Subdural empyema is a collection of pus that accumulates in the space between the dura mater and arachnoid mater. This is a life-threatening condition that should be diagnosed and treated urgently. In most cases, it emerges as a complication of paranasal sinusitis or otitis media.
Subdural empyema (SDE) is a life-threatening neurological condition that frequently has a rapid and aggressive course. This medical emergency is typically featured by the clinical triad of fever, sinusitis, and neurological deficits. Also, patients experience symptoms such as nausea, emesis, and headache , of which the latter is initially characterized as focal but then evolves to generalized. Moreover, the vast majority of patients exhibit meningeal signs such as nuchal rigidity and photophobia. Neurologic signs include hemiparesis, hemiplegia, gait abnormalities, dysphagia, and visual changes. Patients also develop seizures and mental status changes such as confusion, drowsiness, stupor, or even coma.
Remarkable findings on the neurologic exam include aphasia, contralateral motor deficits, gait ataxia, and possibly palsies of the oculomotor, trigeminal, and abducens cranial nerves. Ophthalmologic exam shows papilledema, which is reflective of elevated intracranial pressure. An altered mental status is also apparent.
It should be noted that the clinical presentation of subdural empyema closely resembles that of other forms of intracranial infections. Hence, the differential diagnoses are meningitis, viral encephalitis, brain abscess, and cerebritis  .
Entire Body System
Malaise, fever, and declining mental status can occur rapidly. Complications can include dural venous thrombosis, parenchymal abscess, epidural abscess, and meningitis. Mass effect or secondary venous infarction can cause focal neurologic deficits. [epilepsy.com]
Fever, a persistent headache, nausea, vomiting and malaise are often reported at the outset, along with symptoms relating to the source of infection. This is not conclusive for a subdural empyema. [healthhype.com]
The most commonly encountered symptoms of subdural empyema include: Fever, nausea, vomiting, malaise, persistent headache, stiff neck, lethargy, confusion, drowsiness, papilledema, seizures, one sided weakness, abnormal sensation with numbness, blurry [epainassist.com]
We present a three-year old girl lapsing into unconsciousness following a seizure while undergoing treatment for malaria. Imaging revealed a large heterogenous density, left hemispheric acute subdural haematoma with brain herniation. [ncbi.nlm.nih.gov]
One theory is that the normal development of the paranasal sinuses in males results in anatomic differences that predispose them to recurrent sinusitis. Subdural empyema can occur at any age, but about two thirds of patients are aged 10-40 years. [emedicine.com]
We highlight the difficulties in diagnosing Hunt syndrome and argue the case for early treatment of all patients with Hunt syndrome and Bell's palsy with a combination of systemic steroids and antiviral drugs. [ncbi.nlm.nih.gov]
DISCUSSION Although uncommon, neurologic complications of varicella include postinfectious cerebellar ataxia, meningoencephalitis, Reye syndrome, myelitis, optic neuritis, stroke, Guillain-Barré syndrome, seventh cranial nerve palsy, and Ramsay-Hunt syndrome [pediatrics.aappublications.org]
On hospital day 2, cerebral spinal fluid cultures and blood cultures grew Streptococcus pyogenes, and repeat physical examination was consistent with acute streptococcal pharyngitis. [ncbi.nlm.nih.gov]
Streptococcal pharyngitis: an uncommon cause of subdural empyema. BMJ Case Rep. 2015;211312. [ Links ] 19. Giamarellou HJ, Tsagarakis J, Petrikkos G, Mavroudis K, Veldekis D, Daikos GK. [scielo.br]
Jaw & Teeth
fontanelle, seizures DIFFERENTIAL Epidural abscess - not as ill, rare nuchal rigidity Cerebral abscess - chronic course, rare nuchal rigidity SDH - no contrast enhancement on CT DIAGNOSIS Fevers, high WBC, ESR, CRP CT w/ contrast: hypodense /- peripheral [learnneurosurgery.com]
The rest of the clinical manifestations were described according to the age of our patient, negative nuchal rigidity but bulging fontanelle. It may be for this reason that early symptoms of the subdural empyema were masked by meningitis. [casesjournal.biomedcentral.com]
His head was noted to be disproportionately large compared with the rest of his body (95 th vs. 25 th percentile), but without a bulging fontanelle. The pupils were equal round and reactive to light. [esciencecentral.org]
Bulging fontanelle in infants. Differential diagnosis Meningitis. Encephalitis. Brain tumour or other intracranial space-occupying lesion. Investigations [ 8, 9 ] FBC: marked leukocytosis. Raised ESR and CRP. [patient.info]
He was irritable during handling, was hyperreflexic, had a bulging fontanelle, and was still under the sedative effects of anticonvulsants. [pediatrics.aappublications.org]
Cerebellar signs were elicited only in 40%. The most common source was untreated middle ear infection. Pus usually accumulates over the cerebellar convexity and is associated with hydrocephalus in 74% of patients. [ncbi.nlm.nih.gov]
This is particularly true in cases of infratentorial subdural empyema that occurs infrequently, but that is easily suspected if cerebellar signs such as ataxia and nystagmus are present ( 27 ). [oncohemakey.com]
Physical examination Remarkable findings on the neurologic exam include aphasia, contralateral motor deficits, gait ataxia, and possibly palsies of the oculomotor, trigeminal, and abducens cranial nerves. [symptoma.com]
When evaluating an individual with a clinical picture suggestive of subdural empyema, the medical team should obtain a detailed history including any recent infections such as sinusitis, otitis media, respiratory infection, meningitis, or sinus/cranial surgery. Very importantly, a thorough physical exam must be performed. Finally, diagnostic studies are a crucial component of the workup.
Critical studies include a complete blood count (CBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) , a complete metabolic panel (CMP), and blood cultures.
Magnetic Resonance Imaging (MRI) with gadolinium enhancement is the preferred diagnostic study  . The hallmark feature of subdural empyema on MRI is the appearance of a fluid collection surrounded by an enhanced rim. Moreover, MRI with diffusion-weighted imaging will provide information about intra-axial lesions . Overall, MRI is more sensitive than computed tomography (CT) for sinogenic intracranial infections .
Historically, CT testing has been considered important for the diagnosis of subdural empyema  and is the test of choice in patients with contraindications to MRI, those who are critically ill, or if MRI is not available or possible . CT scan displays subdural empyema as a hypodense region. While nonenhanced CT is insensitive, contrast-enhanced CT improves the diagnostic accuracy.
Other imaging techniques that may be used include cranial ultrasound, radionuclide brain scan, and angiography.
We report a clinical case of meningoencephalitis with subdural empyema in an immunocompromised farmer caused by toxigenic Clostridium perfringens type A, which was identified by 16S RNA gene analysis of cerebrospinal fluid and subdural empyema. [ncbi.nlm.nih.gov]
The sequences of the PCR products (465 and 468 bp, respectively) showed 100% identity to the 16S rRNA gene of Clostridium perfringens. [jcm.asm.org]
Blood Culture Positive
Pus culture was positive in four and blood culture positive in two cases. There was only a single mortality in our series. The outcome was assessed by the Glasgow Outcome Scale. [ncbi.nlm.nih.gov]
Mycoplasma hominis is a commensal of the genitourinary tract, which is infrequently associated with urogenital infections. Extra-urogenital infections due to M. hominis are rare. [ncbi.nlm.nih.gov]
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