This is a 74-year-old male who had undergone surgery for a left frontal parasagittal transitional (WHO grade I) meningioma.
One month after this surgery, the patient consulted due to an infection of the surgical wound that presented a central zone of manifestation of purulent material.
The patient had no fever, his general condition was good and his neurological examination was normal.
Magnetic resonance imaging (MRI) performed at that time showed, adjacent to the craniectomy area, a hypodense subdural collection with bubbles inside, which was enhanced peripherally after administration.
A craniotomy was reopened and an epidural purulent collection was removed and sent for microbiological study.
Empirical antibiotic therapy was initiated with intravenous ceftazidime and vancomycin.
Bacterial cultures were negative.
The patient was discharged with oral treatment with ciprofloxacin and cotrimoxazole for two weeks.
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One and a half months after discharge, the patient was taken to the emergency department for a generalized tonic-clonic seizure.
She had had a fever the previous days without any other relevant clinical data.
Physical examination revealed good general condition, malaise, Glasgow 15/15, no neurological focality, and surgical wound showed no infection data.
Anticonvulsant treatment was initiated and a computed tomography was performed which showed a subdural collection with hypodense predominance, with peripheral enhancement after contrast administration and a convex internal margin in the brain toward the parenchyma.
Air remained inside the collection.
Empirical antibiotic treatment was initiated with ceftazidime and vancomycin.
With the diagnostic suspicion of recurrence of subdural empyema a third craniectomy was performed which showed a subdural collection of purulent aspect that was evaccinated.
Samples were sent for microbiology of the drained material and a craniectomy specimen adjacent to the collection that was removed for therapeutic purposes due to eventual infection and soaked in juice processing.
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Five days after inoculation, growth of Proprionibacterium acnes (P. acnes) was observed in solid medium and in atmosphere of enrichment broth anaerobosis.
Antibiogram by E-test showed resistance to metronidazole and sensitivity to penicillin, amoxicillin-clavulanate, ceftazidime, clindamycin and vancomycin.
Vancomycin and ceftazidime were discontinued and amoxicillin-clavulanate was started.
The patient progressed well and was discharged with oral amoxicillin for one month and the diagnosis of "recurrence of postsurgical subdural empyema by Propionibacterium acnes".
