Case report of Actinomyces turicensis meningitis as a complication of purulent mastoiditis.

BACKGROUND: Central nervous system (CNS) infections caused by Actinomyces spp. including brain abscess, actinomycoma, subdural empyema and epidural abscess are well described, however reports of Actinomyces-associated meningitis are scarcely reported. CASE REPORT: We present the case of a 43-year-old Hungarian male patient with poor socioeconomic status who developed acute bacterial meningitis caused by Actinomyces turicensis originating from the left side mastoiditis. The bacterial cultures of both cerebrospinal fluid (CSF) and purulent discharge collected during the mastoid surgery showed slow growing Gram-positive rods that were identified by automated systems (API, VITEK) as A. turicensis The bacterial identification was confirmed by 16S rRNA PCR and subsequent nucleic acid sequencing. No bacterial growth was detected in blood culture bottles after 5 days of incubation. Hence, multiple antibacterial treatments and surgical intervention the patient passed away. CONCLUSIONS: Anaerobes are rarely involved in CNS infections therefore anaerobic culture of CSF samples is routinely not performed. However, anaerobic bacteria should be considered as potential pathogens when certain risk factors are present, such as paranasal sinusitis, mastoiditis in patients with poor socioeconomic condition. To the best of our knowledge, our case report is the first description of A. turicensis meningitis that has been diagnosed as consequence of purulent mastoiditis.

Subdural empyema due to Escherichia coli and Neisseria meningitides in an immunocompetent infant (a case report).

Subdural empyema (SDE) is a focal accumulation of pus between the arachnoid and dura matter. In infants and young children, it is usually attributed to meningitis complications. SDE is considered a serious neurological condition and the culprit is usually a single organism. In rare occasions, polymicrobial is the cause and the organisms involved are, usually streptococci and anaerobe bacteria. A search of the PubMed database was carried out, using a combination of the following terms: subdural empyema , infant, and meningitis. The majority studies conducted on infants mentioned one single organism as the cause of subdural empyema. We are presenting a rare, if not unique, case of subdural empyema in an immunocompetent infant due to an unusual combination of Escherichia coli and Neisseria meningitides. Meningitis is a dynamic disease, and its detrimental consequences could be avoided if diagnosed early. It will be crucial to re-sample the CSF looking for additional organism if a patient with meningitis continues to be febrile, despite antibiotics therapy. Although CSF culture is considered the gold standard in identifying the organism in meningitis, it could be missed due to different reasons including technical flaws. Latex bacterial antigen test could be an indispensable ancillary technique in the diagnosis of meningitis and hence treatment.

Subdural empyema in bacterial meningitis.

OBJECTIVE: To evaluate the occurrence, treatment, and outcome of subdural empyema complicating community-acquired bacterial meningitis in adults. METHODS: Case series from a prospective nationwide cohort study from Dutch hospitals from 2006 to 2011. RESULTS: Subdural empyema was diagnosed in 28 of 1,034 episodes (2.7%), and was present on admission in 10 episodes and diagnosed during admission in 18. Predisposing conditions were present in 26 patients (93%), and consisted of otitis or sinusitis in 21 patients (75%). In all these patients the otitis or sinusitis spread to the subdural space. Twenty-three patients (82%) presented with neurologic symptoms (paresis, focal seizures, dysesthesia contralateral to the empyema). Streptococcus pneumoniae was identified in 26 patients (93%) and Streptococcus pyogenes in 1 (3%); 1 patient had negative CSF cultures. Clinical course was frequently complicated with seizures (50%), focal neurologic abnormalities (54%), and hearing impairment (39%), causing an unfavorable outcome in 19 episodes (68%). Neurosurgical evacuation of the empyema was performed in 5 patients, all with considerable midline shift. CONCLUSIONS: Although rare, subdural empyema must be considered in patients with community-acquired bacterial meningitis and otitis or sinusitis, focal neurologic deficits, or epileptic seizures. S pneumoniae is the predominant causative organism and neurosurgical intervention should be regarded as first-choice therapy in patients with empyema causing midline shift and focal neurologic abnormalities or a decreased level of consciousness.

Bacterial spinal epidural abscess. Review of 43 cases and literature survey.

We have reviewed our experience with 43 cases of bacterial spinal epidural abscess, as well as previously reported series of cases. We found a striking male predominance of the disease, accounting for 86% of cases. Most patients had some underlying conditions that predisposed to infection, a prior infection at a distant site, or an abnormality or trauma to the spine. Presenting symptoms included backache (72%), radicular pain (47%), weakness of an extremity (35%), sensory deficit (23%), bladder or bowel dysfunction (30%), and frank paralysis (21%). Patients cared for in public hospitals tended to seek medical attention in later stages of the disease than patients admitted to private hospitals. Spinal epidural abscess was the suspected diagnosis in only 40% of the cases; the remainder of the time various other infections, tumors, neurologic diseases, or degenerative conditions were considered. Patients in whom the diagnosis of spinal epidural abscess was not initially entertained on admission suffered delays in diagnosis and experienced neurologic deterioration. Staphylococcus aureus was the predominant pathogen (65%) and was associated with positive blood cultures in nearly every case; aerobic or facultative gram-negative bacilli were next most common. Coagulase-negative staphylococci caused infection only in patients who had previous spinal instrumentation. Although analysis of CSF was abnormal in the majority of cases, abnormalities were nonspecific, Gram stain was always negative and culture was rarely diagnostic. Abscesses extended over an average of 4 vertebrae, and the majority were located in the lumbar region followed by thoracic and cervical regions. Unlike previous series, we noted an equal frequency of anterior and posterior epidural abscesses; although differences were not statistically significant, posterior abscesses tended to be more extensive but less commonly associated with radiographic abnormalities of osteomyelitis. Myelography revealed an abnormality in every case in which it was done. Computerized tomographic scanning after intrathecal injection of contrast material always provided additional useful information. Even though magnetic resonance imaging was diagnostic in only 4 of 5 cases (80%) in our series, this test is noninvasive and clearly delineates the location and nature of spinal lesion. It should, therefore, probably replace myelography as an initial definitive study in patients suspected of having spinal infection. Plain roentgenograms and nuclear scans contributed little useful information that was not already available from other radiographic procedures. Surgical drainage together with antibiotics was the treatment of choice; 35 of our 43 patients underwent operative intervention. The preoperative status clearly predicted the final neurologic outcome.(ABSTRACT TRUNCATED AT 400 WORDS)

Subdural empyema--continuing diagnostic problems in the CT scan era.

Fourteen cases of subdural empyema seen in Oxford since the introduction of the CT scanner are reviewed; 11 were male and 12 survived. The clinical presentation was stereotyped and characterised by severe headache, fever and meningism followed after a few days by rapidly progressive drowsiness, focal signs, papilloedema and seizures. All had radiological evidence of paranasal sinus disease (particularly frontal) although this was not apparent clinically in the majority. Plain skull and sinus radiographs remain important early investigations. Over-reliance can be placed on the CT scan which initially may be normal or show only non-specific hemisphere swelling. Parafalcine collections are easily missed. The diagnosis of subdural empyema remains difficult and a high index of clinical suspicion is required. Outcome depends on prompt treatment with parenteral antibiotics and surgical drainage.