September 2001

A 17-year-old Hispanic boy was admitted to the hospital with the chief complaint of headache and low-grade fever. His problem started 6 days earlier. At the onset, his fever was up to 104°F and he was having nausea and vomiting. He was seen twice as an outpatient with the diagnosis of viral syndrome and treated symptomatically. No antibiotics were given. This occurred in August, and there were several cases of apparent enteroviral aseptic meningitis infections in the community. On his third trip to his physician, he was complaining of more head pain but had less fever. His pain was mostly in the forehead area over the right eye and radiating around the right side of his head. He also had complained of photophobia. On admission he had no other complaints.

His past medical history is significant only for a well-documented episode of sinusitis about 2 months earlier with a couple of courses of antibiotics. He has otherwise been a strong, athletic, healthy adolescent.

His immunizations are up-to-date and documented. There were no known sick contacts, insect bites, animal exposure, or travel. He denies any tobacco, alcohol or drug use. He is an average student in the 12th grade and has been sexually active, but denies any sexually transmitted diseases.

Examination is positive for fever of 101°F with some photophobia. He was alert and well oriented and had no other positive findings. A screening complete blood count and chemistry profile was normal. Cerebrospinal fluid (CSF) revealed a cell count of 4 red blood cells, 155 white blood cells (66% segs, 12% lymphs, 22% monos), a protein of 134 mg/dl, and a glucose of 74 mg/dl. The CSF Gram’s stain was negative. Because his headache was getting worse, a CT scan was done (figures 1-6).

What’s Your Diagnosis?

1. Enteroviral aseptic meningitis
2. Pott’s puffy tumor
3. Aseptic meningitis due to parameningeal infection
4. Both 2 & 3

Answer

The answer is #3, aseptic meningitis due to parameningeal infection. This patient had a subdural empyema, which shows up as a fluid collection on the CT scan, which also shows findings consistent with pan-sinusitis (figures 2 and 3). This apparently started as a frontal sinusitis that spread intracranially then around the right parietal area in the subdural space. It then caused an osteomyelitis of the skull, extending to the outer table, producing a subgaleal abscess.

Sorry this sounds so complicated, but that’s the way he presented. I don’t make this stuff up.

I cannot recall ever seeing a case like this, even though we were always taught how serious frontal sinusitis could be. I think because of the short fuse our medical community has for using antibiotics for upper respiratory tract infections, coupled with an overall healthier population, these type of complications of sinusitis are seldom seen, especially in children. However, older literature refers to them as commonplace. This suppurative infection in the subdural space accounts for the sympathetic inflammatory response producing the pleocytosis of the CSF. While there are white blood cells present, the glucose is usually normal, the Gram’s stain is negative, and the protein may or may not be elevated. This is much like the findings in viral meningitis.

However, the clues in this case against aseptic meningitis were the CSF white blood cell differential, being more polys than expected by this point in the illness, and the protracted and worsening course. As seen from his CT scan (figures 5 and 6), there was a significant subgaleal abscess that one would think would be readily detected on exam.

In retrospect, it was palpable, but before getting his head shaved for surgery, he had long and very thick hair that made detecting this collection of fluid on the admission exam difficult without already knowing it was there. It would have helped if he had told us that his scalp felt funny to him.

The CT scan also shows significant shift of the midline with brain edema. He began deteriorating rapidly, within minutes after the scan, and was taken to surgery emergently that night. The subgaleal and subdural spaces were drained and cultured and a large amount of infected bone was removed (figures 7 and 8). The cultures from both sites grew the same three organisms: Streptococcus cremoris, group C strep and Eikenella corrodens. The subdural space also grew Prevotella corporis. During the next several weeks, he was treated with a variety of antibiotic combinations and two additional drainage procedures.

His main neurologic residual deficit was some left-sided hemiparesis. On follow-up one year later, he was recovering from his hemiparesis. His prior antibiotic therapy may account for the unusual mix of aerobic and anaerobic organisms.

This is a dramatic and nearly fatal example of the suppurative complications of frontal sinusitis. From what I can gather, this is essentially the same process as a Pott’s puffy tumor. The only reason it’s not is that Sir Percival Pott described this as a complication of frontal bone osteomyelitis with the swelling over the frontal bone. So I guess it’s a matter of semantics. I would not argue with #4 as the answer. Also, the history in this case is typical of a lot of older teenage boys who like to play it sort of tough and deny being as sick as they really are. He was obviously sicker than appreciated on admission.

For Your Information:

• James H. Brien, DO, Pediatric Infectious Disease, Scott and White's Children's Health Center and Texas A&M University, College of Medicine, Temple, Texas. E-mail: jhbriend@aol.com