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.