Subdural empyema due to mixed infections successfully treated medically: A case report with review literature.

Subdural empyema is a rare intracranial infection with an accumulation of purulent material between the dura and arachnoid matter. We report a case of 17 years old presented with an altered conscious level. CSF analysis showed increased WBCs. His situation has improved after treating by acyclovir, ceftriaxone, vancomycin, and dexamethasone.

INTRODUCTION

Subdural empyema (SDE) is a collection of pus between the dura and arachnoid layers of the meninges. It is a rare infection of the brain, and it is an almost fatal condition if left untreated, but since using antibiotics, the mortality rate has decreased and now ranges from 14% to 28%. , In infants, it complicates neonatal meningitis, but in older children, it develops mainly due to ear, sinus infection, or spread from a hematogenous source. , , , , , , In males, SDE is more frequently seen in males, and it is the most commonly encountered intracranial complication of infection. , The patient usually presents with fever, sinusitis, and neurological deficits with less frequent symptoms, including headache and seizures with alteration of the level of consciousness. , , , , , Laboratory investigations vary from blood to imaging. Computed tomography (CT) and magnetic resonance imaging (MRI) are the most important. , Also, white blood cell count, erythrocyte sedimentation rate, and C‐reactive protein level may be helpful. Imaging is recommended for every patient suspected to have a subdural abscess.

In some cases, when the diagnosis by CT and MRI is unclear, hollow screws have a diagnostic value. Road spectrum antibiotics are usually the first‐line management, and they may be enough to control the infection. , , However, the surgical intervention must be considered if the antibiotics fail to maintain or other surgery indications. , The most common surgical procedures are craniotomy and burr holes. , If the surgical intervention has been done within 72 h, the chance for disability is 10% compared to 70% when done after 72 h.

Because of its rarity, many doctors may not have seen a case in recent years. The topic should be re‐visited to remind them to be aware of it. Also, it is difficult to distinguish from meningitis; hence, the attending clinician must have a high suspicion index.

In this report, we presented a SDE case successfully treated by medical treatment in our hospital. Also, we systematically summarized the previously published case reports about SDE.

LITERATURE REVIEW

We searched for published case reports in four electronic databases: PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL) in October 2020 using the following query: (“Empyema, Subdural”[Mesh]). We included all English case reports about SDE in adolescent patients (10–19 years).

Since 1990, approximately 35 studies with 53 patients have reported similar cases in this age group; almost all were males (86.7%). The observed pattern of predisposing events is sinusitis, otitis media, or an upper airway infection. Patients have usually suffered from fever, headache, and drowsiness. The neurological manifestations started with nuchal rigidity (17% of cases), hemiplegia (11.3% of cases), or seizures (18.8% of cases).

Details of each case and the organism isolated from the culture and the outcome are shown in Table 1.

TABLE 1

Summary of the previous case reports , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

Study ID	Sex	Age	Predisposing event	Signs and symptoms	Bilateral or unilateral	Location	Specific location	Medline Shift	Intra‐axial component (yes/no)	CNS infection (causative organism)	Follow‐up period	Intervention used	Outcome
Şahin 2015	Male	16	Sinusitis	Projectile vomiting, lethargy, fever, and headache	Unilateral	Subdural	Around the right cerebral hemisphere then relapse in the posterior interhemispheric fissure	Present	None	Streptococcus constellatus	2 months	Frontoparietal craniotomy	Hemiparesis of the patient improved gradually and SDE regressed completely after ampicillin treatment
Yu ¨cel 1998	Male	14	Upper air way infection	Deterioration of consciousness, right hemiparesis, edema in the left eyelid and seizures	Unilateral	Subdural	Frontal	Absence	None	Streptococcus pneumococcus	2 weeks	Craniectomy	Patient lost vision then he responded for treatment and was released from hospital
Arifianto 2017	Male	17	Allergic rhinitis	Deterioration in consciousness, difficulties in speech, and hemiparesis	Unilateral	Subdural	Interhemispheric and infratentorial	Present	None	Staphylococcus epidermidis	4 weeks	Conservative therapy then craniotomy	All the symptoms resolved; the only remaining symptom was limited extraocular muscle movement
Balfour‐Lynn 1997	Female	16		Seizure and visual hallucination	Unilateral	Subdural empyema	Over the right cerebral hemisphere	Absence	Yes	Burkholderia cepacia	1 year	Craniectomy	Initial recovery then deterioration and obliterative bronchitis of the lung although the use of antibiotics
Banerjee 2010	Male	12	Exposure to an active case of pulmonary tuberculosis	Raised intracranial pressure and fever for 1 month and altered sensorium for 2 days	Unilateral	Subdural empyema	Left frontoparietal and interhemispheric	Absence	No	Acid‐fast bacilli of TB	18 months	Craniectomy	Full recovery and no recurrence
Derin 2015	Male	16	Dental infection	Dental and facial pain and swelling of the left face	Unilateral	Subdural empyema	Frontal	Absence	No	Streptococcus viridans	8 weeks	Sinus drainage for pansinusitis and Empiric therapy	Recovery and patient discharge
Borovich 1990	All of them are males	Case 1: 17 Case 2: 35 Case 3: 58	Case 1: purulent meningitis Cases 2 & 3: acute meningitis	Case 1: headaches, abdominal pain, and fever of 1 month's duration Case 2: 1 day of headaches and fever Case 3: otorrhea, fever, and headaches	Cases 1 & 2: unilateral Case 3: Bilateral	All of them are subtentorial collection with marked mass effect	–	All cases: Absence	All cases: No	Case 1: Pneumococcus and Proteus. Cases 2 & 3: None mentioned	–	Case 1: penicillin and gentamicin then left suboccipital craniectomy Case 2: Antibiotics then suboccipital craniectomy Case 3: penicillin and chloramphenicol then external ventricular drainage, drainage of the subtentorial pus, and a bilateral mastoidectomy	Cases 1 & 2: Recovery and patient discharge Case 3: The patient died 24 h after surgery
Calik 2012	Male	13	Upper air way infection	Fever and cervical micro lymphadenopathy	Unilateral	Subdural empyema	Frontal	Absence	No		4 weeks	Craniotomy and sinusotomy	Recovery and patient discharge
Conlon 1996	Case 1	16	–	Fever and left frontal headache then seizures	Unilateral	Subdural empyema	Frontal	Absence	No		NR	Craniotomy	Recovery and patient discharge
	Female	16	Upper air way infection	Photophobia, frontal headache and periorbital swelling	Unilateral	Cerebritis	Frontal	Absence	No	Pansinusitis by B hemolytic Streptococcus group A	1 week	Pus aspiration from sinus	Recovery and patient discharge
Dolan 1995	Male	16	Suspected sinusitis	Altered mental status and slurring of speech	Unilateral	Subdural empyema	Frontal	Absence	No	NR	NR	Craniotomy and twist drill ventriculostomy	Recovery and patient discharge
Dunn 2013	Male	14	Migraine headaches and acute sinusitis	Vomiting and nausea	Unilateral	Epidural and subdural empyema	Frontopaetial	Present	No	Threatening	6 weeks	Bifrontal craniotomy, physical and speech therapies in follow‐up	Full recovery and no recurrence
Harris 1987	Male	12	Sinusitis	Fever, lethargy and monoplegia	Unilateral	Subdural empyema	–	Absence	No	NR	NR	Craniotomy	Recovery and patient discharge
Heilbronn 1984	Male	13	Pansinusitis	Frontal headache early then the patient developed neck stiffness	Unilateral	Subdural	Frontal and temporal	Absence	No	Pansinusitis by B hemolytic Streptococcus group A	NR	Exploration surgery and resection of necrotized tissue	Patient death
	Female	12	Pharyngitis	Fever, neck stiffness	Unilateral	Subdural empyema	Lateral ventricles	Absence	No		NR	Craniectomy	Recovery and patient discharge with anticonvulsant therapy
Holland 2012	Male	15	Sinusitis	Headache and low‐grade fever then motor disability	Unilateral	Subdural empyema	Right frontal sinus	Present	No	Pneumococcus	6 months	Craniotomy, ventricular drain, speech, and physical therapy	Postsurgical facial droop and unequal pupil dilation, after recovery the patient was discharged with residual left‐sided weakness
Jones 1997	Female	14	Previous infection of mixed coliforms and Enterococcus	Deterioration of consciousness and bilateral abducent nerve palsy	Unilateral	Sub‐tentorial empyema	Left cerebellar hemisphere	Absence	No	Enterococcus faecalis	4 weeks	Craniectomy and radical mastoidectomy	Full recovery and no recurrence
Kageyama 2000	Male	18		Neurological deterioration, mild fever and vomiting	Unilateral	Subdural empyema	Paranasal sinuses and convexity	Absence	No	Streptococcus milleri	2 weeks	Burr holes drainage and barbiturates	Recovery and patient discharge
Kuczkowski 2005	Male	14	Purulent rhinorrhea and upper respiratory tract infection	Headache, nausea, vomiting	Bilateral	Subdural empyema	Frontal brain lobes	Absence	No	β‐hemolytic group C Streptococcus		Craniotomy	Full recovery and no recurrence
	Male	12	Purulent rhinorrhea and upper respiratory tract infection	Headache, periorbital swelling and meningitis	Unilateral	Subdural empyema	Frontal sinuses	Absence	No	Negative		Craniotomy	Death 13 days after surgery
Kwangong 2002	All are males	7 patients (9–14)	Sinusitis	Headache, fever, motor deficit, seizures, and altered mental status	Unilateral	Subdural empyema	Frontal sinusitis	Absence	No			Craniotomies and endoscopic sinus surgeries	5 complete recovery and 1 hydrocephalus
Lefebvre 2009	Male	15	Sinusitis	Headache and hemiparesis	Unilateral	Subdural empyema	Subdural and maxillary sinus	Absence	No	Streptococcus constellatus	6 months	Craniotomy	Recurrent interhemispheric empyema then total recovery
Manjila 2017	Male	14	Sinusitis	Epistaxis due to suspected carotid artery damage	Unilateral	Subdural empyema and cavernous sinus pseudo aneurism	Frontal and temporal regions	Absence	No	Methicillin‐sensitive Staphylococcus aureus		Craniotomy and arterial resection and reconstruction	Recovery and patient discharge
Martins 2014	Male	18	Sinusitis	Dysarthria, fever and purulent rhinorrhea	Unilateral	Subdural empyema	Maxillary sinus and frontal sinus	Absence	No	Alpha hemolytic streptococci	3 months	Craniotomy and maxillary antrostomy	Recovery and improvement of dysarthria
Millar 1996	Male	14	Flu‐like illness	Hemiparesis, headache and fever	Unilateral	Subdural empyema	Right frontal	Absence	No		2 weeks	Craniotomy	Death 3 days after surgery
Mitsuoka 1995	Male	14	Retrobulbar pain and eye swelling	Seizure and loss of consciousness	Unilateral	Subdural and interhemispheric empyema	Falx	Absence	NO	Streptococcus species	4 weeks	Craniotomy	Full recovery and no recurrence
Morgan 1995	Male	17		Dysarthria, headache and neck stiffness and decreased sensation	Bilateral		Basal cisterns and subdural	Absence	NO	Anaerobic hemolytic streptococci		3 drainage operations yet he developed meningitis and his condition deteriorated	Death after complications
	Male	15	Chronic otitis	Bilateral papilledema, nystagmus, ataxia, and photophobia	Unilateral	Subdural empyema	–	Absence	NO	Nonhemolytic streptococci		Craniectomy and radical mastoidectomy	recovery and discharge
	Male	17		Postnasal discharge, fever and retroorbital pain, later he developed limb weakness	Unilateral	Subdural empyema	–	Absence	NO	Beta hemolytic streptococci of Lancefield group C	4 weeks	2 craniotomies	Full recovery and no recurrence
Nica 2011	Male	15	Meningio‐encephalitis	Drowsiness, cervical pain and headache	Unilateral	Subdural empyema	Fronto‐temporo‐parietal	Absence	NO	Fusobacterium varium, Fusobacterium mortiferum and Propionibacterium propionicum	1.5 years	Craniectomy	Full recovery after physical therapy
Ong 2002	Male	13		Fever, drowsiness, headaches, and nausea later he developed unequal pupils and a suspected hemorrhagic infarct on CT scan	Unilateral	Subdural empyema	–	Absence	NO	Streptococcus constellatus		Craniectomy	Recovery and patient discharge
Pattisapu 2008	Male	11	Otitis media and mastoiditis	Nuchal rigidity, headache and lethargy	Bilateral	Subdural empyema	Subtentorial	Absence	No	Proteus, E. coli and Bacteroides	48 months	Burrhole catheter drainage	Recovery and patient discharge
	Male	11	meningitis	Seizures, nuchal rigidity and decorticate posturing	Bilateral	Subdural empyema	Subfrontal, parafalcine	Absence	No	Salmonella Type C	45 months	Burrhole catheter drainage	Recovery and patient discharge
	Female	13	Ethmoiditis and frontal osteomyelitis	Facial swelling, orbital cellulitis and hemiparesis	Bilateral	Subdural empyema	Parafalcine	Absence	No	Group D Streptococcus, Bacteroides melaningenicus	38 months	Craniotomy and ethmoidectomy	Recovery and patient discharge
Sengul 2009	Male	15	Left otitis media and meningitis	Fever, headache, earache, and neck stiffness	Unilateral	Subdural empyema	–	Absence	No	No organisms on culture	2 years	Craniectomy	Recovery and patient discharge
Per 2010	Male	15		Facial swelling and fever later, he developed hemiparesis and seizures	Unilateral	Epidural and subdural empyema	Frontal	Absence	Yes	Pasteurella multocida	4.5 years	Empyema evacuation	Recovery and the patient is kept on antiepileptic therapy
Salunke 2010	4 males and 2 females	6 patients (12–19)		All presented with headache, vomiting, and fever only one patient had advance seizures and hemiparesis	Unilateral	Subdural empyema	Front parietal subdural	Absence	No	4 Negative cultures ‐1 MRSA ‐1 E. coli	3–60 months	Craniotomy	Recovery and discharge
Tankhiwale 2014	Male	14		High grade intermittent fever, altered sensorium, neck stiffness, and seizures	Bilateral	Subdural empyema	Subdural	Absence	No	Mycobacterium fortuitum	6 weeks	Craniotomy	Full recovery and no recurrence
Teelin 2017	Male	14	Sinusitis	Seizures, headache, intermittent low‐grade fever	Unilateral	Subdural empyema	Frontal	Absence	No	Streptococcus anginosus		Craniotomy	Full recovery and no recurrence
Teng 2012	Male	17	Sore throat	Fever, nuchal rigidity and drowsiness	Unilateral	Epidural and subdural empyema	Frontoparietal subdural and medial‐frontal epidural	Absence	No	Fusobacterium species		Craniotomy	Full recovery and no recurrence
Waseem 2008	Male	14	Upper air way infection	Fever and headaches, later he developed deep dull ache and facial heaviness	Unilateral	Subdural empyema	Frontal and ethmoid sinuses	Absence	No	Group F streptococci	2 months	Craniotomy	Recovery and discharge
Westhout 2007	Male	16	Sore throat	Dyspnea, neck pain, anorexia and oliguria	Bilateral	Subdural empyema	–	Absence	No	Streptococcus species	7 weeks	Conservative treatment after tonsillectomy	Recovery and discharge

CASE REPORT

A 17‐year‐old male patient was referred to our hospital. He had no history of co‐morbid illnesses. At first sight, he seemed distracted, and an altered conscious level was noted. By history, 7 days ago, the condition was started with a headache and low‐grade fever without apparent septic focus; no tonsillitis or upper respiratory tract infection. The patient came to our hospital with his family member (from whom the history had been taken). They complained that the patient had a fever, which was not improved by analgesics associated with malaise and disturbing consciousness level in drowsiness and confusion; the patient was inattentive and disoriented to time, place, and persons. On examination, the patient was feverish (38.5), drowsy, confused, and had no focal neurological deficit with positive meningeal irritation signs, neck stiffness, positive kerning's, and stretch leg signs. CT brain at once showed mild diffuse brain edema of the right cerebral hemisphere with a suspected thin rim of overlying extra‐axial fluid collection (Figure 1). We asked for a lumbar puncture (after taking consent from the family) to obtain a CSF sample for analysis. Septic screen samples, urine analysis and cultures, nasal swab, axillary culture, throat culture, blood culture, and sputum culture were also withdrawn. Routine laboratories were withdrawn as well, including complete blood count with differential, kidney and liver functions, and electrolyte levels.

FIGURE 1

CT brain at presentation: mild diffuse brain edema of the right cerebral hemisphere

Few days later, the results of CSF analysis showed that CSF was clear colorless fluid, RBCs 400 cells/cmm, WBCs 66 cells/cmm (neutrophils 30%, lymphocytes 65%, mononuclear cells 5%), CSF glucose was 4.8 mmol/L which is high (normal range 2.2–3.9 mmol/L), CSF protein was 52.7 mg/dl which is also high (normal range 15–45 mg/dl). Also, CSF cultures were negative for any bacterial growth, including gram bacteria and acid‐fast bacilli. Acid‐fast bacilli PCR is also negative.

Septic screen results also were negative for any bacterial growth. The rest of the tests were normal except for an increased W.B.C.s count of 14 × 103 with increased neutrophils 87.9.

Low‐grade fever at first, high glucose level, and predominance of lymphocytes in CSF are evidence of viral infection. In addition, mucocele and the presence of sinusitis are bacterial infections, so a treatment that covers possible causes of C.N.S. infection was initiated: acyclovir (10 mg/kg IV ter in die [tid]; three times a day), ceftriaxone (2 g IV bis in die [bid]; twice a day), vancomycin (750 mg IV bid), and dexamethasone (4 mg IV quarter in die [qid]; four times a day).

The following day, an MRI brain with contrast was conducted and showed mild diffuse thickening of the pachy/leptomeninges overlying the right cerebral hemisphere with mild intervening fluid collection seen eliciting low signal on t1 and high signal on t2‐weighted images with evidence of diffusion restriction, features suggestive right‐side meningitis with mild SDE. Evidence of right‐sided mild mass effects that was manifested by effacement of the underlying cortical sulci with mild compression on the right lateral ventricle. In addition to that, there was obliteration and mildly expansion of the frontal sinus, showing a high signal on both t1‐, and t2‐weighted images, likely representing mucocele formation. Also, the sphenoid, right ethmoid sinuses, and suitable mastoid air cells have been destroyed (Figure 2).

FIGURE 2

MRI brain with contrast at the next morning: Mild diffuse thickening of the pachy/leptomeninges over lying the right cerebral hemisphere with mild intervening fluid collection

At the end of the second day after admission, the patient developed serial attacks of generalized tonic colonic fits, controlled by giving loading phenytoin (15 mg/kg); after that, we kept him on levetiracetam (500 mg P.O. B.I.D.). Also, E.E.G. was done, which showed slowness in activity (Figure 3). The patient's condition improved on the 5th day regarding consciousness level, and no more fits had occurred. The patient was continued on the same treatment measures. A follow‐up MRI. brain with contrast was done after 1 week (Figure 4) and 3 weeks (Figure 5), which showed significant regression of the meningeal thickening and enhancement for the right SDE.

FIGURE 3

EEG sheet which showed slowness activity

FIGURE 4

MRI brain with contrast during the follow up after 1 week

FIGURE 5

MRI brain with contrast during the follow up after 3 weeks

The patient was discharged with marked improvement up to his normal state with no complaints.

DISCUSSION

This case report presents a patient with SDE resulting from a mixed bacterial and viral infection. The patient suffered from sinusitis 7 days before our investigation. The CSF analysis showed an increasing number of WBCs (66 cells/cmm) and 30% neutrophils. The CT scan showed mild diffuse brain edema of the right cerebral hemisphere with suspected mucocele formation, which is considered evidence of bacterial infection. Also, CSF analysis showed an increase in the number of lymphocytes 65% and glucose 4.8 mmol/L, which is evidence of viral infection. Our case showed a thin rim in CT and no significant midline shift in MRI, so it is considered a mild case. Although surgery is the first line in the treatment of SDE, there is a widely unutilized option to use antibiotics in mild cases. , So we treated our patient medically with acyclovir (10 mg/kg IV tid) for viral infection; ceftriaxone (2 g IV bid) and vancomycin (750 mg IV bid) for bacterial infection and dexamethasone (4 mg qid). The treatment was effective, and the patient had recovered with no severe side effects or disability.

What makes this case unique is a mixed infection; the patient was also treated medically, while a limitation was no PCR analysis for causative organisms. The case was diagnosed as SDE depending on the clinical history (fever, disturbed conscious level, meningeal irritation signs, fits, and preceding infection), CSF findings (which showed the proof of mixed infection), and MRI brain findings. Also, there was evidence of EEG changes in the form of slowness activity, which is going with Mauser H.W et al. They found multiple EEG changes that may occur with SDE cases, including diffuse slowness. Thus, diagnosis depends only on clinical history, signs, laboratories, EEG, and radiology findings.

Ruth et al. concluded that a nonsurgical strategy might be considered for patients with a good clinical condition with a minor shift from the midline on radiology results. , For 4 weeks, Musa et al. reported evidence of pre‐surgical treatment with I.V chloramphenicol and metronidazole. They increased a Glasgow coma scale from 8/15 to 15/15 with no seizures. SDE had reported getting negative in culture test; a case series by Madhugiri et al. consisting of 27 patients with a mean age of 10 years reported that 26% of patients get negative in culture test.

Based on our case, physicians should consider the treatment of viral and bacterial infections in similar circumstances. Medical treatment of mild SDE patients can be effective and safe. Future research is needed to investigate the merits and limitations of using medical therapy alone in SDE with mild and moderate cases. In conclusion, as there were multiple conflicts in differentiation between SDE and meningitis, all attending doctors must suspect it. Start medical treatment as soon as possible for all suspected cases depending on the clinical, radiological, and laboratory findings. According to the case degree, early intervention in those cases, whether medical or surgical, can improve patient outcomes and good prognosis. In spite, our case showed marked improvement only on using medical treatments. Multiple researches should be conducted for clarification and putting criteria for either medical or surgical therapies for SDE patients.

AUTHOR CONTRIBUTIONS

All authors have contributed in writing and reviewing the manuscript.

CONFLICT OF INTEREST

There is no conflict of interest.

ETHICAL APPROVAL

Consent to case study report given by Nassau University Medical Centre, NY.

CONSENT

We obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient knew that his name and initials would not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.

GUARANTOR

Sarya Swed.