INTRODUCTION:

A potentially fatal infection called intracranial subdural empyema (SDE) can develop between the dura and arachnoid membrane, which are the outer and middle layers of the meninges, respectively^1–3. Meningitis is the most frequent cause of SDE in newborns, but otitis media and sinus disease are the most frequent causes in adults and older kids⁴. It can result from a variety of conditions, such as sinusitis, mastoiditis, infected cranial surgeries, or dental issues, emphasizing the significance of gathering an exhaustive prior medical history^5–8. It has been estimated that SDE accounts for 5 to 25% of intracranial infections⁹.

Streptococcus and Staphylococcus species have been the most often isolated organisms from SDE cases^1,2. SDE is frequently a neurosurgical emergency that requires immediate attention to prevent significant neurologic repercussions because it is rarely seen, difficult to diagnose, and rare². Procedure for surgery for culture an essential component of the patient's diagnosis and care is the empyema. However, in a rare case, culture cannot determine the causal organism because no microbe growth has occurred¹⁰. Here, we describe a rare instance of sterile SDE in a child who had previously had head trauma and had a chronic subdural hematoma (CSDH). For an early diagnosis and the best possible outcome, the patient underwent a head CT scan.

CASE PRESENTATION:

A ten-year-old girl with the primary complaint of weakness in the right hand since two days before admission. The complaint was accompanied by headaches that worsened within a few days. The patient was difficult to communicate with and was restless. The patient also complained of vomiting once two days ago. Fever, convulsions, and cough were denied. The patient had a toothache that radiated to the left face on the previous 11 days, accompanied by fever. The patient went to a general practitioner and was prescribed analgesics and antibiotics. She fell off the bicycle two months before admission, and her head hit the ground. However, the patient's condition was stable at that time, and there was no history of loss of consciousness.

GCS 11, stable vital signs, and average body temperature were found on physical examination. There was no wound on the patient's head. The patient developed weakness and lateralization of the right limb. Other neurological functions are unremarkable. The results of blood laboratory tests showed no specific abnormalities other than an increase in leukocytes 14,660 (Lymphocyte 10.4% and Neutrophil 82.6%).

We decided to perform a head CT scan with and without contrast. The examination results found a crescentic-shaped isodense area in the left frontotemporoparietal region 11mm thick and an isodense interhemispheric lesion with a higher density of CSF, suggesting chronic subdural hemorrhage. There was also blurring of the sulcus, and flattened gyrus, accompanied by obliteration of the left lateral ventricle and midline shift 0.6 mm contralateral to the lesion, suggesting brain edema (Figure 1).

Figure 1: Head CT-Scan A: Without contrast CT; B: After given contrast CT, a cresentic-shaped isodense area was found in the left frontotemporoparietal region with 11 mm thick and isodense interhemispheric lesion with a higher density of CSF, suggesting chronic subdural hemorrhage. There was also blurring of sulcus, flattened gyrus, accompanied by obliteration of the left lateral ventricle and midline shift 0.6 mm contralateral to the lesion, suggesting brain edema.

The patient undergo surgery with burr hole drainage for chronic SDH and was found with subdural empyema during surgery. We decided to perform an open evacuation of empyema and subdural drainage. Samples were taken and cultured for microbiological examination. The patient has been treated with the antibiotic Ceftriaxone 2x1.5g per day for 14 days and Metronidazole 2x500mg. The results of culture with gram stain and KOH staining were no growth of bacteria and fungi. On anaerobic culture examination, there was also no growth of microorganisms. During the treatment, the patient's condition continued to improve, the patient was discharged on day 14, fully conscious, with no complaints and stable vital signs. It is concluded that this patient was diagnosed with sterile subdural empyema.

DISCUSSION:

SDE is an rare, dangerous, purulent buildup of tissue between the inner and outer arachnoid maters¹⁰. Meningitis is the most frequent cause of SDE in infants and young children, whereas sinus illness and otitis media are the most frequent causes in adults and older children¹¹. Clinical signs of SDE typically appear slowly ^4,12,13. Headache, fatigue, and fever are the most frequent symptoms of SDE. Non-specific symptoms make diagnosing SDE much more difficult. Patients often present with impaired mental states (AMS), necessitating cranial CT imaging. As in our case report, a patient came to our emergency department with decreased consciousness conditions. The patient undergo an emergency head CT-Scan for diagnosis.

Lab results could show leukocytosis and an elevated erythrocyte sedimentation rate (ESR), a sign of inflammation¹⁴. The body will create an inflammatory membrane to enclose the pus collection when there is an empyema, as part of the body's pathophysiological attempt to wall off any infection and prevent it from spreading⁴. This condition aids in the imaging-based differentiation of SDE from SDH. SDH is characterized by a hypodense set in a crescentic pattern that does not match the suture lines' contour. Even though it happens far less frequently in SDH, a surrounding membrane can nonetheless form¹¹. However, SDE typically manifests as a thin, low-density collection over the cerebral convexity, and it has an adjacent membrane that can augment when contrast is added during imaging^12,14. Rim enhancement is a critical factor in differentiating SDE from subacute or chronic SDH since the degree of rim enhancement seen with empyema is not often present in cases of subdural hematoma⁴.

According to Bruner et al. and Yuan et al., magnetic resonance imaging (MRI) with gadolinium contrast has a high sensitivity for the discovery of subdural empyema and other intracranial infections because it can accurately reflect the collection and its surrounding capsule^1,15–17. Another imaging technique that can help distinguish SDE and SDH is diffusion-weighted imaging (DWI). Subdural empyema and subacute subdural hematoma each have the potential to cause an intensive material collection. Restricted diffusion on DWI, on the other hand, confirms the existence of empyema.^18,19 The restriction on DWI is thought to be influenced by the empyema's viscosity and purulent character^1,6,20,21. Immediately once SDE is identified, neurosurgical treatment is necessary.

Despite the fact that operative cultures can identify the responsible organisms, 7% to 52% of instances result in no growth, which is primarily due to the use of antibiotics in the past or inappropriate anaerobic culture technique^10,22,23. In this situation, we could not recognize any pathogens after the culture of the purulent sample was collected intraoperatively. It is a widespread complication in subdural empyemas. sterile specimens of subdural empyema were also recorded in other studies. The Nathoo et al. sequence is a collection of short stories by Nathoo et al. (5 out of 22 cases)²⁴ and the Madhugiri et al. series (7 out of 27)²⁵. Cultures of the suppurative substance were sterile in several other minor reports, such as the two Taha patients²⁶.

CONCLUSION:

Intracranial subdural empyema (SDE) is an emergency condition and life-threatening infection. SDE can also mimic chronic SDH and make it difficult to diagnose. Emergency surgery is required for a better outcome for the patient. Culture empyema from collecting pus is not always found in the microorganism pathogen, which could be in sterile conditions.

CONFLICT OF INTEREST:

The authors have no conflicts of interest regarding this study.

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Received on 05.06.2023 Modified on 02.08.2023

Research J. Pharm. and Tech 2024; 17(5):2040-2042.

DOI: 10.52711/0974-360X.2024.00323