A controlled hypertensive 46-year-old woman presented with holocraneal headache accompanied by nausea, vomiting and fever, whose intensity reached 10/10 on the third day of evolution.
The onset of consciousness compromise occurred when the patient was seen in the emergency department.
She was admitted with confusion, poor fluent language, neck stiffness, reactive isocoric pupils and eye fundus with bilateral papilledema.
He moved the four limbs, had live osteotendinous reflexes and bilateral Babinski.
Blood pressure 108/64 mmHg, heart rate 56 lmp, subfebrile (t°C).
There were no mucosal or skin lesions and no dental, sinus, otic or respiratory foci.
Brain tomography (CT) showed rounded left frontal hypodensity, with local mass effect on adjacent structures.
Citrus liquid, 760 leukocytes mm3 (97% PMN), proteins 101.8 mg/dL, glucose 69 mg/dL (cerebrospinal glucose test 116 mg/dL), Gram negative staining.
Blood lactate 29.9%, hemoglobin 9.8 g/L, leukocytes 25.800 k/uL, (91.9% segmented), platelets 286.000 uL, CRP 428 mg/L, prothrombin 66%
HBV, HCV, HTLV-1, Chagas and HIV negative.
Intravenous antibiotic treatment was initiated with ceftriaxone 2 g c/12 h, clindamycin 600 mg c/8 h, vancomycin 1 g c/12 h and betamethasone 4 mg c/8 h.
The patient remained consciously impaired (Glasgow 12), with neck and opisthotonous stiffness.
reactive isochoric ppiles, oculocephalic and corneal reflexes preserved, maintained papilledema, generalized hyperreflexia and bilateral Babinski.
Magnetic resonance imaging (MRI) performed on the second day of hospitalization defined an anterior bifrontal process with left predominance, restricted diffusion and perilesional vasogenic edema.
Leptomeningeal contrast uptake was observed and a 6 mm left frontotemporal subdural collection was identified. The angioresonance did not add significant elements.
The study was interpreted as certis bifrontal accedade, left frontal-parietal empyema and leptomeningitis.
Neurosurgical evaluation at that time suggested medical management of the condition.
Echocardiography and ultrasound to non-pelvic know-how were normal.
Blood culture, urine culture, bronchial secretion and CSF culture were negative.
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On the fourth day of hospitalization, consciousness compromise was accentuated (Glasgow 4).
Brain CT showed a significant increase in cerebral edema without changes in the lesions described.
The neurosurgical reassessment decided to evacuate the left subdural collection, leaving purulent material.
The procedure was uneventful.
In the immediate post-surgical stage, the patient received support with vasoactive drugs, but did not have consciousness, remaining in coma, with the pupils in the mid-reflective phase, without trunk responses.
CT showed ventricular collapse, absence of grooves and blurring of the basal cisterns.
The EEG showed plane trace.
Brain death was defined.
Culture of the subdural collection was positive for Streptococcus anginosus group (SAG).
