A seven-year-old patient was taken to the emergency room with a history of frontal headache, maximum fever of 40 °C and vomiting for three days, associated with neck pain and swelling in the right eye in the last 24 hours.
She had a history of endoscopic surgical correction of trigonocephalia at four months.
On admission, he had a heart rate of 137 bpm, respiratory rate of 25 bpm, blood pressure of 102/60 mm Hg and temperature of 36.8 °C. Neurologically, he was conscious, oriented and cooperative, with Glasgow 15/15.
Neck stiffness with positive Kig and Brudzinski signs.
The right periorbital region showed swelling with erythema, local heat and conserved eye movements.
Blood tests were performed with leukocytosis 14 500/mm3, neutrophilia 13 900/mm3, lymphopenia 390/mm3 and increased acute phase reactants: fibrinogen 881 mg/dl and C-reactive protein 241 mg/mm.
Lumbar puncture was performed, after confirming normal eye fundus, obtaining cloudy cerebrospinal fluid, which in the cytochemical analysis showed 380 leukocytes/mm3 with 38% polymorphonuclear and hypoglycemic bacteria.
S. pyogenes was isolated from the blood culture.
Cranial computed tomography showed partial occupation of left and frontal hair cells and swelling of the right periorbital soft tissues.
Empirical treatment with cefoxime and vancomycin was started, suspending the latter to isolate S. pyogenes, and clindamycin was associated with scarlatiniform rash.
On the seventh day of admission she had a tonic-clonic seizure episode focused on the left hemibody which subsequently became generalized.
A cranial magnetic resonance imaging revealed thrombosis of the right ophthalmic vein and partial occupation of the right sinus, as well as persistence of meningeal enhancement.
She was treated with valproic acid and dexamethasone, and anticoagulation was initiated.
Subsequently, the patient was successfully treated with intravenous antibiotics for 21 days, with normal clinical, neurological and electromagnetic resonance imaging findings and no neurological sequelae.
