Primary cerebrospinal fluid leak complicated with meningitis and parainfectious vasculitis: case report and literature review / Fístula liquórica primária complicada com meningite e vasculite parainfecciosa: relato de caso e revisão de literatura

This paper aims to describe a case of an immunocompetent 60-year-old patient presenting a subarachnoid hemorrhage in the absence of aneurysmal disease. Initial evaluation pointed to vasculitis of the central nervous system secondary to meningeal infection. After initial treatment, a cerebrospinal fluid leak was identified, with no antecedent of trauma, elucidating the origin of infection. Primary cerebrospinal fluid rhinorrhea has nonspecific symptomatology, defying diagnosis, and potentially serious complications. It represents an unusual predisposing factor for meningeal infection and secondary vasculitis. This case report exemplifies a feared complication of spontaneous cerebrospinal fluid leakage.

O estudo objetiva relatar um caso clínico de uma paciente imunocompetente de 60 anos apresentando hemorragia subaracnoide na ausência de doença aneurismática. Avaliação inicial apontou para vasculite de sistema nervoso central secundária à infecção meníngea. Após tratamento inicial, uma fístula liquórica foi identificada, sem antecedente de trauma, elucidando a origem da infecção. Rinorreia liquórica primária possui sintomatologia inespecífica, diagnóstico desafiador e complicações potencialmente graves. Representa um raro fator predisponente para infecção meníngea e vasculite. Este relato de caso exemplifica uma complicação temida da rinorreia liquórica espontânea.

Meningitis bacteriana aguda por Streptococcus agalactiae en una mujer no embarazada asociada a una fístula de LCR: comunicación de un caso / Acute bacterial meningitis by Streptococcus agalactiae in a non pregnant woman associated to a cerebrospinal fluid leak: a case report

Streptococcus agalactiae is a rare cause of acute bacterial meningitis. We report the case of a middle age non-pregnant female patient, with no comorbitidies, who was hospitalized with acute meningitis. The pathogen was identified both in blood and CSF. She recovered uneventfully with ceftriaxone and dexamethasone. A CSF leak was suspected by previous history of unilateral watery rhinorrhea, that was demonstrated with a high resolution paranasal sinus CT and beta-2 transferrin analysis of the nasal fluid. Vulvovaginitis was also diagnosed after admission, but no cultures were obtained. Streptococcus agalactiae is an infrequent cause of bacterial meningitis that should promote the search of anatomical abnormalities or comorbidities in non-pregnant adults and beyond newborn period.

Streptococcus agalactiae es una causa infrecuente de meningitis bacteriana aguda. Comunicamos el caso de una mujer de edad media sin co-morbilidades que ingresó por un cuadro de meningitis producido por este patógeno, el que también fue identificado en hemocultivos. La paciente se trató con ceftriaxona y corticoesteroides i.v., recuperándose satisfactoriamente. Por el antecedente de una rinorrea acuosa unilateral, se sospechó una fístula de LCR, la que se demostró con una tomografía computada multicorte de senos paranasales y por una prueba de ß2 transferrina en fluido nasal. En forma concomitante se diagnosticó una vulvovaginitis sin estudio microbiológico. Streptococcus agalactiae es una causa infrecuente de meningitis bacteriana que si no se presenta asociada al embarazo o en neonatos, obliga a la búsqueda de anormalidades anatómicas o co-morbilidades.

[Acute bacterial meningitis by Streptococcus agalactiae in a non pregnant woman associated to a cerebrospinal fluid leak: a case report]. / Meningitis bacteriana aguda por Streptococcus agalactiae en una mujer no embarazada asociada a una fístula de LCR: comunicación de un caso.

Streptococcus agalactiae is a rare cause of acute bacterial meningitis. We report the case of a middle age non-pregnant female patient, with no comorbitidies, who was hospitalized with acute meningitis. The pathogen was identified both in blood and CSF. She recovered uneventfully with ceftriaxone and dexamethasone. A CSF leak was suspected by previous history of unilateral watery rhinorrhea, that was demonstrated with a high resolution paranasal sinus CT and beta-2 transferrin analysis of the nasal fluid. Vulvovaginitis was also diagnosed after admission, but no cultures were obtained. Streptococcus agalactiae is an infrequent cause of bacterial meningitis that should promote the search of anatomical abnormalities or comorbidities in non-pregnant adults and beyond newborn period.

Management of globe luxation followed by traumatic liquoric fistula: case report.

This report describes the only case in the literature of globe luxation due to traumatic cerebrospinal fluid fistula to the orbit caused by fire gun with ocular globe maintenance. E.N., female, white, 7 months, admitted with left orbitocranial injury by fire gun. Ocular globe luxation was detected with complete ocular motility restriction and absence of pupillary reflex in the left orbit. Computed tomography showed fracture of the medial orbital wall; bone fragments near the apex of the orbit and a stretched optic nerve. Surgical exploration was performed, showing liquor fistula through the ethmoid-sphenoid wall that was blocked with sponge (Gelfoam®) plus organic glue in the left orbit posterior wall, with immediate resolution of the proptosis and ocular integrity maintenance. Although controversial, maintenance of the ocular globe instead of enucleation was performed due to the integrity of the globe in this case. Despite the blindness, we considered the result to the proposed treatment excellent, once the maintenance of the ocular globe provides a good appearance and will contribute to an adequate facial bone development.

Fístula liquórica traumática com luxação de globo ocular: relato de caso / Management of globe luxation followed by traumatic liquoric fistula: case report

This report describes the only case in the literature of globe luxation due to traumatic cerebrospinal fluid fistula to the orbit caused by fire gun with ocular globe maintenance. E.N., female, white, 7 months, admitted with left orbitocranial injury by fire gun. Ocular globe luxation was detected with complete ocular motility restriction and absence of pupillary reflex in the left orbit. Computed tomography showed fracture of the medial orbital wall; bone fragments near the apex of the orbit and a stretched optic nerve. Surgical exploration was performed, showing liquor fistula through the ethmoid-sphenoid wall that was blocked with sponge (Gelfoam®) plus organic glue in the left orbit posterior wall, with immediate resolution of the proptosis and ocular integrity maintenance. Although controversial, maintenance of the ocular globe instead of enucleation was performed due to the integrity of the globe in this case. Despite the blindness, we considered the result to the proposed treatment excellent, once the maintenance of the ocular globe provides a good appearance and will contribute to an adequate facial bone development.

O presente estudo apresenta o único caso de luxação de globo ocular devido fístula liquórica traumática em vítima de trauma órbito-cerebral por projétil de arma de fogo com a preservação do globo ocular. E.N., feminino, branca, 7 meses, admitida com ferimento por projétil de arma de fogo em região órbito-craniana esquerda. Apresentava luxação de globo ocular esquerdo com restrição completa da motilidade ocular e reflexo fotomotor ausente à esquerda. À tomografia: fraturas da parede medial da órbita; fragmentos ósseos próximos ao ápice da órbita. Realizou-se exploração cirúrgica, evidenciando-se fístula liquórica através de fratura etmoido-esfenoidal a qual foi tamponada com esponja (Gelfoam®) e cola orgânica na parte posterior da parede medial da órbita esquerda, com regressão imediata da luxação do globo ocular, sendo o mesmo mantido íntegro. Embora controversa na literatura, optou-se pela preservação do globo ocular à enucleação, visto que o mesmo estava íntegro. Apesar da cegueira, consideramos um excelente resultado ao tratamento proposto, tendo em vista que a preservação do globo ocular provém uma boa aparência, favorecendo também o desenvolvimento ósseo da face.

Rinorrea traumática de líquido cefalorraquídeo: nuestra experiencia en su diagnóstico y tratamiento / Traumatic cerebrospinal fluid rhinorrhea: our experience in diagnosing and treating this illness

Se realizó un estudio observacional descriptivo longitudinal en el Hospital Clinicoquirúrgico Provincial Docente Manuel Ascunce Domenech de Camagüey, en el período de enero a diciembre del 2004, para evaluar el manejo diagnóstico y terapéutico de la rinorrea traumática de líquido cefalorraquídeo (LCR). Se seleccionaron previo consentimiento informado 16 pacientes provenientes del Servicio de Urgencias. De estos, 11 fueron hombres y el 32 por ciento se encontraba en las edades comprendidas entre 15 y 29 años. Se determinaron síntomas asociados, estudios complementarios, tratamiento médico-quirúrgico, complicaciones y evolución. Se realizó estadística descriptiva e inferencial. Los síntomas más frecuentes fueron las cefaleas (87,5 por ciento), anosmia y vértigos. Los métodos diagnósticos más efectivos fueron la inspección visual (100,0 por ciento), la TAC simple y la rinoscopia. Los tratamientos más frecuentes fueron la antibioticoterapia y reducción de fracturas Lefort y nasoetmoidales con 62,5 por ciento y 87,5 por ciento, respectivamente. El 81,3 por ciento de los casos evolucionó favorablemente, solo 2 (12,5 por ciento) se complicaron con meningitis(AU)

A longitudinal, descriptive and observational study was undertaken from January to December, 2004 at Manuel Ascunce Domenech clinical and surgical hospital in Camaguey province, for the purpose of evaluating the diagnostic and therapeutic management of traumatic cerebrospinal fluid rhinorrhea. After obtaining their informed consent, 16 patients from the Emergency Dental Service were selected. Eleven of them were males and 32 percent was in the 15-29 years old group. Associated symptoms, supplementary studies, medical & surgical treatment, complications and recovery period were considered. Descriptive and inference statistics were used. The most frequent symptoms were headaches (87,5 percent), anosmia and dizziness. The most effective diagnosing methods were visual survey (100 percent), simple CT and rhinoscopy. The most common treatment regimes were antibiotic therapy and LeFort and nasoethmoidal fracture reduction with 62,5 percent and 87,5 percent of cases respectively. Recovery was satisfactory in 81,3 percent of cases, although two (12,5 percent) suffered complications from meningitis(AU)

Meningitis aguda por Streptococcus agalactiae en una paciente adulta con fistula de liquido cefalorraquideo / Acute menigitis caused by Streptococcus agalactiae in adult patient with a central spinal fluid fistula

La meningitis aguda en adultos por Streptococcus agalactiae es una entidad rara. Hasta la fecha sólo hay dos casos documentados asociados con una fístula de líquido cefalorraquídeo. Comunicamos el tercer caso en la literatura internacional. Se presentó en una paciente de 60 años de edad que tenía rinorraquia intermitente de 12 años de evolución, a consecuencia de un traumatismo de cráneo. Se le efectuó una tomografía computada del macizo craneofacial con administración de lopamidol intratecal que demostró la fístula en la pared posterior y superior del seno esfenoidal.

Meningitis aguda por Streptococcus agalactiae en una paciente adulta con fistula de liquido cefalorraquideo / Acute menigitis caused by Streptococcus agalactiae in adult patient with a central spinal fluid fistula

La meningitis aguda en adultos por Streptococcus agalactiae es una entidad rara. Hasta la fecha sólo hay dos casos documentados asociados con una fístula de líquido cefalorraquídeo. Comunicamos el tercer caso en la literatura internacional. Se presentó en una paciente de 60 años de edad que tenía rinorraquia intermitente de 12 años de evolución, a consecuencia de un traumatismo de cráneo. Se le efectuó una tomografía computada del macizo craneofacial con administración de lopamidol intratecal que demostró la fístula en la pared posterior y superior del seno esfenoidal. (AU)

Fístula de líquido cefalorraquídeo / Cerebro spinal fuid fistula

La rinorrea del líquido cefelorraquídeo (LCR) tiene un riesgo potencial de infección intracraneal por lo que es importante el diagnóstico cñínico y demostración radiológica de la fístula. Se analizaron 19 enfermos con fístula de lìquido cefalorraquídeo (FLC) de variable etiología traumática, postquirúrgica y espontánea. Todas las fístulas fueron evaluadas con tomografía computada (TC). En 18 casos la fístula fue demostrada sin utilizar material de contraste y solamente una fístula fue necesario contraste intratercal en un paciente para demostrar la fístula. Nosotros sugerimos que las fístulas de líquido cefalorraquídeo pueden ser evaluadas sin la ayuda de material de contraste.

[Recurrent meningitis and cerebrospinal fluid fistula in fronto-basal cranio-encephalic trauma. Report of a case]. / Meningite e fístula liquórica recidivantes em traumatismo cranio-encefálico frontobasal. Registro de um caso.

A case of fronto-basal traumatism with isolated fracture of the left sphenoidal sinus is reported. Meningitis occurred 5, 8 and 11 years, respectively, after injury. Cerebrospinal fluid cranio-nasal fistula was observed at the first time 8 years after injury and remained intermitent in the last 6 years. The surgical technic was accomplished according to the procedure devised by Dietz and consisted of plastics of the anterior floor of the skull accompanied by galeaperiosteal junction taken out from the scalp.