A 10-year-old male student 9 months old, with no relevant morbid history.
She had a one week history of headache, fever and right periorbital edema, so she was hospitalized in another center where a CT scan of paranasal sinuses and cloxic abscess showed orbital antimicrobial treatment.
At 48 hours after admission, the patient presented with acute confusional state and psychomotor agitation crisis associated with signs of meningeal irritation glucorrhagia, and therefore a lumbar puncture was performed with a negative CSF and CSF 90
A contrast-enhanced brain CT scan showed cerebral edema and bilateral subdural meningitis collection performed at our center for neurosurgical evaluation with diagnoses of sinusitis, acute secondary meningitis and subdural collection
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On admission to the pediatric intensive care unit, physical examination revealed: axillary node 38.3 °C, heart rate of 65 per min, blood pressure 140/90 mm Hg, Glasgow scale: 6, bilateral hyperreflexia, anorexy.
CRP was 215 mg/L, leukocyte count was 15.800/mm3, and platelet count was normal.
Management of endocranial hypertension was initiated with endotracheal intubation and connection to mechanical ventilation associated with the administration of mannitol, sedoanalgesia with midazolam-fentanyl and inotropic support with dopamine.
Anticonvulsant therapy was established with phenytoin and triad antibiotic treatment with ceftriaxone, metronidazole and vancomycin.
A new brain CT with and without contrast showed cerebral edema and progression of the subdural collection, suggesting the diagnosis of subdural empyema with initial mass effect.
The patient was evaluated by the otorhinolaryngology and neurosurgery team performing exploration of the middle meatus and drainage of the right maxillary sinus endoscopically and in the following hours right ethmoidectomy, drainage of a purulent abscess in the right orbital material.
Microbiological culture of these zones for aerobics and anaerobics, fixed in BEC/ALERT® FN system with negative oxidized potential reduction and activated carbon, was negative.
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The patient remained on assisted ventilation for seven days, with regression of the signs of endocraneal hypertension and progressive recovery in the Glasgow scale.
After three weeks of antibiotic therapy, a new cerebral contrast CAT scan was performed, showing abundant frontal orifices with two layers, which required a new surgical drainage: crapiectomy.
Cultures were again negative.
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The subsequent evolution was complete 5 weeks of antibiotic therapy and follow-up brain CT with contrast medium did not reveal the formation of new urticaria.
In post-patient clinical controls, the patient presented aphasia of expression, achieving communication in writing and a right hemiparesis currently in regression.
