BAYERS INDIA LTD
Dr. K. K. Pateria, MD
National Hospital, Bhopal
High grade fever with chills and rigors - 2 months
Severe headache - 2 months
Vomiting off and on - 2 months
Altered sensorium - 3-4 days
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.
Complaints on admission
Vomiting, pain in abdomen, poor intake
Along with altered sensorium
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
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.
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
Investigations : Contd…
MRI Brain : - Large Right temporoparietal subdural
- Significant surrounding mass effect
- Trans-tentorial herniation
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
4. In meningitis – No focal deficit usually.
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
ETIOLOGY - SDE
- Aerobic or anaerobic bacteria
- Staph, Strepto or enterococci
- Anaerobic bacteria – most common in SDE associated
PATHOPHYSIOLOGY - SDE
a). Retrograde – Sinusitis related SDE spreads from
septic thrombophlebitis of mucosal veins
b). Contiguous – From osteomyelitis of posterior wall
of frontal and other sinuses
c). Direct – Due to neurosurgery
- Epidural empyema (40 %)
- Cortical thrombophlebitis (35 %)
- Cerebritis (25 %)
1. Increasing headache and fever
2. Focal neurological deficit
3. Seizures, partial motor becoming secondary
4. Nuchal rigidity
5. Signs of raised ICP
6. Contra lateral hemiplegia – most common deficit, direct
or due to venous infarct
TREATMENT - SDE
1. Neurosurgical evacuation
• Empirical antibiotic treatment – Vancomycin, 3rd gen.
3. Specific antibiotic – according to c/s.
4. Duration of treatment – 4 weeks of parenteral antibiotic
Depends on –
1. Level of consciousness on admission
Long term Neurological Sequele –
1. Seizures and hemiparesis in 50 %