Female patient, 52 years old, with a history of a simple TBI 20 years ago without sequelae and with a three-week history of aqueous rhinorrhea, without fever or headache.
She was diagnosed with probable vasomotor rinitis in otolaryngology.
Intranasal and systemic corticosteroids (prednisone 10 mg daily) were prescribed and administered orally for seven days.
After a transient improvement of the clinical picture presented a sudden onset holocraneal headache, associated with cervical pain, impaired consciousness without evident neurological focus and chills, so he consulted in our emergency department.
At admission, there were blood pressure limits (108/70 mm Hg) that responded to volume, fever (T° 38.5°C), temporo-spatial disorientation, psychomotor agitation and meningeal signs.
Hemocultures were taken and a lumbar puncture was performed that gave rise to turbid CSF, cytochemical 8,480 cvs. treatment was initiated with an empirical ceftria, 100% polymorphoprotein 370 mg/dl and dexamethasone 2 mg.
10 mg, 4 times a day, the last for 4 days.
Computed axial tomography (CAT) of the brain showed no significant alterations.
He was admitted to the Critical Patients Unit where he did not require any vasoactive drugs, with a drop in the febrile curve and recovery of his neurological condition in less than 24 h.
Gram stain of CSF showed no bacteria and staining for acridine showed cocoids.
Both CSF and hemocultives showed identification of S. aureus susceptible to penicillin, and clindamycin susceptible.
The reference laboratory (Instituto de Salud Pública de Chile) subsequently confirmed the findings of the cultures, also reporting that it corresponded to serotype Ib.
The patient was evaluated by gynecologists in order to detect vulvovaginitis and uterine fibroids. No microbiological study was performed.
Otorhinolaryngological examination revealed abundant aqueous rhinorrhea in the left nasal fossa, as evidenced by the Valsalva maneuver.
Due to the suspicion of CSF fistula, a high resolution paranasal sinus CT was performed, which revealed loss of continuity at the level of the cribriform layer of the left ethmoid layer and thinning of the left craniolateral wall.
A positive β2-transferrin nasal fluid study was requested.
A CT scan of the abdomen and pelvis showed no significant findings.
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The clinical evolution was favorable, with progressive decrease of inflammatory parameters, completing 14 days with ceftriaxone.
The patient was discharged with delayed surgical resolution of CSF fistula.
A conjugated antipneumococcal conjugate vaccine was recommended.
The patient reported recurrent minor strokes in her head several weeks prior to admission with a wall beneath a staircase that allowed her to access a common patio to lay clothes.
The patient also recognized having occupied the same hygienic role to clean the genital and nasal area a few days before admission due to the lack of it in the bathroom, during the visit to a family and attending to his intense rhinorrhea.
After discharge, the patient did not present CSF leak through the nose.
Nevertheless, due to the fact that the patient presented a probable spontaneous episode and had already had an episode of MBA, she was advised to undergo surgery to repair the anterior endoscopic skull fistula origin base.
