American Journal of Emergency Medicine xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Subdural empyema with pneumocephaly from acute mastoiditis in a healthy adult: a rare complication of a rare disease☆,☆☆,★ Mastoiditis is a rare but serious complication of otitis media. As otitis media is largely a disease of childhood, most of what is known about mastoiditis and other uncommon pyogenic complications of otitis media are extrapolated from pediatric populations. Even more rare than mastoiditis, intracranial extension of otogenic infection represents the most serious complication, necessitating emergent operative therapy. Most commonly, a history of chronic ear infection or recent skull trauma or surgery is the proximate cause of intracranial empyema. Proper management requires emergent surgical drainage and appropriate antibiotic therapy. We report a case of a healthy immunocompetent male who had only a 2-day bout of ear pain before presenting to the emergency department with altered mental status. Computed tomography revealed not only acute coalescent mastoiditis but also subdural empyema and pneumocephalus. Prompt surgical intervention, including hemicraniectomy, led to a favorable outcome. Clinicians should be aware that subdural empyema may present as a sudden alteration in mental status even in immunocompetent patients with minimal prodromal symptoms. Subdural empyema is an uncommon entity in modern emergency medicine practice and particularly rare in immunocompetent patients. We report a case of a previously healthy 45-year-old man who presented afebrile but with severely altered mental status, which proved to be an intracranial complication of suppurative mastoiditis. The patient presented via emergency medical services with the chief complaint of headache of less than 12 hours duration and an acutely altered mental status with severe agitation. The wife related that the patient had complained of an ear ache for approximately 48 hours, subjective fever for 1 day, and altered mental status that was noted only upon awakening in the last hour. The patient had taken a single dose of amoxicillin-clavulanate 1 day previously and had used ofloxacin ear drops one day before that but was on no other meds; he was not diabetic or immunocompromised in any way. The patient was afebrile with normal vital signs. He was globally disoriented and severely agitated but nonverbal. Examination of the left ear revealed a bulging, injected tympanic membrane. No mastoid tenderness was noted, although severe agitation and disorientation made complete evaluation problematic. There was no cervical adenopathy and no focal neurologic signs were evident. Laboratory findings were remarkable for a lactate of 4.5 mmol/L and a white blood cell count of 20.7 K/uL with 90% polys. Head computed tomography after mild sedation demonstrated a “left mastoiditis with tegmen dehiscence, a left sided subdural collection and multiple small foci of air, as well as a 7 mm rightward midline shift” (Figure). After intubation, antibiotic therapy with vancomycin and ☆ No reprints. ☆☆ No conflicts of interest. ★ No funding.
ceftriaxone and the administration of 10-mg dexamethasone, he received prompt neurosurgical intervention. A left-sided hemicraniectomy revealed copious purulent material under pressure, which was evacuated. Rare gram-negative rods were noted on gram stain, but there was no growth on culture. The postoperative course was one of gradual improvement over a 2-week period; a right upper extremity weakness resolved, and the mental status gradually returned to normal. Recent reviews [1,2] of subdural empyema covering 15 years and 10 years, respectively, emphasize the rarity of the condition and note that otogenic infection is the third most common cause (14%), after neurosurgical procedures (44%) and sinusitis (28%). Historically, the mortality rate from subdural empyema has ranged from 15% to 41%. In recent decades, computed tomography and magnetic resonance imaging have helped to decrease mortality rate, with recent studies suggesting mortality varying between 6% and 15% [3]. Significant morbidity continues to occur with 12% to 37.5% having persistent seizures. Other neurologic deficits occur in up to 50% of survivors with 15% to 35% reported to have hemiparesis. Current reviews of mastoiditis as a complication of otitis media in adults agree that this complication is seen in less than 0.5% of cases [4,5]; the true number is undoubtedly much less. Pneumocephaly has rarely been reported as a complication of acute mastoiditis in adults [6]. Our case demonstrates this finding (Figure). The bacteriology of subdural empyema is variable and includes gram-negative organisms such as Escherichia coli, but Streptococcus pneumoniae has been identified as the predominant causative organism [7]. It is unclear why the gramnegative bacilli noted on our patient’s gram stain did not grow on culture. Although mastoiditis is a recognized cause of subdural empyema, both entities are extremely rare, especially in modern adult emergency practice and have received little attention in recent years. Our case demonstrates not only that both entities should be considered by the emergency practitioner but also that the presentation may be hyperacute and life threatening with urgent surgical intervention mandatory. Zhou Zhang MD Jessica Fleisher-Black MD Daniel Goldstein MD Christine Preblick MD Michael Heller MD ⁎ Department of Emergency Medicine, Mt. Sinai Beth Israel Medical Center, New York, NY ⁎ Corresponding author.
http://dx.doi.org/10.1016/j.ajem.2015.01.016
0735-6757/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Zhang Z, et al, Subdural empyema with pneumocephaly from acute mastoiditis in a healthy adult: a rare complication of a rare disease, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.01.016
2
Z. Zhang et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx
Figure. Left, computed tomography demonstrates subdural empyema with pneumocephalus (arrows). Right, computed tomography demonstrates left-sided opacification of mastoid air cells and intracranial extension (arrow).
References [1] Yildirmak T, Gedik H, Simsek F, Kanturk A. Community-acquired intracranial suppurative infections: A 15-year report. Surg Neurol Int 2014;5:142. [2] French H, Schaefer N, Keijzers G, Barison D, Olson S. Intracranial subdural empyema. A 10 year study. Oschner J 2014;14(2):188–94. [3] Bruner D, Littlejohn L, Pritchard A. Subdural empyema presenting with seizure, confusion, and focal weakness. West J Emerg Med 2012;13(6):509–11.
[4] Hafidh M, Keogh I, Walsh RM, Walsh M, Rawluk D. Otogenic intracranial complications. A 7-year retrospective review. Am J Otolaryngol 2006;27:390–5. [5] Leskinen K, Jero J. Acute complications of otitis media in adults. Clin Otolaryngol 2005;30:511–6. [6] Laupland KB, Bosch JD. Acute group A streptococcal mastoiditis complicated by pneumocephaly in a previously healthy adult. Scand J Infect Dis 2006;38(8):719–21. [7] Jim KK, Brouwer MC, Ende A, Beek D. Subdural empyema in bacterial meningitis. Neurology 2012;79(21):2133–9.
Please cite this article as: Zhang Z, et al, Subdural empyema with pneumocephaly from acute mastoiditis in a healthy adult: a rare complication of a rare disease, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.01.016
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Subdural empyema with pneumocephaly from acute mastoiditis in a healthy adult: a rare complication of a rare disease☆,☆☆,★ Mastoiditis is a rare but serious complication of otitis media. As otitis media is largely a disease of childhood, most of what is known about mastoiditis and other uncommon pyogenic complications of otitis media are extrapolated from pediatric populations. Even more rare than mastoiditis, intracranial extension of otogenic infection represents the most serious complication, necessitating emergent operative therapy. Most commonly, a history of chronic ear infection or recent skull trauma or surgery is the proximate cause of intracranial empyema. Proper management requires emergent surgical drainage and appropriate antibiotic therapy. We report a case of a healthy immunocompetent male who had only a 2-day bout of ear pain before presenting to the emergency department with altered mental status. Computed tomography revealed not only acute coalescent mastoiditis but also subdural empyema and pneumocephalus. Prompt surgical intervention, including hemicraniectomy, led to a favorable outcome. Clinicians should be aware that subdural empyema may present as a sudden alteration in mental status even in immunocompetent patients with minimal prodromal symptoms. Subdural empyema is an uncommon entity in modern emergency medicine practice and particularly rare in immunocompetent patients. We report a case of a previously healthy 45-year-old man who presented afebrile but with severely altered mental status, which proved to be an intracranial complication of suppurative mastoiditis. The patient presented via emergency medical services with the chief complaint of headache of less than 12 hours duration and an acutely altered mental status with severe agitation. The wife related that the patient had complained of an ear ache for approximately 48 hours, subjective fever for 1 day, and altered mental status that was noted only upon awakening in the last hour. The patient had taken a single dose of amoxicillin-clavulanate 1 day previously and had used ofloxacin ear drops one day before that but was on no other meds; he was not diabetic or immunocompromised in any way. The patient was afebrile with normal vital signs. He was globally disoriented and severely agitated but nonverbal. Examination of the left ear revealed a bulging, injected tympanic membrane. No mastoid tenderness was noted, although severe agitation and disorientation made complete evaluation problematic. There was no cervical adenopathy and no focal neurologic signs were evident. Laboratory findings were remarkable for a lactate of 4.5 mmol/L and a white blood cell count of 20.7 K/uL with 90% polys. Head computed tomography after mild sedation demonstrated a “left mastoiditis with tegmen dehiscence, a left sided subdural collection and multiple small foci of air, as well as a 7 mm rightward midline shift” (Figure). After intubation, antibiotic therapy with vancomycin and ☆ No reprints. ☆☆ No conflicts of interest. ★ No funding.
ceftriaxone and the administration of 10-mg dexamethasone, he received prompt neurosurgical intervention. A left-sided hemicraniectomy revealed copious purulent material under pressure, which was evacuated. Rare gram-negative rods were noted on gram stain, but there was no growth on culture. The postoperative course was one of gradual improvement over a 2-week period; a right upper extremity weakness resolved, and the mental status gradually returned to normal. Recent reviews [1,2] of subdural empyema covering 15 years and 10 years, respectively, emphasize the rarity of the condition and note that otogenic infection is the third most common cause (14%), after neurosurgical procedures (44%) and sinusitis (28%). Historically, the mortality rate from subdural empyema has ranged from 15% to 41%. In recent decades, computed tomography and magnetic resonance imaging have helped to decrease mortality rate, with recent studies suggesting mortality varying between 6% and 15% [3]. Significant morbidity continues to occur with 12% to 37.5% having persistent seizures. Other neurologic deficits occur in up to 50% of survivors with 15% to 35% reported to have hemiparesis. Current reviews of mastoiditis as a complication of otitis media in adults agree that this complication is seen in less than 0.5% of cases [4,5]; the true number is undoubtedly much less. Pneumocephaly has rarely been reported as a complication of acute mastoiditis in adults [6]. Our case demonstrates this finding (Figure). The bacteriology of subdural empyema is variable and includes gram-negative organisms such as Escherichia coli, but Streptococcus pneumoniae has been identified as the predominant causative organism [7]. It is unclear why the gramnegative bacilli noted on our patient’s gram stain did not grow on culture. Although mastoiditis is a recognized cause of subdural empyema, both entities are extremely rare, especially in modern adult emergency practice and have received little attention in recent years. Our case demonstrates not only that both entities should be considered by the emergency practitioner but also that the presentation may be hyperacute and life threatening with urgent surgical intervention mandatory. Zhou Zhang MD Jessica Fleisher-Black MD Daniel Goldstein MD Christine Preblick MD Michael Heller MD ⁎ Department of Emergency Medicine, Mt. Sinai Beth Israel Medical Center, New York, NY ⁎ Corresponding author.
http://dx.doi.org/10.1016/j.ajem.2015.01.016
0735-6757/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Zhang Z, et al, Subdural empyema with pneumocephaly from acute mastoiditis in a healthy adult: a rare complication of a rare disease, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.01.016
2
Z. Zhang et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx
Figure. Left, computed tomography demonstrates subdural empyema with pneumocephalus (arrows). Right, computed tomography demonstrates left-sided opacification of mastoid air cells and intracranial extension (arrow).
References [1] Yildirmak T, Gedik H, Simsek F, Kanturk A. Community-acquired intracranial suppurative infections: A 15-year report. Surg Neurol Int 2014;5:142. [2] French H, Schaefer N, Keijzers G, Barison D, Olson S. Intracranial subdural empyema. A 10 year study. Oschner J 2014;14(2):188–94. [3] Bruner D, Littlejohn L, Pritchard A. Subdural empyema presenting with seizure, confusion, and focal weakness. West J Emerg Med 2012;13(6):509–11.
[4] Hafidh M, Keogh I, Walsh RM, Walsh M, Rawluk D. Otogenic intracranial complications. A 7-year retrospective review. Am J Otolaryngol 2006;27:390–5. [5] Leskinen K, Jero J. Acute complications of otitis media in adults. Clin Otolaryngol 2005;30:511–6. [6] Laupland KB, Bosch JD. Acute group A streptococcal mastoiditis complicated by pneumocephaly in a previously healthy adult. Scand J Infect Dis 2006;38(8):719–21. [7] Jim KK, Brouwer MC, Ende A, Beek D. Subdural empyema in bacterial meningitis. Neurology 2012;79(21):2133–9.
Please cite this article as: Zhang Z, et al, Subdural empyema with pneumocephaly from acute mastoiditis in a healthy adult: a rare complication of a rare disease, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.01.016
