PHYSICIANS’ FORUM
  SPONSORED BY
 BAYERS INDIA LTD
   25TH Nov.2008

       Case Review
             by
   Dr. K. K. Pater...
History
High grade fever with chills and rigors   - 2 months
Severe headache                           - 2 months
Vomiting...
Presenting history
Took anti-malarials and remained afebrile for 2 days.
Again had fever with chills – took some treatment...
Complaints on admission



Vomiting, pain in abdomen, poor intake
Along with altered sensorium
Examination :
O/E : P = 76/min, R = 16/min, BP = 80/60 mm of Hg,
      Afebrile. Mild pallor,
      No icterus, clubbing o...
Exam : CNS
Conscious slightly altered.
Pupils – BPNERL
NR – +/-
Moving all 4 limbs Power grade IV-V.
Slight left side late...
Investigations :
1.   CBP      : Hb         = 13.1 g%
              : WBC        = 15000/cumm
                            ...
Investigations : Contd…
1.   ADA          = 26.3 U/L
2.   HIV I & II          = Negative
3.   Urine R/M    = 2-4 pc/hpf, o...
Investigations : Contd…
1. CXR                  = Normal
13. USG Abd. & Pelvis   = Normal
3. Fundus examination   = bilate...
???




?
Possibilities ?
1.   Bacterial/tubercular Meningitis
2.   Encephalitis
3.   Brain abscess
4.   Subdural Hematoma
5.   Supe...
Investigations : Contd…
1. CSF : Qty        = 2 ml
         Color      = Watery
         Appearance       = Clear
        ...
video
• play
Investigations : Contd…
MRI Brain : -   Large Right temporoparietal subdural
                empyema
            -   Signi...
Diagnosis
1.   Neuroimaging
2.   MRI – better than CT in early stages, superior for
     abscess in posterior fossa.
3.   ...
Discussion - SDE
- Rare disorder
- 15-20 % of suppurative CND infection
- Sinusitis esp. frontal, most common predisposing...
ETIOLOGY - SDE
- Aerobic or anaerobic bacteria
- Staph, Strepto or enterococci
- Anaerobic bacteria – most common in SDE a...
PATHOPHYSIOLOGY - SDE
1.   Spread
       a).     Retrograde – Sinusitis related SDE spreads from
               septic thr...
CLINICAL PRESENTATION-SDE
1.   Increasing headache and fever
2.   Focal neurological deficit
3.   Seizures, partial motor ...
TREATMENT - SDE
1.   Neurosurgical evacuation
•    Empirical antibiotic treatment – Vancomycin, 3rd gen.
     Cephalospori...
PROGNOSIS
Depends on –
  1. Level of consciousness on admission
  2. Size

Long term Neurological Sequele –
  1. Seizures ...
physicians' forum bhopal
physicians' forum bhopal
physicians' forum bhopal
physicians' forum bhopal
physicians' forum bhopal
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physicians' forum bhopal

  1. 1. PHYSICIANS’ FORUM SPONSORED BY BAYERS INDIA LTD 25TH Nov.2008 Case Review by Dr. K. K. Pateria, MD National Hospital, Bhopal
  2. 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. 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. 4. Complaints on admission Vomiting, pain in abdomen, poor intake Along with altered sensorium
  5. 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. 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. 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. 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. 9. Investigations : Contd… 1. CXR = Normal 13. USG Abd. & Pelvis = Normal 3. Fundus examination = bilateral papilloedema with mild optic atrophy.
  10. 10. ??? ?
  11. 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. 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. 13. video • play
  14. 14. Investigations : Contd… MRI Brain : - Large Right temporoparietal subdural empyema - Significant surrounding mass effect - Trans-tentorial herniation
  15. 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. 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. 17. ETIOLOGY - SDE - Aerobic or anaerobic bacteria - Staph, Strepto or enterococci - Anaerobic bacteria – most common in SDE associated with sinusitis
  18. 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. 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. 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. 21. PROGNOSIS Depends on – 1. Level of consciousness on admission 2. Size Long term Neurological Sequele – 1. Seizures and hemiparesis in 50 %

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