14-year-old male presents with severe headache

A previously healthy 14-year-old boy presented to adolescent clinic with a 5-day history of a severe headache. He had been seen in clinic 3 days prior and was diagnosed with acute sinusitis, for which he was prescribed cefdinir. His pain was localized to left frontal forehead, left orbit and left cheek. He also reported bilateral clear rhinorrhea.

On the day of admission, he reported an increase in severity of headache accompanied by nausea, vomiting and a low-grade fever. His mother noticed left eye swelling and redness that had developed over the last 24 hours. The patient denied vision changes, ear pain or neck stiffness. His mother denied mental status changes, confusion, somnolence or seizure-like activity.

His past medical history was only significant for an isolated episode of rectal bleeding secondary to a fissure. He had no previous surgeries and had never before been hospitalized. He had been taking cefdinir for 3 days for suspected sinusitis and received a one-time intramuscular injection of ceftriaxone in the ED the day before presentation. Immunizations were up to date for age. There were no known sick contacts. No rashes were noted on skin exam.

Vital signs on presentation showed a temperature of 99.4°F with a heart rate of 95 beats per minute and blood pressure 125/62 mm Hg. On exam, he appeared tired and uncomfortable. His pupils were equal, round and reactive to light. There was mild erythema superior to left eye, warmth, and mild peri-orbital swelling of the upper eyelid. Pain was elicited on upward gaze. He had no oropharyngeal erythema or lesions. Mucous membranes were moist. No lymphadenopathy was noted. Tragal manipulation did not elicit pain. His tympanic membranes were clear bilaterally. His cardiovascular exam was significant for a grade 1/6 holosystolic vibratory murmur, best heard over the lower left sternal border. Distal pulses were strong. His lungs were clear to auscultation without wheezes, crackles or rales. His abdomen was soft and nontender. The liver and spleen were not palpable. No rashes were noted on skin exam.

What evaluation would you undertake at this time?

Given the severity and nature of his symptoms, a significant sinus infection with possible intracranial extension or other complication was suspected. While waiting for imaging, blood was drawn for laboratory evaluation. His complete blood count revealed a white blood cell count of 7,700, hemoglobin of 14.0 g/dL, and platelets of 170,000.

Erythrocyte sedimentation rate was 53 mm/hr (normal=0-20) and C- reactive protein was 11.4 mg/dL (normal=0-1). His electrolytes were all normal for age. A contrast computed topography scan of the head and sinuses was performed with a representative slice pictured to the right. This image shows the finding of a 4.3 x 1.4 x 2.8-cm left frontal epidural abscess with associated osteomyelitis of the left frontal bone. In addition, the scan demonstrated bilateral frontal, left ethmoid and left maxillary sinusitis.

What should be done next?

The neurosurgery team was then consulted. The decision was made to perform a left frontal craniotomy for evacuation of the abscess. Purulent fluid was encountered and sent for bacterial, fungal and mycobacterial cultures. A subgaleal drain was left in place for continued evacuation.

Broad antimicrobial coverage with good central nervous system penetration was the goal for this complicated intracranial infection. Given the significant amount of adjacent sinus disease, there was need to cover for the most common agents of sinusitis, Streptococcus pneumonia, Moraxella catarrhalis and Haemophilus influenza, in addition to anaerobic pathogens. Our empiric regimen consisted of intravenous vancomycin, ceftriaxone and metronidazole.

Sinusitis

Sinusitis is one of the most commonly occurring suppurative infections in children. It is estimated that 6% to 13% of viral upper respiratory infections are complicated by the development of a secondary bacterial sinusitis.

Predisposing factors to sinusitis include viral upper respiratory infection, allergic rhinitis, anatomic obstruction and mucosal irritants. The most common presenting symptoms in children are a cough and nasal discharge. Acute bacterial sinusitis can usually be distinguished from a simple viral upper respiratory infection by the severity and duration of symptoms. Clues to diagnosis include nasal symptoms or cough lasting more than 10 days and either not improving or acutely worsening, or the presence of severe symptoms. These include a high fever, more than 39·C, and purulent nasal discharge for 3 to 4 days in a child that appears ill. Adolescents are more likely to present with the adult-like symptoms of facial pain, tenderness and facial edema. Diagnosis relies heavily upon clinical suspicion, with radiographic imaging being utilized in atypical or severe cases in which complications are likely.

Streptococcus pneumoniae, Haemophilus influenzae (non-typeable), and Moraxella catarrhalis are the predominant causes of acute bacterial sinusitis. Viridans streptococci, Staphylococcus aureus, Mycoplasma pneumoniae, Streptococcus pyogenes (group A Streptococcus), Chlamydophila pneumoniae, Aspergillus sp., and Bacteroides sp. represent less common causes. Suppurative complications of sinusitis are uncommon but carry the potential for significant morbidity and mortality. The complications can be differentiated into extracranial and intracranial. Extracranial complications include orbital/periorbital cellulitis or abscess and forehead abscesses. The list of possible intracranial complications is more extensive and consists of epidural abscess, subdural empyema, meningitis, encephalitis, intracerebral abscess, dural sinus thrombophlebitis and middle cerebral artery ischemia. In most studies, epidural abscess is the most common intracranial complication of sinusitis.

Epidural abscess

Epidural abscess is a rare suppurative infection of the central nervous system. The lesions can occur intracranially or spinal, with spinal epidural abscess being nine times more common than cranial. Cranial epidural abscess is almost always the result of contiguous extension of infection from sinuses, middle ear or orbit.

Symptoms can be nonspecific for weeks, followed by fever, headache, localized pain and changes in mental status. Signs of increased intracranial pressure such as vomiting, coma and papilledema are rarely seen.

Drainage and debridement of a cranial epidural abscess is usually recommended in addition to appropriate antibiotic therapy. In selected patients whose isolated epidural abscess complicates sinusitis with only a minimal mass effect, adequate sinus drainage combined with appropriate antibiotics may be sufficient without the need for a neurosurgical procedure. In the absence of osteomyelitis, 3 to 4 weeks of antibiotic therapy intravenously should be adequate; if osteomyelitis is present, therapy should be continued for at least 6 weeks. With the increasing role of methicillin-resistant Staphylococcus aureus and Staphylococcus epidermidis in focal central nervous system infections, vancomycin should be given empirically with a third-generation cephalosporin and possibly metronidazole.

Streptococcus species are the most common organisms isolated post-surgery in these clinical settings, accounting for more than half of the positive cultures. Of the Streptococcus species, viridians streptococci are the most prevalent (30% of Streptococcus species). Among the viridans streptococci, organisms from the anginosus group often are isolated from patients with brain abscesses or abscesses in other sites. Staphylococcus species are the second most commonly isolated organisms, followed by gram negative rods (Pseudomonas aeruginosa, Haemophilus influenzae). In one study, multiple organisms were isolated from 54% of the postoperative cultures, emphasizing the importance of broad spectrum antibiotic coverage in these patients.

Conclusion

Our patient improved significantly after surgical intervention. He was noted to be afebrile 24 hours post-operatively and reported complete resolution of headache and nausea.

A peripherally inserted central catheter was placed to facilitate long-term antibiotic therapy with arrangements for home health care made. At the time of discharge on postoperative day 5, all of his intraoperative cultures remained negative. Although his wound culture later revealed light growth of a viridians group streptococcus, he was continued on broad spectrum antibiotics (vancomycin, ceftriaxone and metronidazole) because of the likelihood of a polymicrobial infection. He remained clinically well following discharge with a follow-up head CT 2 weeks later showing interval improvement of sinusitis without evidence of intracranial infection. By 3 weeks after his surgery, his ESR and CRP had returned to the normal range. He ultimately completed a 6-week course of broad spectrum antibiotic therapy without complications.

Disclaimer: The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Air Force, U.S. Army or Department of Defense.

Corey Falcon, MD, is a Captain in the U.S. Air Force. He is currently a pediatric resident at the San Antonio Military Medical Consortium in San Antonio.

Ashley M. Maranich, MD, is a Major in the U.S. Army. She is a pediatric infectious disease staff physician at the San Antonio Military Medical Consortium in San Antonio and an assistant professor of pediatrics at the F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences in Bethesda, Md.

For more information:

• Germiller JA. Intracranial complications of sinusitis in children and adolescents and their outcomes. Arch Otolaryngol Head Neck Surg. 2006;132:969-976.
• Kombogiorgas D. Suppurative intracranial complications of sinusitis in adolescence. Single institute experience and review of literature. Br J Neurosurg. 2007;21:603 – 609.
• Long S. Principles and Practice of Pediatric Infectious Disease. 2nd ed. Philadelphia:Elsevier Science; 2003.