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  • 1. PHYSICIANS’ FORUM SPONSORED BY BAYERS INDIA LTD 25TH Nov.2008 Case Review by Dr. K. K. Pateria, MD National Hospital, Bhopal
  • 2. History High grade fever with chills and rigors - 2 months Severe headache - 2 months Vomiting off and on - 2 months Altered sensorium - 3-4 days
  • 3. Presenting history Took anti-malarials and remained afebrile for 2 days. Again had fever with chills – took some treatment, details not available, but developed vomiting and fever. Admitted in Hoshangabad in hospital for 20 days and had GTCS and unconsciousness on 4th day of admission. Details of treatment and investigations not available, though CT was also done. Hospitalised in PG hospital, Karond for 9 days but with no relief. Took DOR. Details of treatment not available. Had Low grade fever, vomiting, GTCS 3 times followed by post ictal phase lasting 30 min.
  • 4. Complaints on admission Vomiting, pain in abdomen, poor intake Along with altered sensorium
  • 5. Examination : O/E : P = 76/min, R = 16/min, BP = 80/60 mm of Hg, Afebrile. Mild pallor, No icterus, clubbing or edema. No lymphadenopathy, Mild dehydration +. CVS : Normal RS : Normal P/A : Normal
  • 6. Exam : CNS Conscious slightly altered. Pupils – BPNERL NR – +/- Moving all 4 limbs Power grade IV-V. Slight left side lateral rectus palsy. Planters – B/L Flexor.
  • 7. Investigations : 1. CBP : Hb = 13.1 g% : WBC = 15000/cumm P82 L14 E03 M01 4. ESR = 27 mm FHR 5. PS for MP = Negative 4. Malaria Antigen = Negative 7. Widal = Negative 8. LFT = Normal 9. RFT = Normal 8. Coagulation profile = Normal
  • 8. Investigations : Contd… 1. ADA = 26.3 U/L 2. HIV I & II = Negative 3. Urine R/M = 2-4 pc/hpf, otherwise normal
  • 9. Investigations : Contd… 1. CXR = Normal 13. USG Abd. & Pelvis = Normal 3. Fundus examination = bilateral papilloedema with mild optic atrophy.
  • 10. ??? ?
  • 11. Possibilities ? 1. Bacterial/tubercular Meningitis 2. Encephalitis 3. Brain abscess 4. Subdural Hematoma 5. Superior Saggital thrombosis 6. Disseminated encephalomyelitis 7. Tuberculoma 8. SOL
  • 12. Investigations : Contd… 1. CSF : Qty = 2 ml Color = Watery Appearance = Clear Coagulum = Not seen Blood = Absent Proteins = 17 mg % Pandy’s test= Negative Sugar = 61 mg % Cells = 05 / cumm, All mononuclear ADA = 4.6
  • 13. video • play
  • 14. Investigations : Contd… MRI Brain : - Large Right temporoparietal subdural empyema - Significant surrounding mass effect - Trans-tentorial herniation
  • 15. Diagnosis 1. Neuroimaging 2. MRI – better than CT in early stages, superior for abscess in posterior fossa. 3. Nuchal rigidity – unusual in abscess and epidural empyema, but if present suggest Subdural empyema (SDE). 4. In meningitis – No focal deficit usually.
  • 16. Discussion - SDE - Rare disorder - 15-20 % of suppurative CND infection - Sinusitis esp. frontal, most common predisposing factor, 1-2 % can complicating to SDE - Young male preponderance - 70 % occurring in 2 & 3rd decade of life - May be complication of head trauma, neurosurgery or subdural effusion
  • 17. ETIOLOGY - SDE - Aerobic or anaerobic bacteria - Staph, Strepto or enterococci - Anaerobic bacteria – most common in SDE associated with sinusitis
  • 18. PATHOPHYSIOLOGY - SDE 1. Spread a). Retrograde – Sinusitis related SDE spreads from septic thrombophlebitis of mucosal veins draining sinuses b). Contiguous – From osteomyelitis of posterior wall of frontal and other sinuses c). Direct – Due to neurosurgery 6. Association - Epidural empyema (40 %) - Cortical thrombophlebitis (35 %) - Cerebritis (25 %)
  • 19. CLINICAL PRESENTATION-SDE 1. Increasing headache and fever 2. Focal neurological deficit 3. Seizures, partial motor becoming secondary generalized 4. Nuchal rigidity 5. Signs of raised ICP 6. Contra lateral hemiplegia – most common deficit, direct or due to venous infarct
  • 20. TREATMENT - SDE 1. Neurosurgical evacuation • Empirical antibiotic treatment – Vancomycin, 3rd gen. Cephalosporin, Metronidazole. 3. Specific antibiotic – according to c/s. 4. Duration of treatment – 4 weeks of parenteral antibiotic treatment
  • 21. PROGNOSIS Depends on – 1. Level of consciousness on admission 2. Size Long term Neurological Sequele – 1. Seizures and hemiparesis in 50 %