Neonato con sobreinfección de un cefalohematoma complicado con meningitis: a propósito de un caso / Newborn with infected cephalohematoma complicated with meningitis: report of one case

INTRODUCCIÓN: La infección del cefalohematoma es una patología muy infrecuente, aunque potencialmente grave por las complicaciones asociadas que puede conllevar: osteomielitis del hueso subyacente, meningitis o sepsis. CASO CLÍNICO: Se expone un caso de una recién nacida por cesárea con antecedente de atresia duodenal intervenida, que desarrolla, al octavo día de vida, la infección de un cefalohematoma con cuadro séptico y meningitis asociada. Tras un drenaje del cefalohematoma y la administración de antibioterapia durante 3 semanas, la paciente evoluciona favorablemente. CONCLUSIÓN: Ante la sospecha de la infección de un cefalohematoma, el drenaje del mismo es la clave diagnóstica y terapéutica, ya que la antibioterapia de forma aislada puede no ser suficiente para erradicar el patógeno. Se deben descartar otras complicaciones asociadas, como meningitis, sepsis u osteomielitis del hueso subyacente

INTRODUCTION: The infection of a cephalohematoma is an infrequente but potentially fatal condition due to its possible complications such as osteomyelitis, meningitis or sepsis. CASE REPORT: The report describes a newborn delivered by cesarean section, and a history of duodenal atresia with surgical correction, who develops, at 8 days of life, an infection of a cephalohematoma with sepsis and meningitis. After aspiration of the cephalohematoma and a three week course of antibiotics, she showed a favorable outcome. CONCLUSION: When the infection of a cephalohematoma is suspected, its drainage is both a diagnostic and therapeutic tool, as antibiotic therapy alone is often insufficient. Possible complications such as meningitis, osteomyelitis and sepsis must be ruled out

Head injury profoundly affects gut microbiota homeostasis: Results of a pilot study.

OBJECTIVES: Head injury (HI) induces a hypercatabolic state, dysimmunity, and septic complications that increase morbidity and mortality. Although compromised immune function is usually incriminated in infection occurrence, gut dysbiosis could also be involved in this phenomenon and, to our knowledge, has never been considered. To assess if HI could affect microbiota, we explored the impact of HI on intestinal microbiota in a rodent model of fluid percussion. METHODS: Nineteen rats were randomly assigned to two groups: Healthy rats fed ad libitum (n = 7) and HI rats (n = 12), which received standard enteral nutrition for 4 d. Four days after HI, rats were euthanized and cecal contents were sampled. Cecal microbiota was assessed using real-time quantitative polymerase chain reaction. RESULTS: HI significantly decreased the cecal content of strict anaerobic groups, Bacteroides/Prevotella group (HI 8.9 versus healthy controls 9.3 median log10 colony forming units [CFU]/g, P = 0.007), Clostridium cluster XIVab (HI 7.9 versus healthy controls 8.9 median log10 CFU/g, P = 0.002), Lactobacillus/Leuconostoc group (HI 8.5 versus healthy controls 9.4 median log10 CFU/g, P = 0.044), and Bifidobacterium sp. (HI 3.0 versus healthy controls 8.2 median log10 CFU/g, P < 0.001). In contrast, colonization by Escherichia coli was dramatically increased (HI 10.5 versus healthy controls 7.0 median log10 CFU/g, P < 0.001). CONCLUSIONS: HI profoundly modified the gut microbiota homeostasis and thus could contribute to infection in head trauma patients. These preliminary results open a new field of research in the management of patients with HI.

[Monitoring and antibiotic resistance profile of tracheal aspirate microbiota in ICU children with severe craniocerebral trauma].

Nosocomial infections and their rational antibiotic treatment represent a major challenge for the healthcare nowadays. In this context, gramnegative bacteria including Pseudomonas aeruginosa, Acinetobacter baumanii and Enterobacteriaceae spp. are etiologically important and characterized by a significant level of antibiotic resistance. To examine dynamics of the respiratory tract colonization by hospital flora, tracheal aspirates obtained at three time points from 69 children with severe craniocerebral trauma during their stay in ICU were analysed. Colonization was observed on the 4th day of the ICU stay with predomination of K. pneumoniae (45%) and A. baumanii (27-37%). P. aeruginosa was detected after the 8th day of the ICU stay with the isolation rate of 33%. Substantial proportions of P. aeruginosa (61%), A. baumanii (78%) and K. pneumoniae (25%) were resistant to carbapenems. In 65 carbapemen resistant isolates, the presence of carbapenemases was examined using PCRs. OXA-48 carbapenemase was detected in 11 out of 14 (78%) K. pneumoniae isolates. Among the A. baumanii isolates, 30/31 (97%) carried OXA-40 and 1/31 (3%) had OXA-23 carbapenemases. None of the examined A. baumanii and K. pneumoniae isolates produced metallo-betalactamases (MBL). In contrast, all 20 carbapenem resistant P. aeruginosa isolates produced a MBL, and in 12 out of 20 (60%) of theme VIM-2 was detected. Thus, gramnegative nosocomial microflora rapidly colonizes ICU patients and has a high level of resistance to antibiotics, including carbapenems.

Fatal tetanus complicating an untreated mild open head injury: a case-illustrated review of cephalic tetanus.

BACKGROUND: Tetanus is now a rare disease in the Western world, but not so in developing countries. Cephalic tetanus, unlike some other local forms of the disease, is likely to be fatal. METHODS: We describe the clinical presentation of a case of fatal cephalic tetanus complicating an unattended open non-severe head injury with a review of the literature on the disease. RESULTS: Few cases of cephalic tetanus complicating head injury are found in the world literature, and many were diagnosed late. Cephalic tetanus from open or compound depressed skull fracture is even more rare. Our patient was a young male with an uncertain tetanus immunization history who sustained mild head injury (scalp laceration) and an unattended open depressed skull fracture in a motorcycle crash. He developed cephalic tetanus seven days later, presented late to our service, and died while being prepared for surgical debridement of his cranial wounds. At the immediate post-trauma medical contact, in an across-the-street "clinic," he had received suboptimal care for his head wound and inadequate tetanus prophylaxis. CONCLUSION: Cephalic tetanus is a rare form of the disease. Although it is preventable easily by well-established medical and surgical treatment paradigms, it continues to catch many clinicians disastrously unaware.

The impact of tracheostomy timing in patients with severe head injury: an observational cohort study.

STUDY DESIGN: A retrospective analysis of 66 adults with severe head injury admitted to the neurosurgical intensive care unit (ICU) who required tracheostomy. OBJECTIVE: The purpose of this cohort study was to examine the impact of the tracheostomy timing in patients with severe head injury. METHODS: Patients were included in this study if they were admitted to the neurosurgical ICU because of severe head injury and if tracheostomy was performed. The patients were classified into 2 groups: early tracheostomy (ET) and late tracheostomy (LT). The timing of tracheostomy was considered early if it was performed by day 10 of mechanical ventilation and late if it was performed after day 10. We compared the duration of mechanical ventilation, length of stay (LOS) at ICU, hospital LOS, incidence of pneumonia, duration of antibiotics use, and mortality between the ET and LT groups. RESULTS: Of the 2481 patients with severe head injury admitted to the neurosurgical ICU, 66 (2.7%) required tracheostomy; 16 of whom were in the ET group and 50 were in the LT group. The ICU LOS was significantly shorter in the ET group (p<0.001). The incidence of nosocomial pneumonia was lower in the ET group (p=0.04) and the duration of antibiotic use was significantly shorter in the ET group (p<0.001). The patients in the ET group had a lower incidence of pneumonia caused by gram-negative microorganisms (p=0.001). CONCLUSIONS: ET in patients with severe head injury might contribute to a shorter duration of ICU LOS, lower incidence of gram-negative microorganism-related nosocomial pneumonia, and shorter duration of antibiotic use.

[Invasive trichosporonosis caused by Trichosporon asahii in a polytraumatized neurosurgical patient: case report]. / Invazivna trihosporonoza uzrokovana gljivom Trichosporon asahii u politraumatiziranog neurokirurskog bolesnika.

Trichosporon asahii (formerly T. beigelii) is a rare cause of human infections with very varied clinical manifestations ranging from superficial infections to severe and systemic diseases. T. asahii is a life-threatening opportunistic pathogen especially for granulocytopenic, immunocompromised and immunodeficient patients. It is the possible cause of summer-type hypersensitivity pneumonitis in Japan and systemic infections in transplant patients, patients on corticosteroid therapy, patients with solid tumors and burn patients. Cases of infection in non-immunocompromised surgical patients and patients with long-term stay in ICU are described in the literature. We report on T. asahii fungemia in a polytraumatized neurosurgical patient with long-term stay in the hospital. Urinary tract was the source of fungemia, with the same pathogen isolated from urine and blood at the same time. In the Referral Center for Systemic Mycoses, Croatian Institute of Public Health, Zagreb, the strain from the urine and blood culture was identified as T. asahii, with good susceptibility to fluconazole, voriconazole and 5 fluorocytosine, reduced susceptibility to itraconazole and resistance to amphotericin B. The patient responded to fluconazole therapy very well. Since systemic trichosporonoses are generally associated with immunocompromised patients (hematologic, granulocytopenic and AIDS patients), this case confirms the possibility of infection with this pathogen in patients with long-term hospital stay and reduced local immunity, but without classic immunodeficiency.

Arginine reduces bacterial invasion in rats with head injury: an in vivo evaluation by bioluminescence.

OBJECTIVES: The benefit of arginine in intensive care unit patients with severe sepsis is still controversial. An excessive supply of arginine could lead to an overproduction of nitric oxide and could be responsible for septic shock and multiorgan failure. However, this claim is not supported by any experimental or clinical data. We set out to determine whether an enteral supply of arginine would modulate bacterial invasion in rats with head injury. METHODS: Male Sprague-Dawley rats with head injury were randomized into two groups. Group 1 included rats with head injury fed a standard enteral nutrition (Sondalis HP, n = 10) and group 2 included rats with head injury fed the standard enteral nutrition plus arginine (4 g/kg/d, n = 11). Two days after head injury, the rats received a single enteral bolus of luminescent Escherichia coli Xen 14. Bacterial proliferation was evaluated in vivo at time + 2 hrs and time + 6 hrs after E. coli challenge. Four days after head injury, blood was sampled for arginine and fibrinogen assay. Muscles, intestine, spleen, and thymus were removed and weighed. RESULTS: There was no mortality in either group. The luminescence signal was similar in the two groups at time +2 hrs (group 1: 414 [5-823] vs. group 2: 496 [0.1-993] (median value[min-max]; not significant) and was significantly lower at time +6 hrs in group 2 (group 1: 71 [0-142] vs. group 2: 8.5 [0-17]; p = .026). Arginine treatment did not improve any nutritional parameters. CONCLUSIONS: Arginine was not responsible for mortality in rats with head injury with infectious complications and reduced the intensity of bacterial invasion.

In vivo bioluminescent imaging of a new model of infectious complications in head-injury rats.

Infectious complications are responsible for 10-25% of mortality in head-injured patients. In the present work we developed a model of infectious complications in head-injury rats using Escherichia coli (E. coli) with a stable copy of the lux operon, and monitored the infection in vivo by optical imaging. Rats were randomized into three groups: AL (healthy rats), HI (head-injury rats), and HI-EC (HI rats+single enteral bolus of E. coli, 1.3×10(9)/rat given 2 days after HI). Infection was evaluated with a camera at 2 and 6 h after E. coli challenge. Blood and organs were sampled to assess biological parameters. HI was associated with body weight loss, muscle atrophy, and plasma amino acid disturbances, in particular glutamine depletion (AL 919±37 versus HI 647±25 and HI-EC 717±20 µmol/L; p<0.05). In the HI-EC rats, the luminescence signal was observed at T+2 (mean [range]: 34,778 cpm [1617-2,918,810]), and was significantly decreased at T+6 (0 cpm [0-847,922]; p<0.05). Bacterial challenge was associated with a specific body weight loss and a decrease in gastrocnemius protein content, in alanine (AL 512±41 versus HI-EC 395±29 µmol/L; p<0.05), and in sulfur plasma amino acids. In conclusion, we propose a controlled model of HI with infectious complications characterized by specific metabolic alterations. Combined with the in vivo monitoring of the infection by bioluminescence, this model offers a valuable tool to evaluate specific strategies for HI patients.

Maxillary sinusitis in patients ventilated for a severe head injury and with nostrils free of any foreign body.

BACKGROUND: This study aims to determine the frequency of maxillary sinusitis in the patients with traumatic head injury and nostrils free of any foreign body. In addition, the sensitivity and specificity of ultrasonography (US) for the detection of the presence of fluid in maxillary sinuses were evaluated. PATIENTS AND METHODS: Forty patients with severe traumatic head injury were included in the study. The patients who had displaced maxillary sinus fracture at the medial wall and naso-tracheal and/or naso-gastric tube were excluded. Paranasal computed tomography (CT) was performed along with the routine cranial CT scanning or in case of unknown source of infection and compared with the results of ultrasonographic examination of maxillary sinuses performed by a single radiologist who was unaware of the CT results. In the patients, who had clinical and radiological signs of sinusitis, a trans-nasal puncture was performed using sinoject (SinoJect, ATOS Medical, Sweden), a spring-activated puncture instrument, to take a sample for microbiologic examination and to drain maxillary sinuses. RESULTS: Eighty-five percent of the patients were tracheotomised on the fifth day (on average) of their intensive care unit (ICU) stay. The frequency of sinusitis in the study group was found to be 32.5% (13 patients). The most frequently isolated species were Pseudomonas spp. (37.5%), Escherichia coli (20.8%) and Peptostreptococcus (16.7%). Five of the aspirates were polymicrobial. The sensitivity, specificity, positive predictive value and negative predictive value of B-mode US, compared with CT for the detection of fluid presence in maxillary sinuses in a 100 maxillary sinus examinations, were 92.2%, 81.6%, 83.9% and 90.9%, respectively. CONCLUSION: Maxillary sinusitis should be considered as a source of infection or sepsis in patients with traumatic head injury because of its high frequency. US is likely to be used as the first-line diagnostic tool for the determination of fluid in maxillary sinuses, especially in patients who do not require CT or cannot be transported to a radiology unit for CT.

Management of bite wounds in the head and neck.

An estimated 50% of people in the United States will incur an animal or human bite wound at least once in their lifetimes. Although the majority of these individuals do not seek medical attention, bite wounds to the head and neck are a common reason for emergency department visits. Facial bites are complex injuries due to the functional and cosmetic nature of the area, as well as the unique polymicrobial infection potential that exists. We present a review of the epidemiology and microbiology of bite injuries to the head and neck and provide evidence-based recommendations regarding surgical wound closure and antibiotic therapy.

Escherichia coli--infected cephalohematoma in an infant.

This report describes a 1-month-old female with bacteremia and meningitis complicated by an infected cephalohematoma that resulted from hematogenous seeding. This report serves as a reminder that, although occurring rarely, inflammation overlying a cephalohematoma in an infant with bacteremia can indicate focal infection that requires incision and drainage for resolution.

An unusual presentation of a minor head injury sustained during a game of rugby.

In the UK, about 2% of the population attend the accident and emergency (A&E) department every year after a head injury. A majority of the patients have minor head injury and are discharged. Studies reveal that patients who reattend the A&E after a minor head injury represent a high-risk group. Concussion injuries are common and not all require treatment at the time of presentation. However, some may worsen after initial presentation and develop signs of serious head injury. A case of minor head injury as a result of head butt during a game of rugby, not associated with alteration in conscious state or focal neurological signs, and subsequent development of frontal lobe abscess a month later is reported. It is important that patients fit to be discharged at the time of consultation are discharged in the care of a responsible adult with clear head injury instruction sheets and are advised to return should their symptoms change. A high index of suspicion should be maintained and an early imaging technique, such as CT scan should be considered in patients reattending the A&E with persistent symptoms even after minor head injury.

Head injury-associated bone fractures induce bacterial translocation: an experimental study.

OBJECTIVES: To determine whether long bone fractures cause bacterial translocation and to investigate the effect of concomitant head trauma on this process. DESIGN: An in vivo animal model. SETTING: Animal Laboratory, University of Mersin School of Medicine, Mersin, Turkey. SUBJECTS: Male Sprague-Dawley rats (n = 60). INTERVENTION: Sixty male Sprague-Dawley rats were divided into five groups: (1). anesthesia only (control group, n = 12); (2). anesthesia and tibia fracture (n = 12); (3). anesthesia, tibia fracture, and femur fracture (n = 12); (4). anesthesia, tibia fracture, femur fracture, and moderate head trauma (n = 12); and (5). moderate head trauma only (n = 12). After 24 hours, mesenteric lymph nodes, liver, spleen, ileum, and systemic blood samples were quantitatively cultured for aerobic organisms. MAIN OUTCOME MEASUREMENTS: Colony-forming unit per gram for bacteria count. RESULTS: The incidence of bacterial translocation was higher in groups that had fractures (4/12 in group 2; 5/12 in group 3) than in the control group (2/12); however, this did not reach statistical significance. There was a significant increase in the number of subjects with bacterial translocation in group 4 (9/12) compared with the control group and group 5 (3/12) (P = 0.0123, P = 0.0391). CONCLUSIONS: Multiple fractures of long bones associated with head injury promote bacterial translocation.

Fiberoptic intraparenchymal brain pressure monitoring with the Camino V420 monitor: reflections on our experience in 163 severely head-injured patients.

To assess the safety and accuracy of the Camino intraparenchymal sensor, we prospectively evaluated hemorrhagic complications, zero-drift, infection, and system malfunction in 163 patients monitored after a severe head injury. Mean duration of intracranial pressure (ICP) monitoring was 5 +/- 2.2 days (range: 12 h to 11 days). Of the 141 patients with a control CT scan, four showed a 1-2-cc collection of blood at the catheter's end. When removed, the sensors underread the true ICP value (negative zero-drift) in 80 of the 126 sensors evaluated (63.5%). Fourteen sensors showed no zero-drift, and 32 sensors overread the true ICP value (positive zero-drift) (median: -1 mm Hg; interquartile range: -4 to +1 mm Hg). No significant relationship was found between zero-drift, the surgeon who implanted the sensor, intracranial hypertension, or duration of ICP monitoring. No clinical infections could be attributed to the devices. Sixteen patients (9.8%) required more than one ICP sensor due to malfunctioning of the system. In conclusion, continuous ICP monitoring using the Camino intraparenchymal sensor has a low complication rate. However, this sensor may underread the real ICP values in a high number of patients. The lack of correlation between duration of ICP monitoring and zero-drift suggests that, contrary to the recommendations of other reports, the intraparenchymatous Camino sensor can provide reliable readings after the fifth day of use.

Bacterial colonization patterns in mechanically ventilated patients with traumatic and medical head injury. Incidence, risk factors, and association with ventilator-associated pneumonia.

We prospectively evaluated the relation of upper airway, lower airway, and gastric colonization patterns with the development of pneumonia and its etiology in 48 patients with surgical (n = 25) and medical (n = 23) head injury. Initial colonization was assessed by cultures of nasal and pharyngeal swabs, tracheobronchial aspirates, gastric juice, and bronchoscopically retrieved protected specimen brush. Follow-up colonization was determined until the end points extubation, suspected ventilator-associated pneumonia (VAP), or death. The initial colonization rate at any site at ICU admission was 39/47 (83%). It mainly accounted for Group I pathogens (Streptococcus pneumoniae, Staphylococcus aureus, Hemophilus influenzae) of the upper and lower airways. At follow-up, colonization rates with Group II pathogens (Gram-negative enteric bacilli and Pseudomonas spp.) increased significantly. The high initial bacterial load with Group I pathogens of the upper airways and trachea decreased during Days 2 to 4, whereas that of Group II pathogens increased. Upper airway colonization was an independent predictor of follow-up tracheobronchial colonization (odds ratio [OR], 9.9; 95% confidence interval [CI], 1.8 to 56.3 for initial colonization with Group I pathogens; OR, 23.9; 95% CI, 3.8 to 153.3 for follow-up colonization with Group II pathogens). Previous (short-term) antibiotics had a protective effect against colonization with Group I pathogens of the lower respiratory tract (OR, 0.2; 95% CI, 0.05 to 0.86), but they were a risk factor for colonization with Group II pathogens (OR, 6.1; 95% CI, 1.3 to 29). Initial tracheobronchial colonization with Group I pathogens was associated with a higher probability of early onset pneumonia (OR, 4. 1; 95% CI, 0.7 to 23.3), whereas prolonged antibiotic treatment (> 24 h) independently predicted late-onset pneumonia (OR, 9.2; 95% CI, 1.7 to 51.3). We conclude that patients with head injury are colonized in the airways mainly by Group I pathogens early in the evolution of illness. The upper airways represent the main reservoir for subsequent lower airway colonization with Group I pathogens. Previous (short-term) antibiotic treatment is protective against initial tracheobronchial colonization with Group I pathogens, but it represents a risk factor for subsequent lower airway colonization by Group II pathogens.

Comparative study of bacteriological contamination between primary and secondary exploration of missile head wounds.

Aerobic and anaerobic bacterial contamination of scalp wounds, indriven bone fragments, and brain tracks were studied in two groups (A and B) of nonrandomized patients with missile head wounds in a 20-month study of patients from the front lines of the Iran-Iraq war. In the 53 Group B patients, the primary debridements, most of which had been performed within 24 hours after injury, were deemed insufficient and a secondary definitive exploration was performed. Group A patients (62) had primary definitive explorations at Nemazee Hospital after a mean of 66.5 hours since injury. All of the patients had been started on dexamethasone and a combination of either ampicillin and chloramphenicol or crystalline penicillin G and chloramphenicol after field evacuation. The contamination rate of scalp wounds, bone fragments and brain tracks was slightly higher in Group A (38.4%, 22.2%, and 29.6% respectively, for Group A and 31.9%, 19.5%, and 27% for Group B, respectively). Staphylococcus albus among the gram-positive and Acinetobacter among gram-negative bacteria were the most common infecting organisms. Fifty per cent of the bacteria cultured from the brain tracks of Group A and 30.8% of those cultured from Group B patients were gram-negative. A total of 125 patients in four groups was included in our overall study of victims of missile wounds that violated the dura mater. Four patients developed meningitis at Nemazee Hospital (3 postoperatively and 1 after facial penetration). Two patients in Group B were admitted with meningitis (1 with an accompanying abscess), 1 of them 20 days and the other 60 days after exploration at two different centers.(ABSTRACT TRUNCATED AT 250 WORDS)

Intracranial infection by Vibrio alginolyticus following injury in salt water.

A 20-year-old man presented with an epidural abscess 3 months after a seawater diving accident. Cultures of the abscess cavity obtained by surgical drainage revealed a pure culture of Vibrio alginolyticus. Marine vibrios may produce serious intracranial infection after head injury in salt water.

[Post-traumatic meningitis due to Pasteurella multocida]. / Posttraumatische Meningitis durch Pasteurella multocida

The clinical data of a 14-year old female patient with posttraumatic meningitis by Pasteurella multocida are reported. The behaviour of the isolated strain is recorded in cultural and biochemical aspect as well as in animal experiment. The importance of the infection with Pasteurella multocida is lined out and the possible origin of the disease in the reported case is discussed. Finally some problems of special bacteriological diagnosis are explained and hints are given in this respect.

Isolation of Aeromonas species from clinical sources.

In a period of one year, in a general hospital, Aeromonas hydrophila was isolated from 13 patients and Aeromonas shigelloides from one patient. Eight of the patients had superficial infections, two had urinary tract infections, and four had bacteriaemia. The association of Aeromonas bacteriaemia with cirrhosis of the liver and malignant disease, which has been previously reported, was observed in three of the four bacteriaemic patients. The key to laboratory diagnosis of this genus is the routine performance of the oxidase test in bacteriological procedures for the identification of Gram-negative bacilli.