with no peri-operative complications. The postoperative scans showed significant radiological improvement, with important reduction of the pus volume. In all cases, the microbiological cultures showed positivity. CONCLUSIONS: In our experience, the use of the flexible scope proved feasible and effective in the treatment of intracranial purulent collections. Visual awareness of the internal capsule is not limited to a direct inspection of the fluid pus; it rather allows an active removal of the more solid (and perhaps more microbiologically significant) fibrinoid component, and also assists in final bleeding control and in assessing the extent of the evacuation. The steering capabilities of the fiberscope are particularly suitable for such purposes, allowing sampling the solid internal layer of the pyogenic membrane, and potentially shedding light on the actual clinical significance of this component of the abscess.

Unilateral hearing loss in a 94-year-old patient.

A case report of a 94-year-old, previously well male patient who presented with fever thought to be caused by community acquired pneumonia, new unilateral hearing loss and reduced consciousness. Despite antibiotic treatment he continued to deteriorate. Brain imaging with computer tomography and magnetic resonance imaging revealed a left otomastoiditis with osteomyelitis of the skull base, associated with an adjacent subdural empyema. He was also found to have a venous sinus thrombosis, most likely secondary to otitis media. He was managed with intravenous antibiotics, anticoagulation, grommet insertion and a hearing aid and he made a good recovery. This case reminds us to consider otitis media in older patients who present with hearing loss and fever. Otitis media can lead to serious complications including subdural empyema and osteomyelitis of the skull base.

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.

Aspiration of parafalcine empyemas with flexible scope.

PURPOSE: Subdural empyemas are considered neurosurgical emergencies, and the parafalcine location is particularly insidious. We revised the experience of general surgeons who are used to manage chronic pleural purulent collections with video-assisted thoracoscopy. METHODS: With a similar technique, we successfully aspirated a parafalcine empyema using a flexible scope avoiding a more invasive craniotomy. A review of the treatment options of empyematous collections is also provided, focusing particularly on the hazardous parafalcine location. RESULTS: The management of subdural empyemas poses different decision-making problems compared to common brain abscesses, urging a more rapid and holistic surgical treatment with minimally invasive approach. Endoscopic aspiration of parafalcine empyema was followed by complete recovery in our patient. CONCLUSIONS: Flexible endoscopy is a promising method to obtain complete pus removal even from loculated collections through a bur hole, avoiding large craniotomies and consequent potential complications.

Masked subdural empyema secondary to frontal sinusitis.

Intracranial complications of pediatric sinusitis are rare but potentially life threatening. These complications include cavernous sinus thrombosis, orbital infection, meningitis, and subdural empyema. Children with these complications may experience significant morbidity from their infection. In such cases, delay in diagnosis and treatment may lead to severe brain damage or death. Emergency physicians, pediatricians, and otolaryngologists should maintain a high index of suspicion for this complication of disease when treating patients with sinusitis in the emergency department or outpatient clinic. Early and accurate diagnosis of subdural empyema will lead to prompt treatment and a favorable outcome for the patient. We report a case of subdural empyema secondary to frontal sinusitis in an otherwise healthy immunocompetent adolescent boy.

Surgical treatment of neurologic complications of bacterial meningitis in children in Kosovo.

UNLABELLED: Neurologic complications of bacterial meningitis can occur any time during the course of the disease and some of them need neurosurgical aproach. OBJECTIVE: to determine the incidence of neurologic complications of bacterial meningitis in children requring neurosurgical treatment. MATERIAL AND METHODOLOGY: a total of 277 children were followed and treated for bacterial meningitis at the Clinic of Infectious Diseases in Prishtina. The authors have analyzed cases who developed acute neurologic complications and treatment procedures. RESULTS: of the 277 children treated for bacterial meningitis, due to the suspicion for neurologic complications, 109 children underwent a head computerized tomography scan. About 47 cases (43%) had evident structural abnormalities while only 15/277 cases (5%) required neurosurgical treatment; 9/38 cases with subdural collections, 5 cases with hydrocephalus and 1 case of spinal abscess. CONCLUSION: Neurosurgical intervention were not common in pediatric bacterial meningitis cases (5%) but were highly significant in cases complicated with acute neurologic complications (32%).

Fusobacterium septicemia complicated by cerebral subdural and epidural empyemas: a rare case of Lemierre syndrome.

BACKGROUND: Lemierre syndrome is characterized by postanginal septicemia and internal jugular vein thrombophlebitis with secondary septic emboli, typically to the lungs. The central nervous system (CNS) is rarely involved. OBJECTIVE: To present a case of Lemierre syndrome featuring cerebral subdural and epidural empyemas. CASE REPORT: This case report describes the case of a 17-year-old youth with cerebral subdural and epidural empyemas. The findings of chest computed tomography of the neck and the blood cultures were compatible with Lemierre syndrome. The patient recovered well after antibiotic treatment and surgical debridement. CONCLUSION: Lemierre syndrome can result in infection spreading to the CNS, including cerebral subdural and epidural empyemas. This disease entity should be included in the differential diagnoses of CNS bacterial infections.

Multidrug-resistant tuberculous subdural empyema with secondary methicillin-resistant Staphylococcus aureus infection: an unusual presentation of cranial tuberculosis in an infant.

Despite tuberculosis (TB) being endemic in many parts of the world, its prevalence in infancy is low. Neurotuberculosis in this age is even rarer and presents either as meningitis or intracranial tuberculoma on the background of exposure to the disease. We report occurrence of multidrug-resistant tuberculous subdural empyema in a three-month-old girl as the initial presenting manifestation of TB in the absence of any exposure to the disease. She was successfully managed with surgery and drugs with good outcome at 18 months.

Large calcified subdural empyema.

Subdural empyema is a known disease entity; however, calcified subdural empyema is uncommon. The authors present a case of an 11-year-old boy in whom there was diagnosed a chronic calcified subdural empyema 10 years after an attack of meningitis. The patient had suffered from generalized tonic clonic seizures occurring 2-6 times in a month. A large fronto-temporo-parietal craniotomy was carried out and the subdural empyema filled with numerous uncharacteristic tissue fragments with thick pus together with the partially calcified and ossified capsule was removed. The empyema mass was found to be sterile for bacteria. After the operation, no epileptic seizure occurred and the boy is on sodium valporate. We must emphasize the unusual occurrence of the chronic subdural empyema presenting with calcification-ossification and large size as observed in our case.

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.

Intracranial empyema complicating sinusitis in childhood: Epidemiology, imaging findings and outcome.

BACKGROUND: To describe clinical presentations of intracranial sinusitis complications in childhood, their pitfalls and imaging findings. MATERIEL AND METHODS: This retrospective IRB-approved single-center study included infants diagnosed with sinusitis and empyema and/or other intracranial complications who underwent imaging between September 2008 and September 2019. Three radiologists individually reviewed clinical charts and imaging findings, including sinusitis complications and at-risk anatomical variations. RESULTS: 21 children (76% males and 24% females, mean age 13±3.1 years) with imaging pansinusitis were included. Headache (95%) and fever (90%) were the main clinical nonspecific signs. Ten (48%) children presented an extradural empyema, nine (43%) children had a subdural empyema and two (10%) children had both. Frontal location sinusitis was the most common (76%). In MRI, all empyema presented as a hypo intensity on pre-contrast T1-WI, a hyperintensity on T2-WI, a reduced apparent diffusion coefficient (ADC) on diffusion weighted imaging (DWI) and a peripheral contrast enhancement on post-contrast T1-WI. CT or MRI revealed intracranial complications such as a collection size increase (52%), a midline shift (62%), intraparenchymal abscesses (24%), a cerebral venous thrombosis (29%), an intracranial pressure increase (29%), cerebral ischemia (43%) and Pott's Puffy Tumor (10%). Imaging highlighted sinus anatomical abnormalities in 52% of cases. All children were treated with sinus drainage and/or neurosurgery. Long-term follow-up was favorable in 14 cases (67%). CONCLUSION: Complications of sinusitis are life threatening in the studied population. Empyema and cerebral complications may be misleading. Brain contrast-enhanced CT covering sinuses and orbits, is mainly the first examination done but MRI is mandatory.

Posterior fossa subdural empyema in children--management and outcome.

AIMS: The aims of this study were to analyze the clinical features, radiologic findings, bacteriologic spectrum, and management protocols and outcomes in posterior fossa subdural empyemas in children. MATERIALS AND METHODS: This study is a retrospective analysis of all children (age, <18 years) treated over a ten-year period (1994-2004) at NIMHANS, India. Clinical, bacteriologic, radiologic, and follow-up data were analyzed. RESULTS: Twenty-seven children with posterior fossa empyemas were treated during this period, making this the largest series to date dealing with this rare entity. Posterior fossa empyemas are seen more commonly in the summer months and in males. Of the patients, 74.1% were in altered sensorium. The clinical features included the triad of fever, headache, and vomiting, which is a nonspecific picture. Cerebellar signs were elicited only in 40%. The most common source was untreated middle ear infection. Pus usually accumulates over the cerebellar convexity and is associated with hydrocephalus in 74% of patients. Cultures of the empyema pus were positive in 74% of cases, and 18.5% had polymicrobial infections. Only 21% of the patients needed a permanent CSF diversion procedure. Craniectomy is the treatment of choice in these cases. CONCLUSIONS: The clinical features are nonspecific. Early surgery can salvage most patients and obviate the need for permanent CSF diversion procedures. Surgery (evacuation of empyema and mastoidectomy), antibiotics, and management of hydrocephalus are the mainstays of treatment.

Falcotentorial subdural empyema: analysis of 10 cases.

OBJECT: Parafalcine subdural empyema and those along the superior and inferior surface of the tentorium are rare entities. We present a series of 10 patients where we have attempted to describe the pathophysiology, clinical features, and management of subdural empyema. METHODS: The study group included 10 cases of falcotentorial subdural empyemas managed between 2004 and 2010. The mean age group was 14.4 years. Seven patients had empyema along the falx or superior surface of tent, and the remaining three had empyema along the inferior surface of tent. Fever, raised intracranial pressure symptoms, falx syndrome, and seizures were the usual presenting features. These patients had an indolent presentation as compared to convexity subdural empyemas. The diagnosis was made based on radiology. Chronic suppurative otitis media was a causative factor in five patients; in the remaining patients, the source was ascribed to be hematogenous. All patients were treated with antibiotic therapy (6 weeks) ± surgery. Two patients were treated conservatively, and the remaining eight patients underwent definitive surgery in the form of craniotomy (supratentorial)/craniectomy (infratentorial) and evacuation of pus. The pus was limited within two leaves, one adherent to the falx/tent and the other one to the pia-arachnoid of adjacent parenchyma. The wall along the falx or tent could be peeled off easily and was excised in all cases to lay open the cavity widely. The wall along pia-arachnoid was left as it is. Pus culture was positive in four and blood culture positive in two cases. There was only a single mortality in our series. The outcome was assessed by the Glasgow Outcome Scale. The mean duration of follow-up was for 18.8 months, and all patients who survived had a good outcome. CONCLUSION: Falcotentorial empyema remains a rare entity. The presentation is indolent as compared to convexity subdural empyemas, possibly due to its limitation secondary to arachnoid adhesions at the junction of falx, tent, and convexity dura. The main stay of management remains craniotomy, evacuation, and partial excision of the wall, laying it completely open, unless it is extremely thin. With appropriate surgery and antibiotic therapy, a good outcome can be expected.