Case Presentation
An 8 years old female patient presented with the complaint of right ear purulent discharge and right post auricular swelling of two weeks and intermittent high grade fever and altered mental status of 3 days duration prior to admission. She had history of recurrent purulent discharge from right ear for almost 2 years. Consequently, her parents brought her to pediatric hospital and was referred to the ENT department. She was diagnosed chronic otitis media for which she was given amoxicillin syrup for 7 days and was told to return after 3 months for surgery.
On physical examination, she was confused with a GCS of 13/15. She was tachycardic and febrile otherwise the other vital signs were within the normal range. She had purulent foul smelling discharge from the right ear. There was a 3cm by 4cm swelling in the postauricular area which was erythematous and a 0.5cm by 0.4 cm opening with a serosanguinous discharge over the most fluctuant part of the swelling. She was admitted to the Pediatric ICU with the diagnosis of right ear chronic suppurative otitis media, acute mastoiditis, and right post-auricular subperiostial abscess. She was started on empiric antibiotics: metronidazole (7.5mg/Kg IV q8hrs) and ceftriaxone (50mg/Kg IV q12hrs). Five hours following her admission, her GCS lowered to 10/15 and 12 hours later to 6/15. Thus a diagnosis of brain abscess was entertained. On the 3rdday of her admission, her GCS was 3/15 and her right pupil was dilated and nonreactive to light while the left was midway dilated with sluggish reaction to light. Full blood count was done and revealed Hgb of 6g/dL, WBC-22.3x103 /micL and 80.8% Neutrophils. She was transfused with 2 units of blood (PRBC). Up on her admission to the Pediatric ICU, despite the patient’s altered level of consciousness, lumbar puncture was decided to be necessary. Even though, the patient had altered level of consciousness, she had none of the lateralizing signs (no signs of focal neurological deficit) nor did she have any of the Cushing’s triad (an increased systolic blood pressure, bradycardia, and an abnormal respiratory pattern) that indicate the possibility of an increased intracranial pressure. And during her arrival, MRI/CT scan could not be done nor were there any other ways the intracranial pressure could be measured. Moreover, as the patient had nuchal rigidity during admission along with the altered mental status, meningoencephalitis was one of the top differentials. These were the reasons LP had to be done in the presence of altered level of consciousness, before the patient was started on any antibiotics. CSF analysis was normal with no blood cells or organisms present under microscopic analysis, a glucose level of 65mg/dL and a total protein level of 0.2g/L. Culture of the pus taken from the right ear and the right postauricular area had no growth; thus she continued her treatment with Metronidazole and Ceftriaxone. MRI was done on day three of her admission and showed right fronto-tempo-parietal subdural empyema with mass effect, effacing the adjacent cortical sulci and compressing the right lateral ventricle, shifting the midline to the left. On the neurosurgical team were consulted and they decided to do an emergency craniotomy. In the OR an estimated amount of 30ml of pus was removed from the subdural space. Incision and drainage of the post auricular subperiostial abscess was also done intraoperatively. Vancomycin (15mg/Kg IV q6hrs) and Chloramphenicol ear drops were added to her antibiotic regimen for 14 days. Preoperatively she was also given mannitol to lower the intracranial pressure until the surgical intervention was done. The patient showed marked improvement post-operatively. She became fully conscious with GCS 15/15 and was communicating well by post-op day 4.