From Pansinusitis to Cerebritis Due to Eikenella corrodens

Abstract

Meningitis is a rare but possible complication of sinusitis. We present a case of a 21-year-old woman with a history of fever, headache and nasal obstruction who presented at the emergency department with psychomotor agitation. Orotracheal intubation and invasive mechanical ventilation were given to protect airway. Blood analysis showed leukocytosis and elevated C-reactive protein. Cerebral and maxillofacial computed tomography (CT) demonstrated pansinusitis with gas foci more prominent in the left frontal sinus with an area of ​​bone rarefaction on the posterior wall with possible communication with the cranial cavity. Lumbar puncture was performed. Empirical antibiotic and corticosteroid therapy were started. Neurosurgery (NC) and Ear Nose and Throat (ENT) surgeons declined indication for urgent surgery and she was admitted at General ICU. On the fourth day of hospitalization, a brain magnetic resonance imaging (CE-MRI) was performed, revealing subdural empyema and cerebritis adjacent to the frontal sinus. She was transferred to the reference neurosurgical center for surgical interventions and was admitted post-operatively at the Neurocritical Care Unit (NCCU). Reevaluation MRI showed residual anterior frontal empyema and absence of focus control in peri-nasal sinusitis, requiring a new ENT surgery. A Streptococcus spp was isolated from the blood, Eikenella corrodens from the pus collected from the sinuses, and the CSF was sterile. The patient completed 21 days of antibiotic therapy. She was extubated on the 19th day, with Broca's aphasia and right hemiparesis, and on the 23rd day transferred to the ENT Service and later to the Rehabilitation Service. We present a case of atypical central nervous system (CNS) infection by a rare agent, highlighting the importance of vigilance, focus control, and neurocritical care. In a severe and complex manifestation like this, the management typically involves medical and surgical interventions. Subdural empyema should be treated as a neurosurgical emergency due to the potential rapid deterioration in patient's neurological condition, attributed to secondary damage. In this case, brain multimodal monitoring, was very helpful in acute phase management. Neurocritical care teams should be involved early in patients with this presentation of CNS infection to provide optimal management, reducing complications and secondary brain lesions therefore improving patient outcomes.