Indian J Pediatr

DOI 10.1007/s12098-015-1771-x

CLINICAL BRIEF

Is Sinusitis Innocent? Unilateral Subdural Empyema

in an Immunocompetent Child
Sevim ahin 1 & Uur Yazar 2 & Ali Cansu 1 & Sibel Kul 3 & Seluk Kaya 4 &
Elif Bahat zdoan 5

Received: 8 December 2014 / Accepted: 9 April 2015

# Dr. K C Chaudhuri Foundation 2015

Abstract Subdural empyema related to Streptococcus Keywords Streptococcus constellatus . Staphylococcus

constellatus is extremely rare in an immunocompetent child,
and also there is no reported case along with Staphylococcus
lugdunensis infection. Although Streptococcus constellatus
has been determined as a co-pathogen with anerobic bacteria
in many infections, it has not been reported in combination
with Staphylococcus lugdunensis. The authors describe a case
of previously healthy 16-y-old child with unilateral subdural
empyema due to these bacteria. Sinusitis was the only predis-
posing factor in the index case. The authors propose that some
cases of culture-negative intracranial infections may be due to
these infectious agents. Therefore, these agents should be con-
sidered as causes of intracranial infection in persistent com-
plaints such as fever and headache after sinusitis in children. It
is important to treat them with effective antibiotics and early
surgical intervention for favorable outcome, because fatal
cases were reported due to Streptococcus constellatus
infections.
lugdunensis . Subdural empyema . Child
Introduction
Intracranial empyema, though rare in children is an emer-
gency due to life-threatening complications [1]. Herein, the
authors describe a previously healthy child with unilateral
subdural empyema (SDE) related to Streptococcus
constellatus and Staphylococcus lugdunensis. SDE associat-
ed with Streptococcus constellatus has been described in
only one case [2] in the English literature, and there is no
case associated with Staphylococcus lugdunensis, to the
authors knowledge. Also, the presence of co-pathogens
such as Streptococcus constellatus and its combination with
Staphylococcus lugdunensis has not been previously report-
ed. This case is presented to ensure consideration of these
rare microorganisms as causes of SDE even in immuno-
competent children.

* Sevim ahin
sevimsahin1@yahoo.com Case Report

1
Department of Pediatric Neurology, School of Medicine, Karadeniz
A 16-y-old boy was referred to the Emergency department
Technical University, 61000 Trabzon, Turkey with complaints of projectile vomiting and lethargy for one
2
Department of Neurosurgery, School of Medicine, Karadeniz
day, headache for 3d, and fever for 2d. The headache was
Technical University, Trabzon, Turkey especially on the right side, and fever was up to 39 C. He
3
Department of Radiology, School of Medicine, Karadeniz Technical
had been started oral antibiotic treatment 2d ago for sinusitis.
University, Trabzon, Turkey His past medical and family history were unremarkable.
4
Department of Infectious Diseases and Clinical Microbiology,
The physical examination revealed somnolence and
School of Medicine, Karadeniz Technical University, anisocoria. He had eye opening and localized motor
Trabzon, Turkey response to pain, but no verbal response. Also, general-
5
Department of Pediatrics, School of Medicine, Karadeniz Technical ized tonic-clonic seizure were observed. In laboratory
University, Trabzon, Turkey examination, his leukocyte count (12,100/mm3) and C-
 Indian J Pediatr

reactive protein (20.62mg/dl) were increased. Brain magnetic
resonance imaging (MRI) revealed SDE surrounding
the right cerebral hemisphere (Fig. 1). There was com-
pression of the ventricles, anterior displacement of the
brain stem and subfalcine herniation on the left.
Inflammatory changes were present in the maxillary si-
nus and ethmoid cells. Right frontoparietal craniotomy
was performed, and subdural empyema was drained at
the Neurosurgery department. Treatment with vancomy-
cin (60mg/kg/d), ceftriaxone (100mg/kg/d) and metronida-
zole (30mg/kg/d) was initiated. Acyclovir treatment
(30mg/kg/d) was added for probable herpes simplex vi-
rus (HSV) infection, and continued with positive results
of HSV type 1 and type 2 immunoglobulin M (IgM) in the
serum. Studies of the lymphocyte subgroups and immuno-
globulins were normal.
Streptococcus constellatus was isolated in the abscess ma-
terial; it was sensitive to ceftriaxone. Postoperatively,
Babinskis sign and decrease in score of motor strength (3/5)
on the left side were present.
On day 5, although the patient remained stable clinically,
subdural empyema enlarged in the interhemispheric fissure
(Fig. 1). On day 17, brain MRI showed enlargement of
SDE in the posterior interhemispheric fissure (Fig. 1).
Subfalcine herniation of midline structures to the left and
compression of the third and lateral ventricles were present.
Therefore, surgical drainage was performed again, and con-
sidering penicillin sensitivity tests, antibiotic treatment was
switched to high-dose ampicillin treatment (8g/d
ampicillin-sulbactam in addition to ampicillin of 4g/d).
Staphylococcus lugdunensis was isolated from the latter
abscess material.
In follow-up, hemiparesis of the patient improved gradual-
ly and SDE regressed completely (Fig. 1). Ampicillin treat-
ment was completed in 2mo.
Discussion
The only case of SDE associated with Streptococcus
constellatus in the English literature is of a 7-y-old girl [2].
Unilateral SDE in that case showed fatal outcome [2].
Streptococcus constellatus is a commensal of oropharyngeal
flora [3]. Infections with empyema related to Streptococcus
constellatus are mostly present in the thoracal region. It causes
purulent infections of pleuro-pulmonary, intra-abdominal,
genitourinary, soft tissue and rarely central nervous system
(CNS) [2, 3]. Streptococcus constellatus has been rarely

Fig. 1 Axial images on brain

MRI study of the case. T2 (1, 3)
and T1-weighted (2, 4) images on
admission (A), on the 5th day af-
ter surgical drainage (B), on day
17 prior to second surgical drain-
age (C) and 2 mo after the second
surgery (D). (A) Subdural empy-
ema surrounding the right cere-
bral hemisphere (arrow). Signal
hypointensity on
T1-weighted images (A2, A4)
and signal hyperintensity on
T2-weighted images (A1, A3)
may be seen. There is light shift of
midline structures to the left. (B)
Subdural empyema in the inter-
hemispheric fissure with signal
hyperintensity on
T2-weighted images (B1, B3) and
signal hypointensity on T1-
weighted images (B2, B4). (C)
Increase in the size of the empy-
ema is more pronounced in the
posterior of interhemispheric fis-
sure. (D) Disappearance of sub-
dural empyema

Table 1 Comparison of various studies in pediatric patients with subdural empyema (SDE)
Author
Bair-Merritt et al., 2005 [7]
Wu et al., 2008 [8]
Legrand et al., 2009 [1]
Gupta et al., 2011 [9]
Cole et al., 2012 [10]
Indian J Pediatr
Number of patients S. milleri group Other microorganisms Identified etiology Neurological outcome
with SDE infections n (%)
4 1 (25) Streptococcus salivarius, Group A streptococcus, Sinusitis Seizures in the case of S. milleri
Group D streptococcus, Peptostreptococcus, group. Seizures, dysarthria
Prevotella, Clostridium spp., nontypable expressive aphasia, hemiplegia.
Haemophilus influenzae, Alfa-hemolytic
streptococcus, Beta-hemolytic streptococcus
31 None Streptococcus pneumoniae, Group B streptococcus, Otorhinolaryngeal infections, 3 children died. 38.7% without
Methicillin-sensitive Staphylococcus aureus, head trauma or surgery. neurological sequelae. 51.6%
Haemophilus influenzae type b, Salmonella spp., neurological deficit.
Escherichia coli, Pseudomonas aeruginosa,
Haemophilus parainfluenzae, Enterobacter cloacae
33 7 (21.2) Anaerobes, Group B streptococcus, Streptococcus Bacterial meningitis in 10 infants 1 child died. Permanent
pneumoniae, Enterobacteriaceae, Sinusitis in 18 cases neurological deficits in
Staphylococcus aureus, P. aeruginosa, Otitis in one case 3 children
Haemophilus Tonsillitis in one case
70 extraaxial 27 (38.6) S. aureus, Streptococcus pneumoniae, other Sinusitis 84.3% without neurological
(epidural -hemolytic streptococci spp, Haemophilus Otitis sequelae. Developmental delay,
and SDE) influenzae, other -hemolytic streptococci spp, Meningitis residual focal neurological
Escherichia coli, coagulase-negative Previous neurosurgery deficit.
Staphylococci spp, cryptogenic gram-negative Spinal infections
bacilli spp. Miscellaneous
23 None Pneumococcus, H. influenzae type B, Coagulase Sinusitis in 12 cases 1 child with ventriculoperitoneal
negative Staphylococcus, Lactobacillus, Meningitis in 6 cases shunt died. 20% with
Abiotrophia adiacens, Enterobacter cloacae, Neurosurgery in 2 cases neurological sequelae.
Meningococcus, S. aureus

reported with brain abscess [4], spinal epidural abscess [5] and
meningitis [6] in adult patients.
Sinusitis might have been the predisposing factor in
the index case. No other predisposing factors, such as
dental or oropharyngeal intervention, trauma, any surgi-
cal operation or immunodeficiency were detected.
Sinusal infections have been reported as major predis-
posing factors for intracranial infections in immunocom-
petent children [7].
Streptococcus milleri group including Streptococcus
constellatus has been reported as a cause of SDE. Its frequen-
cy varies in different studies (Table 1). Streptococcus
intermedius in Streptococcus milleri group is the main micro-
organism that cause CNS infections, and a small proportion is
caused by Streptococcus anginosus. Streptococcus
constellatus is very rare in CNS infections [11]. Although
there is no marked difference between the dates of the studies
compared in Table 1, wide range of the rates of Streptococcus
milleri group infections between 0 and 38.6% is remarkable.
The most important reason for that is probably some studies
focused on complications after sinusitis or may had difficulty
in identifying these agents. Streptococcus milleri group and
anerobic bacteria are the most common pathogens in suppu-
rative intracranial complications after sinusitis in previously
healthy children [7]. Probably all the infections of
Streptococcus milleri group cannot be detected. In a study,
Streptococcus milleri group was detected in three cases with
culture-negative brain abscess by 16S rRNA gene amplifica-
tion and sequencing methods [12].
Staphylococcus lugdunensis, another agent in the index
case, is a coagulase negative staphylococcus and causes
skin and soft tissue infections. Severe infections such as
endocarditis, septic shock, peritonitis, osteomyelitis,
spondylodiscitis, septic arthritis, epidural abscess, brain ab-
scess and infection of prosthetic devices have also been re-
ported [13].
The present case indicates that Streptococcus
constellatus and Staphylococcus lugdunensis may cause
SDE even in immunocompetent children. CNS infec-
tions should be considered in cases of increasing symp-
toms after sinusitis. High dose antibiotic treatment is
necessary to provide penetration into the abscess [2].
These infections, although probability of fatal outcome,
can be treated with early surgical intervention, close
neuroimaging and effective antibiotic treatment as in
the index case. Brain MRI should be considered for
Indian J Pediatr
initial diagnosis and at follow-up in these patients to
prevent further complications.
Conflict of Interest None.
Source of Funding None.
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