Presentation
Headache for 10 days, fever for 3 days, and forehead swelling for 1 day.
Patient Data
- Near complete opacification of right frontal, ethmoid, and maxillary sinuses, consistent with sinusitis
- Forehead subperiosteal fluid collection
- Subdural fluid collection along the right frontotemporal convexity and parafalcine region/interhemispheric fissure, up to 6 mm thick
- No clear erosion of the anterior or posterior tables of the frontal sinus
- Mass effect with 6 mm leftward midline shift and effacement of the right lateral ventricle
- Orthodontic hardware related susceptibility artifact limits evaluation of the anterior cranial fossa and skull base on DWI and GRE sequences and also degrades the fluid suppression on FLAIR
- Subdural empyema, as evidenced by diffusion restricting fluid collection over the right frontotemporal convexity and along the falx cerebri
- Meningitis, as evidenced by diffusely increased leptomeningeal enhancement and areas of sulcal T2-FLAIR hyperintensity (allowing for CSF suppression failure in the anterior cranial vault)
- Early cerebritis, as evidenced by right anterior frontal lobe gyral swelling and T2 prolongation in the white matter
- Mass effect with 6 mm leftward midline shift and effacement of the right lateral ventricle
Case Discussion
The patient had right frontal sinusitis complicated by subperiosteal abscess (Pott puffy tumor) and intracranial infection, including evidence of subdural empyema, meningitis, and early cerebritis. The patient was placed on broad-spectrum antibiotics and underwent otolaryngological and neurosurgical interventions consisting of endoscopic right partial ethmoidectomy and maxillary antrostomy, incision and drainage of the frontal subperiosteal abscess, and right frontal burr hole drainage and irrigation of the subdural collection.
Cultures from the subperiosteal abscess grew many Streptococcus anginosus group (part of viridans group streptococci) and rare coagulase-negative Staphylococcus species, of which the former was thought to be the main contributor to infection. Subsequent subdural empyema culture grew many S anginosus group as well, susceptible to penicillin.
On five-year follow-up, the patient had medically refractory epilepsy characterized by focal seizures starting in the right frontal region and then generalizing. The seizures were attributed to encephalomalacia in the right frontal lobe that developed after the infection.
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