day, with recovery of 15 ml of dark, bloody, purulent fluid from each side, in which Gram-positive cocci were seen. Increasing
Subdural Empyema in an Infant Due to Group B \g=b\-Hemolytic
Streptococcus
Subdural empyema is a rare infection in children, and its association with group B Streptococcus has not been previously reported. This case is of further interest in that the pathogenesis is best explained by hematogenous infection of subdural hemato-
Report of a Case.\p=m-\A4-month-old male infant born at 36 weeks' gestation had normal development until one day prior to admission to hospital, when fever, irritability, and poor feeding developed. A gradual increase in head size had been noted. The temperature was 39.7 C; head circumference, 45 cm (> 97th percentile); and height, 60 cm (tenth percentile). The fontanelle was full and tense, with slight separation of the sutures and right occipital flattening. Transillumination of the skull was normal. Fundi were normal. Nuchal rigidity was present with positive Kernig and Brudzinski signs. Deep tendon reflexes were symmetrical and slightly increased. There was no evidence of sensory or motor dysfunction. Laboratory data disclosed the following levels: hemoglobin, 7.1 gm/100 ml; WBC count, 4,700/cu mm, with 10% polymorphonuclear leuko¬ cytes, 1% band cells, 82% lymphocytes, 7% monocytes. The red blood cells were micro-
cytic
and
hypochromic. Skull roentgeno¬
gram showed a slight separation of the sutures with an intact cranial vault and no calcifications. The paranasal sinuses were unremarkable. A lumbar puncture was initially traumatic. The protein concentra¬ tion was 7,000 mg/ml, and the glucose, 8,800 mg/ml. The fluid contained 2,160 red blood cells and 70 white blood cells per cubic millimeter, with 92% lymphocytes. Six hours later, a second lumbar puncture showed 5,800 mg/ml of glucose, 150 red blood cells, and 690 white cells per cubic millimeter with 77% lymphocytes. Grampositive cocci were seen in both spec¬ imens. The patient was initially treated with intravenous potassium penicillin G ther¬ apy, 400,000 u/kg/day, and chloramphenicol, 100 mg/kg/day. The following day, /?-hemolytic streptococci were reported in the blood and spinal fluid cultures, and the chloramphenicol was discontinued. The organism was identified as group /8-hemolytic Streptococcus type I-B. Clinical deterioration led to bilateral subdural aspirations on the third hospital
intracranial pressure with a decrease in pulse and respirations required resuscita¬ tion and assisted ventilation. Burr holes were made bilaterally in the frontal bone, and external drains were left in place. No membranes were noted and no organisms were isolated from this fluid. On the fifth hospital day, the fontanelles appeared full but not tense, and bilateral aspirations yielded 10 to 15 ml of xanthochromic fluid per side. Five milliliters of air were injected subdurally at this time and a right-sided brachial angiogram was per¬ formed, revealing a shift of the midline vessels to the right. A biparietal craniotomy was performed, during which bilat¬ eral subdural empyemas with loculated adhesions were found. On the 27th hospital day, a left carotid angiogram revealed displacement of ante¬ rior cerebral vessels posteriorly. A locu¬ lated subdural abscess was found at surgery, which was removed along with surrounding membranes. Low-grade fever persisted for one day, and subsequently the patient remained afebrile.
the lack of his¬
Comment.—Despite
tory of trauma or evidence of fracture,
believe that the subdural empyema in our patient was the result of an infected subdural hematoma. There was old blood in the subdural space, although membranes were not noted, and a moderately severe, hypochromic, microcytic anemia was present. The bacteriology of subdural em¬ pyema is related to its pathogenesis. Since these are most often related to paranasal and otic infections, nonhemolytic, viridans, and anaerobic strep¬ tococci predominate.' Group A strep¬ tococci are uncommon, and group organisms have not been identified, although they may have been over¬ looked prior to the availability of serotyping. When empyemas are asso¬ ciated with meningitis, Haemophilus influenzae and pneumococci are the usual etiologic agents. Our patient had blood and cerebrospinal fluid cultures that grew group streptococci. However, the cerebrospinal fluid was not typical of early pyogenic meningitis, and there was evidence of cranial enlargement de¬ veloping prior to hospital admission. While subdural effusion, rarely hem¬ orrhagic, may be associated with purulent meningitis, the data are more consistent with seeding of the subdural space and meninges or secondary infection of the meninges from the preexisting subdural em¬ pyemas. we
-
Downloaded From: http://archpedi.jamanetwork.com/ by a Michigan State University User on 06/11/2015
In addition to the extensive de¬
scriptions of septicemia and menin¬ gitis in the neonatal period, the spec¬ trum of infections due to group
has recently expanded to include focal lesions such as arthritis,
streptococci
osteomyelitis, cellulitis, ethmoiditis, and empyema, usually concomitant with a generalized infection.' To our knowledge, hemorrhagic effusions
have not been associated with group streptococcal meningitis. It is of interest that type I- is rarely asso¬ ciated with late-onset meningitis in
early infancy.4
LAWRENCE FERGUSON, MD SAMUEL P. GOTOFF, MD Departments of Surgery and Pediatrics Michael Reese Hospital and Medical Center 29th St and Ellis Ave Chicago, IL 60616
1. Coonrod JD, Dans PE: Subdural empyema. Am J Med 53:85-91, 1972. 2. Kaufman DM, Miller MH, Steigbigel NH: Subdural empyema: Analysis of 17 recent cases and review of the literature. Medicine 54:485-498, 1975. 3. Howard JB, McCracken GH: The spectrum of group B streptococcal infections in infancy. Am J Dis Child 128:815-818, 1974. 4. Baker CJ, Barrett FF, Gordon RC, et al: Suppurative meningitis due to streptococci of Lancefield group B: A study of 33 infants. J Pediatr 82:724-729, 1973.
Pseudogoiter A young girl had a nodular goiter that was thought to represent malignant thyroid disease. However, the lesion proved to be a congenital cyst arising from the respiratory tract. Although such lesions have been described, they have never been
reported
abnormal
to
present
as
thyroid tissue.
suspected
Report of a Case.\p=m-\Agirl, aged 3 years and 2 months, was well until seven months prior to admission to Childrens Hospital of Columbus, Ohio. At that time the mother first noticed a swelling of the left side of her neck. During the next seven months no appreciable change in the size or consistency of the mass was noted by the family physician or the mother. There were no symptoms of thyroid malfunctions. Physical examination showed a normalappearing, pleasant 3-year-old girl. The only abnormal finding was a diffuse nodular enlargement of the entire left lobe and isthmus of the thyroid. The mass moved with swallowing. The serum protein-bound iodine level was 5.6 \g=m\g/100 ml, and serum thyroxine level by column chro-
Subdural Empyema in an Infant Due to Group B \g=b\-Hemolytic
Streptococcus
Subdural empyema is a rare infection in children, and its association with group B Streptococcus has not been previously reported. This case is of further interest in that the pathogenesis is best explained by hematogenous infection of subdural hemato-
Report of a Case.\p=m-\A4-month-old male infant born at 36 weeks' gestation had normal development until one day prior to admission to hospital, when fever, irritability, and poor feeding developed. A gradual increase in head size had been noted. The temperature was 39.7 C; head circumference, 45 cm (> 97th percentile); and height, 60 cm (tenth percentile). The fontanelle was full and tense, with slight separation of the sutures and right occipital flattening. Transillumination of the skull was normal. Fundi were normal. Nuchal rigidity was present with positive Kernig and Brudzinski signs. Deep tendon reflexes were symmetrical and slightly increased. There was no evidence of sensory or motor dysfunction. Laboratory data disclosed the following levels: hemoglobin, 7.1 gm/100 ml; WBC count, 4,700/cu mm, with 10% polymorphonuclear leuko¬ cytes, 1% band cells, 82% lymphocytes, 7% monocytes. The red blood cells were micro-
cytic
and
hypochromic. Skull roentgeno¬
gram showed a slight separation of the sutures with an intact cranial vault and no calcifications. The paranasal sinuses were unremarkable. A lumbar puncture was initially traumatic. The protein concentra¬ tion was 7,000 mg/ml, and the glucose, 8,800 mg/ml. The fluid contained 2,160 red blood cells and 70 white blood cells per cubic millimeter, with 92% lymphocytes. Six hours later, a second lumbar puncture showed 5,800 mg/ml of glucose, 150 red blood cells, and 690 white cells per cubic millimeter with 77% lymphocytes. Grampositive cocci were seen in both spec¬ imens. The patient was initially treated with intravenous potassium penicillin G ther¬ apy, 400,000 u/kg/day, and chloramphenicol, 100 mg/kg/day. The following day, /?-hemolytic streptococci were reported in the blood and spinal fluid cultures, and the chloramphenicol was discontinued. The organism was identified as group /8-hemolytic Streptococcus type I-B. Clinical deterioration led to bilateral subdural aspirations on the third hospital
intracranial pressure with a decrease in pulse and respirations required resuscita¬ tion and assisted ventilation. Burr holes were made bilaterally in the frontal bone, and external drains were left in place. No membranes were noted and no organisms were isolated from this fluid. On the fifth hospital day, the fontanelles appeared full but not tense, and bilateral aspirations yielded 10 to 15 ml of xanthochromic fluid per side. Five milliliters of air were injected subdurally at this time and a right-sided brachial angiogram was per¬ formed, revealing a shift of the midline vessels to the right. A biparietal craniotomy was performed, during which bilat¬ eral subdural empyemas with loculated adhesions were found. On the 27th hospital day, a left carotid angiogram revealed displacement of ante¬ rior cerebral vessels posteriorly. A locu¬ lated subdural abscess was found at surgery, which was removed along with surrounding membranes. Low-grade fever persisted for one day, and subsequently the patient remained afebrile.
the lack of his¬
Comment.—Despite
tory of trauma or evidence of fracture,
believe that the subdural empyema in our patient was the result of an infected subdural hematoma. There was old blood in the subdural space, although membranes were not noted, and a moderately severe, hypochromic, microcytic anemia was present. The bacteriology of subdural em¬ pyema is related to its pathogenesis. Since these are most often related to paranasal and otic infections, nonhemolytic, viridans, and anaerobic strep¬ tococci predominate.' Group A strep¬ tococci are uncommon, and group organisms have not been identified, although they may have been over¬ looked prior to the availability of serotyping. When empyemas are asso¬ ciated with meningitis, Haemophilus influenzae and pneumococci are the usual etiologic agents. Our patient had blood and cerebrospinal fluid cultures that grew group streptococci. However, the cerebrospinal fluid was not typical of early pyogenic meningitis, and there was evidence of cranial enlargement de¬ veloping prior to hospital admission. While subdural effusion, rarely hem¬ orrhagic, may be associated with purulent meningitis, the data are more consistent with seeding of the subdural space and meninges or secondary infection of the meninges from the preexisting subdural em¬ pyemas. we
-
Downloaded From: http://archpedi.jamanetwork.com/ by a Michigan State University User on 06/11/2015
In addition to the extensive de¬
scriptions of septicemia and menin¬ gitis in the neonatal period, the spec¬ trum of infections due to group
has recently expanded to include focal lesions such as arthritis,
streptococci
osteomyelitis, cellulitis, ethmoiditis, and empyema, usually concomitant with a generalized infection.' To our knowledge, hemorrhagic effusions
have not been associated with group streptococcal meningitis. It is of interest that type I- is rarely asso¬ ciated with late-onset meningitis in
early infancy.4
LAWRENCE FERGUSON, MD SAMUEL P. GOTOFF, MD Departments of Surgery and Pediatrics Michael Reese Hospital and Medical Center 29th St and Ellis Ave Chicago, IL 60616
1. Coonrod JD, Dans PE: Subdural empyema. Am J Med 53:85-91, 1972. 2. Kaufman DM, Miller MH, Steigbigel NH: Subdural empyema: Analysis of 17 recent cases and review of the literature. Medicine 54:485-498, 1975. 3. Howard JB, McCracken GH: The spectrum of group B streptococcal infections in infancy. Am J Dis Child 128:815-818, 1974. 4. Baker CJ, Barrett FF, Gordon RC, et al: Suppurative meningitis due to streptococci of Lancefield group B: A study of 33 infants. J Pediatr 82:724-729, 1973.
Pseudogoiter A young girl had a nodular goiter that was thought to represent malignant thyroid disease. However, the lesion proved to be a congenital cyst arising from the respiratory tract. Although such lesions have been described, they have never been
reported
abnormal
to
present
as
thyroid tissue.
suspected
Report of a Case.\p=m-\Agirl, aged 3 years and 2 months, was well until seven months prior to admission to Childrens Hospital of Columbus, Ohio. At that time the mother first noticed a swelling of the left side of her neck. During the next seven months no appreciable change in the size or consistency of the mass was noted by the family physician or the mother. There were no symptoms of thyroid malfunctions. Physical examination showed a normalappearing, pleasant 3-year-old girl. The only abnormal finding was a diffuse nodular enlargement of the entire left lobe and isthmus of the thyroid. The mass moved with swallowing. The serum protein-bound iodine level was 5.6 \g=m\g/100 ml, and serum thyroxine level by column chro-
