PARAPNEUMONIC EMPYEMA Uncomplicated effusion. Thoracic empyema.
Subdural Empyema complicating Sinusitis in Immunocompetent adults Authors Institutions.
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Transcript of Subdural Empyema complicating Sinusitis in Immunocompetent adults Authors Institutions.
Subdural Empyema complicating Subdural Empyema complicating Sinusitis in Immunocompetent adultsSinusitis in Immunocompetent adults
AuthorsInstitutions
Introduction Bacterial sinusitis is a common infection in
adults
Posterior invasion through sinus walls causes subdural empyema
Prompt neurosurgery and antibiotics are needed for successful treatment
We report two causes of subdural empyema in patients who had sinusitis as underlying cause
Case One
30 year old male was admitted via ER
Two weeks h/o head ache
Two days h/o intermittent fever, vomiting, facial twitching and tenderness over frontal region of head
Background Was seen in ER 3 days prior with headache
and fever
Febrile, no nuchal rigidity
Had CT head – Pansinusitis
Discharged with amoxicillin-clavulunate
Did not take antibiotics for two days due to lack of insurance
CT on first ER visit
Other History
PMH: Migraine, remote h/o seizure
PSH: None
Social: Non-smoker, no alcohol use
Family: None significant
Medications: None
Physical Exam
Temp 37.9o C, BP 90/49, PR 52
Drowsy, symmetrical facial twitching and nose wrinkling
Tenderness over frontal sinuses
Mild neck stiffness
Investigations
WBC 17.7
CSF: 295 WBC, protein 104, glucose 67
MRI scan of head
MRI
Management Commenced on cefotaxime, vancomycin,
metronidazole
Debridement of subdural empyema
Cultures grew viridans Streptococcus
Developed seizures and hemiplegia - repeat debridement with craniectomy
Treated with 6 weeks ABX, with resolution of hemiplegia
Case Two 55 year old male
Does not routinely seek medical care
Feeling generally unwell for few weeks
Took few doses of Levofloxacin given by physician friend
Was having intermittent headache, fever and increasingly lethargic
Seen previous day in urgent care, advised to follow with PCP
History continued
Came again with lethargy for 16 hrs, f/b decreased consciousness
PMH : Asthma
PSH: Nasal surgery and knee surgery
Social: Non smoker, no alcohol use
Medications: Advair and Fluticasone
Physical Examination
Temperature 36.8o C, PR 91, BP 125/71
Did not follow commands, obtunded
Mild menigismus
No grimace on percussion over sinuses
Moderate gingivitis
Investigations
Na 127
WBC 20.9
CT brain
CT scan
Management
Commenced on cefotaxime, vancomycin and metronidazole
Emergent fronto-parietal subdural evacuation
Functional endoscopic sinus surgery
Culture of the subdural empyema grew Streptococcus intermedius
Good recovery and was transferred to rehabilitation
Conclusion
Subdural empyema is uncommon but potentially fatal complication of sinusitis.
Suspect subdural empyema in patients with sinusitis plus any of the following:-altered mental status-nuchal rigidity-seizures-focal neurological changes.
MRI is more sensitive than CT for diagnosis.
CT scan & Subdural Empyema
In early stages small subdural empyema can be subtle in non-contrast CT
Subdural empyema do not cross the midline
Have crescent like configurations
It appears iso-attenuation to low attenuation extra axial collections compared to brain parenchyma with rim enhancement
MRI & Subdural Empyema Study of choice for detecting subdural empyema
Higher sensitivity of detection of small subdural fluid collections
Iso-intense signals on T1-weighted imaging
High signals on T2- weighted imaging
Can help to differentiate between subdural empyema from chronic subdural hematomas
( Low signal on T1WI vs. High signal on T1WI)
References
Ziai WC, Lewin JJ 3rd. Update in the diagnosis and management of central nervous system infections. Neurol Clin. 2008 May; 2(2): 427-68, viii.
Foerster BR, Thurnher MM, Malani PN et al. Intracranial infections: clinical and imaging characteristics. Acta Radiol. 2007 Oct; 48(8): 875-93.
Thank You