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  Case Report  Subdural Empyema Complicating Bacterial Meningitis: A Challenging Diagnosis in a Patient with Polysubstance Abuse Melissa Dakkak, William Russell Cullinane Jr., and Virin Rajiv Neil Ramoutar Department of Medicine, University of Florida, 󰀶󰀵󰀳 W. 󰀸th Street, Box L󰀱󰀸, Jacksonville, FL 󰀳󰀲󰀲󰀰󰀹, USA Correspondence should be addressed to Virin Rajiv Neil Ramoutar; virin.ramoutar@gmail.comReceived 󰀲󰀸 June 󰀲󰀰󰀱󰀵; Revised 󰀱󰀷 September 󰀲󰀰󰀱󰀵; Accepted 󰀲󰀷 September 󰀲󰀰󰀱󰀵Academic Editor: Di Lazzaro VincenzoCopyright © 󰀲󰀰󰀱󰀵 Melissa Dakkak et al.TisisanopenaccessarticledistributedundertheCreativeCommonsAttributionLicense,which permits unrestricted use, distribution, and reproduction in any medium, provided the srcinal work is properly cited.Subdural empyema (SDE) and cerebrovascular accident (CVA) are uncommon lie-threatening complications o bacterialmeningitis,whichrequireurgentneurosurgicalinterventiontopreventadverseoutcomes.Cliniciansmustbevigilantotheonseto ocalneurologicde󿬁citsorseizureactivitytoestablishthediagnosisoSDE. Streptococcuspneumoniae accountsor < 󰀱%opyogenicbrainabscesses.TiscasedescribesapresentationocommunityacquiredpneumococcalpneumoniainwhichthediagnosisoSDEwith vasculitis induced CVA was conounded by concomitant substance abuse and sedation. 1. Introduction Streptococcus pneumoniae  is the most common cause o bacterial meningitis in adults but has been uncommonly reported as a cause o pyogenic brain abscess [󰀱]. SDE is aless common complication o community acquired bacterialmeningitis, seen in 󰀲.󰀷% o cases [󰀲]. Tis sequela, althoughrare, must be considered in meningitis patients with con-comitant otitis or sinusitis, ocal neurologic de󿬁cits, epilepticseizures, and ailure to improve clinically despite adequateantibiotics. However, the recognition o SDE may provechallenginginpatientswithalteredsensoriumrompolysub-stance abuse and ICU sedative medications as demonstratedin the case o this 󰀴󰀴-year-old Human Immunode󿬁ciency Virus (HIV) positive emale. 2. Case Presentation A 󰀴󰀴-year-old Caucasian emale with past medical history o schizoaffective disorder, HIV (CD󰀴 o 󰀴󰀹󰀹 cells/  L),seizure disorder, and polysubstance abuse was brought intothe emergency department (ED) afer being ound unre-sponsive in her room. It was reported that she ingested abottle o pills o unknown identity. She had several similarpresentations to hospital over the past 󰀲 years. On initialassessment, her pupils were dilated but not 󿬁xed and shewas unable to provide a history as she responded only topainul stimuli. Examination also revealed a supple neck,normal muscle tone throughout, and downgoing plantars.She was subsequently intubated or airway protection andtranserred to the medical intensive care unit (ICU). Empiricacyclovir, vancomycin, and ceepime were given in the ED inthe setting o leukocytosis to 󰀱󰀶,󰀳󰀰󰀰/mm 3 and a low gradeever o 󰀳󰀸.󰀲 Celsius (󰀱󰀰󰀰.󰀸 Fahrenheit). Head computedtomography (C) on admission revealed no acute ischemicor hemorrhagic stroke and chronic opaci󿬁cation o theright mastoid air cells and middle ear cavity (seen on Cimages 󰀸 months earlier). Inectious workup was perormedand CSF culture was positive or  Streptococcus pneumoniae .Urinedrugscreenwasnegativeorbenzodiazepines,cocaine,opiates, amphetamines, or barbiturates. reatment doses o intravenous Cefriaxone were started at 󰀲 grams twice daily and continued based on antimicrobial sensitivities.She was extubated and transerred to internal medicineservice 󰀴 days later with persistent altered mental state andagitation. Tis was attributed to residual effects o sedationused in ICU versus schizoaffective disorder and possiblealcohol withdrawal. Te patient was placed on haloperidolgiven her psychiatric history and lorazepam as needed oragitation or tremulousness secondary to alcohol withdrawal. Hindawi Publishing CorporationCase Reports in MedicineVolume 2015, Article ID 931819, 3 pageshttp://dx.doi.org/10.1155/2015/931819  󰀲 Case Reports in Medicine 50 mm F󰁩󰁧󰁵󰁲󰁥 󰀱: 󰀱 MRI image demonstrating complicated right hemi-spheric subdural empyemas and right to lef midline shif. 50 mm F󰁩󰁧󰁵󰁲󰁥 󰀲: Diffusion Weighted Imaging (DWI) o the same MRIstudy demonstrating acute right middle cerebral artery territory inarct with loss o 󿬂ow-related enhancement within the rightmiddle cerebral artery. Per radiologist interpretation, 󿬁ndings may be secondary to associated vasculitis. Te patient had intermittent ever spikes but normalizingwhite cell count (decreased rom 󰀱󰀶,󰀳󰀰󰀰/mm 3 to 󰀱󰀰.󰀱). How-ever, afer 󰀲󰀴 hours the patient became less arousable despitenot receiving additional sedative-hypnotics and was unableto protect her airway. Afer reintubation and transer tomedical ICU, she was noted to have preerential right gazeandleflowerextremityweakness.ArepeatheadCrevealedpossible venous temporal inarcts associated with adjacentsubdural collection suggestive o an empyema. Follow-UpMagnetic Resonance Imaging (MRI) was obtained and isdescribed in Figures 󰀱 and 󰀲.Te patient was transerred to the neurocritical careteam and underwent a craniotomy or subdural empyemadrainage 󰀴󰀸 hours later owing to midline shif seen on MRI.A subdural drain was inserted intraoperatively and removed󰀳 days later, at which time the patient was successully extubated. Follow-up MRI revealed right encephalomalaciawith resolution o the subdural empyema 󰀲 weeks aferthe drain was removed. A total o 󰀴 weeks treatment withintravenous Cefriaxone was completed. She had residual lefupperextremityparesiswithintactcognitionupondischarge,when she was transerred to a Skilled Nursing Facility (SNF)or continued rehabilitation. 3. Discussion Bacterial meningitisis a lie-threateningdisease that requiresprompt medical attention. Pneumococci and meningococciare causative pathogens in approximately 󰀸󰀰% o all caseswith mortality rom  S. pneumoniae  ranging rom 󰀱󰀹 to 󰀳󰀷%[󰀳]. Te majority o patients present with two out o our o the ollowing symptoms: headache, ever, neck stiffness, andaltered mental status (as de󿬁ned by a score o   < 󰀱󰀴 on theGlasgow Coma Scale) [󰀴]. Tis patient in this case presentedwith altered sensorium and low grade ever. However, giventhe history o pill ingestion and polysubstance abuse, thediagnosis o bacterial meningitis could easily have beenmissed.In a review by Jim et al. [󰀲], SDE was complication o 󰀲󰀸 o 󰀱,󰀰󰀳󰀴 episodes (󰀲.󰀷%) o community acquired bacterialmeningitis reported in a prospective Dutch cohort study rom 󰀲󰀰󰀰󰀶 to 󰀲󰀰󰀱󰀱. 󰀲󰀳 (󰀸󰀲%) o these patients presented withneurologic symptoms o paresis, ocal seizures, and dysthesiacontralateral to the empyema. Te patient described had aknown history o seizure disorder and was given Divalproexat home doses, which may have explained the absence o seizures in this presentation. Further, a history o substanceabuse and alcoholism avored the diagnosis o withdrawaland as needed sedative-hypnotics in the management o thispatient.Failuretoimprovedespiteappropriateantibioticsandadeclineinconsciousnessaretheusualindicatorsthatrepeatbrain imaging is warranted [󰀳]. Rapid clinical deteriorationand onset o seizures warrant the consideration o SDE asa complication o bacterial meningitis [󰀵]. In the setting o sedative-hypnoticmedication, intubation,psychiatric illness,and possible withdrawal repeat imaging can be easily over-looked.IntheDutchstudy[󰀲],󰀲󰀱(󰀷󰀵%)patientshadconcomitantotitis or sinusitis with contiguous spread to the subduralspace. In this case, there was the opaci󿬁cation o the mastoidair cells and right middle ear cavity that was suggestive o an effusion or inectious process. Te patient was unable toprovide a history on presentation and prior images revealedsimilar 󿬁ndings so the diagnosis o otomastoiditis was notinitially considered. An immunocompromised state was alsoseen in 󰀸 (󰀲󰀹%) o the 󰀲󰀸 reported cases o SDE in the Dutchcohort. Te incidence o SDE in pneumococcal meningitispatientspresentingwithotitiswashighat󰀸%[󰀲].Historically, S. pneumoniae  was thought to be a rare cause o pyogenicbrain abscess occurring in less than 󰀱% o all reported cases[󰀱, 󰀶, 󰀷]. However, pneumococcus was identi󿬁ed in 󰀲󰀶 (󰀹󰀳%)o the 󰀲󰀸 patients with SDE in the Dutch cohort [󰀲].Vascular complications are common in bacterial menin-gitis, occurring in 󰀱󰀵–󰀲󰀰% o all inections and in as many as  Case Reports in Medicine 󰀳one-third o patients with pneumococcal meningitis. Small vessel vasculitis and vasospasm are the primary mechanismsimplicated[󰀸]andthisiswelldemonstratedinFigure 󰀲.Cere-bralinarctsmayinvolvelargevascularterritorieswithsubse-quentbrainedemaandmasseffectleadingtoadeclineincon-sciousness[󰀴].Inthiscase,thepatientsufferedarightmiddlecerebral artery (MCA) territory inarction and appropriately underwent neurosurgical intervention given the presence o midline shif and SDE. Neurosurgical intervention shouldbe regarded as the 󿬁rst-line therapy in patients with SDEcausing midline shif and ocal neurologic abnormalities ora decreased level o consciousness [󰀲]. Te optimal durationoantimicrobialtherapyhasnotbeenestablishedintrialsbutgenerally 󰀳- to 󰀴-week period is advised i an empyema hasbeen evacuated and even longer i conservatively managed[󰀹].Inthiscase,thepatientcompleted󰀴weeksoCefriaxoneintravenously in keeping with antimicrobial sensitivities. 4. Conclusion Tediagnosisobacterialmeningitisinitselcanbechalleng-ing with a low sensitivity or the classic triad o ever, neck stiffness, and altered mental state. When the less commoncomplication o SDE is superimposed on the hospital course,this represents an even greater challenge to physicians. Incases where clinical presentation is conounded by polysub-stance abuse and the need or sedation in the setting o intubation, vigilance must be increased or complications o meningitis. It is suggested that there be a low threshold orrepeat brain imaging when initial 󿬁lms reveal evidence o opaci󿬁cation in the sinuses, ear cavity, or adjacent structures.Further,thegoalinthepatientwithmeningitisshouldalwaysbetominimizesedationtoensurethatneurologicalstatuscanbe properly assessed. Prompt neurosurgical intervention iswarranted when SDE leads to midline shif, ocal neurologicabnormalities, or decreased level o consciousness. Conflict of Interests Te authors o this paper have no con󿬂ict o interests todeclare. References [󰀱] E. Grigoriadis and W. L. Gold, “Pyogenic brain abscess causedby   Streptococcus pneumoniae : case report and review,”  Clinical Infectious Diseases , vol. 󰀲󰀵, no. 󰀵, pp. 󰀱󰀱󰀰󰀸–󰀱󰀱󰀱󰀲, 󰀱󰀹󰀹󰀷.[󰀲] K. K. Jim, M. C. Brouwer, A. van der Ende, and D. van de Beek,“Subduralempyemainbacterialmeningitis,” Neurology  ,vol.󰀷󰀹,no. 󰀲󰀱, pp. 󰀲󰀱󰀳󰀳–󰀲󰀱󰀳󰀹, 󰀲󰀰󰀱󰀲.[󰀳] D. van de Beek, J. de Gans, A. R. unkel, and E. F. M. Wijdicks,“Community-acquired bacterial meningitis in adults,”  Te NewEngland Journal of Medicine , vol. 󰀳󰀵󰀴, no. 󰀱, pp. 󰀴󰀴–󰀵󰀳, 󰀲󰀰󰀰󰀶.[󰀴] D. van de Beek, J. de Gans, L. Spanjaard, M. Weiselt, J. B.Reitsma, and M. Vermeulen, “Clinical eatures and prognosticactors in adults with bacterial meningitis,”  Te New England  Journal of Medicine , vol. 󰀳󰀵󰀱, no. 󰀱󰀸, pp. 󰀱󰀸󰀴󰀹–󰀱󰀸󰀵󰀹, 󰀲󰀰󰀰󰀴.[󰀵] S. R. Dill, C. G. Cobbs, and C. K. McDonald, “Subduralempyema: analysis o 󰀳󰀲 cases and review,”  Clinical InfectiousDiseases , vol. 󰀲󰀰, no. 󰀲, pp. 󰀳󰀷󰀲–󰀳󰀸󰀶, 󰀱󰀹󰀹󰀵.[󰀶] D. Alderson, A. J. Strong, H. R. Ingham, and J. B. Selkon,“Fifeen-year review o the mortality o brain abscess,”  Neuro-surgery  , vol. 󰀸, no. 󰀱, pp. 󰀱–󰀶, 󰀱󰀹󰀸󰀱.[󰀷] A.Nicolosi,W.A.Hauser,M.Musicco,andL..Kurland,“Inci-dence and prognosis o brain abscess in a de󿬁ned population:olmsted County, Minnesota, 󰀱󰀹󰀳󰀵–󰀱󰀹󰀸󰀱,”  Neuroepidemiology  , vol. 󰀱󰀰, no. 󰀳, pp. 󰀱󰀲󰀲–󰀱󰀳󰀱, 󰀱󰀹󰀹󰀱.[󰀸] M.Klein,U.Koedel,S.Kastenbauer,andH.-W.P󿬁ster,“Delayedcerebral thrombosis afer initial good recovery rom pneumo-coccal meningitis,”  Neurology  , vol. 󰀷󰀵, no. 󰀲, pp. 󰀱󰀹󰀳–󰀱󰀹󰀴, 󰀲󰀰󰀱󰀰.[󰀹] A. R. unkel, “Subdural empyema, epidural abscess and suppu-rative intracranial thrombophlebitis,” in  Principles and Practiceof Infectious Diseases , G. L. Mandell, J. F. Bennet, and R.Dolin, Eds., pp. 󰀱󰀲󰀷󰀹–󰀱󰀲󰀸󰀷, Churchill Livingstone Elsevier,Philadelphia, Pa, USA, 󰀷th edition, 󰀲󰀰󰀱󰀰.  Submit your manuscripts athttp://www.hindawi.com
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