MRSA with progression from otitis media and sphenoid sinusitis to clival osteomyelitis, pachymeningitis and abducens nerve palsy in an immunocompetent 10-year-old patient

A Fatal Case of Meningitis Complicating Chronic Otitis Media and Base of Skull Osteomyelitis due to Carbapenemase (OXA-48)-Producing Klebsiella pneumoniae

Osteomyelitis of the base of the skull is a rare but life-threatening disease. Although Klebsiella pneumoniae is not a pathogen that is frequently associated with this infection, the clinical course can rapidly progress to meningitis. Here, we describe a case of chronic otitis media, secondary to OXA-48K. pneumoniae, which was complicated by osteomyelitis of the base of the skull and fatal meningitis.

A clinical approach to hypertrophic pachymeningitis

IMPORTANCE

Hypertrophic pachymeningitis (HP) is a non-usual manifestation of rheumatologic, infectious, and neoplastic diseases. Etiological diagnosis is a challenge, but when made promptly it creates a window of opportunity for treatment, with the possibility of a total reversal of symptoms.

OBSERVATIONS

HP is an inflammatory process of the dura mater that can occur as a manifestation of sarcoidosis, granulomatosis with polyangiitis, and IgG4-related disease. The HP case evaluation is extensive and includes central nervous system imaging, cerebrospinal fluid analysis, serology, rheumatologic tests, and systemic survey for other manifestations sites. After systemic investigation, meningeal biopsy might be necessary. Etiology guides HP treatment, and autoimmune disorders are treated with corticosteroids alone or associated with an immunosuppressor.

CONCLUSION

HP is a manifestation of several diseases, and a precise etiological diagnosis is crucial because of the difference among treatments. An extensive investigation of patients with HP helps early diagnosis and correct treatment.

Clival Osteomyelitis with Cavernous Sinus Thrombosis Due to Fusobacterium nucleatum and Campylobacter rectus Induced by Tooth Extraction

A 70-year-old woman who had suffered from aseptic meningitis complained of chronic headache after dental treatment including tooth extraction. She developed a fever and respiratory failure. Based on chest computed tomography and head magnetic resonance imaging (MRI), she was diagnosed with osteomyelitis in the clivus accompanying moderate pituitary involvement, cavernous sinus thrombosis and septic pulmonary embolism. Both of the causal bacteria, Fusobacterium nucleatum and Campylobacter rectus, were isolated from her blood. Dual infection leading to clival osteomyelitis and cavernous sinus thrombosis has not been reported. It is important to perform enhanced MRI and blood culture for patients with chronic headache related to dental treatment.

Infection of the spheno-occipital synchondrosis: A morbid complication following adenoidectomy

Two 2-year-old males presented post-operatively following adenoidectomy with persistent fever and neck stiffness. After multiple office visits, both patients were admitted and found to have a widened spheno-occipital synchondrosis and other imaging findings indicative of skull base osteomyelitis. Treatment with antibiotics allowed for recovery with good long-term outcomes. Infection involving the spheno-occiptal synchondrosis is rare and its circuitous presentation of these two children no doubt led to delayed diagnosis.

A Comprehensive Review of Skull Base Osteomyelitis: Diagnostic and Therapeutic Challenges among Various Presentations

Skull base osteomyelitis (SBO) is a complex and fatal clinical entity that is often misdiagnosed for malignancy. SBO is commonly a direct complication of otogenic, sinogenic, odontogenic, and rhinogenic infections and can present as central, atypical, or pediatric clival SBO. This review describes the clinical profile, investigational approach, and management techniques for these variants. A comprehensive literature review was performed in PubMed, MEDLINE, Research Gate, EMBASE, Wiley Online Library, and various Neurosurgical and Neurology journals with the keywords including: SBO, central or atypical SBO, fungal osteomyelitis, malignant otitis externa, temporal bone osteomyelitis, and clival osteomyelitis. Each manuscript's reference list was reviewed for potentially relevant articles. The search yielded a total of 153 articles. It was found that with early and aggressive culture guided long-term intravenous broad-spectrum antibiotic therapy decreases post-infection complications. In cases of widespread soft tissue involvement, an early aggressive surgical removal of infectious sequestra with preferentially Hyperbaric Oxygen (HBO) therapy is associated with better prognosis of disease, less neurologic sequelae and mortality rate. Complete resolution of the SBO cases may take several months. Since early treatment can improve mortality rates, it is paramount that the reporting radiologists and treating clinicians are aware of the cardinal diagnostic signs to improve clinical outcomes of the disease. It will decrease delayed diagnosis and under treatment of the condition. However, due to rarity of the condition, complete prognostic factors have not fully been analyzed and discussed in the literature.

Treatment of Staphylococcus aureus Infections

Staphylococcus aureus, although generally identified as a commensal, is also a common cause of human bacterial infections, including of the skin and other soft tissues, bones, bloodstream, and respiratory tract. The history of S. aureus treatment is marked by the development of resistance to each new class of antistaphylococcal antimicrobial drugs, including the penicillins, sulfonamides, tetracyclines, glycopeptides, and others, complicating therapy. S. aureus isolates identified in the 1960s were sometimes resistant to methicillin, a ß-lactam antimicrobial active initially against a majority S. aureus strains. These MRSA isolates, resistant to nearly all ß-lactam antimicrobials, were first largely confined to the health care environment and the patients who attended it. However, in the mid-1990s, new strains, known as community-associated (CA-) MRSA strains, emerged. CA-MRSA organisms, compared with health care-associated (HA-) MRSA strain types, are more often susceptible to multiple classes of non ß-lactam antimicrobials. While infections caused by methicillin-susceptible S. aureus (MSSA) strains are usually treated with drugs in the ß-lactam class, such as cephalosporins, oxacillin or nafcillin, MRSA infections are treated with drugs in other antimicrobial classes. The glycopeptide drug vancomycin, and in some countries teicoplanin, is the most common drug used to treat severe MRSA infections. There are now other classes of antimicrobials available to treat staphylococcal infections, including several that have been approved after 2009. The antimicrobial management of invasive and noninvasive S. aureus infections in the ambulatory and in-patient settings is the topic of this review. Also discussed are common adverse effects of antistaphylococcal antimicrobial agents, advantages of one agent over another for specific clinical syndromes, and the use of adjunctive therapies such as surgery and intravenous immunoglobulin. We have detailed considerations in the therapy of noninvasive and invasive S. aureus infections. This is followed by sections on specific clinical infectious syndromes including skin and soft tissue infections, bacteremia, endocarditis and intravascular infections, pneumonia, osteomyelitis and vertebral discitis, epidural abscess, septic arthritis, pyomyositis, mastitis, necrotizing fasciitis, orbital infections, endophthalmitis, parotitis, staphylococcal toxinoses, urogenital infections, and central nervous system infections.

Symptomatic stroke complicating central skull base osteomyelitis following otitis media in a 2-year old boy: Case report and review of the literature

We describe the youngest case to date of a 2 year old child who developed central skull base osteomyelitis (SBO) initially presenting with a fever, vomiting and sore throat. An extremely rare complication of mastoiditis following otitis media in children is SBO which can present with non-specific symptoms. This report describes the first case of symptomatic ischaemic stroke secondary to SBO in an immunocompetent child. We review the literature of the management and the potential cerebrovascular complications of central SBO in children secondary to otolaryngological infection.

Methicillin resistant Staphylococcus aureus meningitis

Methicillin resistant Staphylococcus aureus (MRSA) meningitis is rarely known to occur in children. We report an 11-year-old girl with fever, headache and vomiting, right hemiparesis with left-sided upper motor neuron facial nerve palsy and bladder incontinence. On investigation, she was found to have MRSA meningitis with an acute left thalamo-corpuscular infarct. She was treated with vancomycin, linezolid and rifampicin. She recovered successfully with residual right-sided lower limb monoparesis. MRSA meningitis is rare but can occur in children.

Nonotogenic Skull Base Osteomyelitis in Children: Two Cases and a Review of the Literature

Skull base osteomyelitis is a rare condition in childhood and can be described according to whether it is associated with spread of infection from the middle ear (otogenic) or not (nonotogenic). Early recognition of this serious disease and prompt treatment are key to preventing extension to adjacent vascular and nervous system structures. Diagnosis can be challenging due to the variable presentation of the disease and potentially subtle radiological appearances. We present 2 cases of nonotogenic skull base osteomyelitis in childhood both affecting the clivus and review the 6 cases previously described. Both children presented with fever, headache and neck stiffness and responded well to medical management alone; detailed imaging was key to making a diagnosis.

Odontogenic infection and pachymeningitis of the cavernous sinus

Hypertrophic pachymeningitis is a rare inflammatory process that causes thickening of the dura mater. Most cases are idiopathic, but it can result from many inflammatory and infective conditions. We present a case of pachymeningitis of the cavernous sinus, the aetiology of which may have been dental.

Petrositis With Bilateral Abducens Nerve Palsies complicated by Acute Otitis Media

Petrous apicitis is a rare but fatal complication of otitis media. An infection within the middle ear can extend within the temporal bone into the air cells of the petrous apex. With only the thin dura mater separating the trigeminal ganglion and the 6th cranial nerve from the bony petrous apex, they are vulnerable to inflammatory processes, resulting in deep facial pain, lateral rectus muscle paralysis, and diplopia. In 1904, Gradenigo described a triad of symptoms related to petrous apicitis, including acute suppurative otitis media, deep facial pain resulting from trigeminal involvement, and abducens nerve palsy. It has traditionally been treated with surgery, but recent advances in imaging, with improved antibiotic treatment, allow conservative management. In this case report, we describe a clinical and neuroradiological evolution of a child with a petrous apicitis after acute otitis media, which was managed medically with a positive outcome.

Skull base osteomyelitis and potential cerebrovascular complications in children

Skull base osteomyelitis is an aggressive, life-threatening infection that can be challenging to diagnose and treat. It occurs predominantly in elderly immunocompromised patients, but it has also been reported in children with normal immunological status. Typical skul base osteomyelitis arises as a complication to ear infection mainly involving the temporal bone and is usually caused by Pseudomonas aeruginosa. Atypical or central skul base osteomyelitis originates from paranasal infections, is primarily centred on the clivus and is usually caused by Aspergillus, Pseudomonas, Salmonella or Staphylococcus species. Potential complications include retropharyngeal abscesses, cranial neuropathies, meningitis, intracranial abscesses, sinovenous thrombosis, and carotid artery involvement with or without ischemic infarcts. The purpose of this pictorial essay is to illustrate the spectrum of imaging findings and potential complications of skul base osteomyelitis.

Abducens nerve palsy complicated by inferior petrosal sinus septic thrombosis due to mastoiditis

We present a very rare case of a 29-month-old boy with acute onset right abducens nerve palsy complicated by inferior petrosal sinus septic thrombosis due to mastoiditis without petrous apicitis. Four months after mastoidectomy, the patient fully recovered from an esotropia of 30 prism diopters and an abduction limitation (-4) in his right eye.

An unusual headache: sphenoiditis in children and adolescents

Sphenoid sinus infection is a rare cause of headaches in children and adolescents. Its symptoms are often non-specific and confusing. The diagnosis is made on the history, examination, nasendoscopy, cultures and CT or MRI. Prompt and aggressive medical treatment in the form of parenteral antibiotics and nasal decongestants is advised to reduce the risk of serious complications such as permanent cranial neuropathies or intracranial spread. Surgical intervention is advocated when symptoms persist or complications develop. Although sphenoiditis is potentially devastating, early collaboration between pediatric medical and ENT surgical teams generally leads to an excellent outcome. This article presents three cases of adolescent sphenoid sinus infection, and reviews the literature on this uncommon condition.

Community-associated methicillin-resistant Staphylococcus aureus: epidemiology and clinical consequences of an emerging epidemic

Staphylococcus aureus is an important cause of skin and soft-tissue infections (SSTIs), endovascular infections, pneumonia, septic arthritis, endocarditis, osteomyelitis, foreign-body infections, and sepsis. Methicillin-resistant S. aureus (MRSA) isolates were once confined largely to hospitals, other health care environments, and patients frequenting these facilities. Since the mid-1990s, however, there has been an explosion in the number of MRSA infections reported in populations lacking risk factors for exposure to the health care system. This increase in the incidence of MRSA infection has been associated with the recognition of new MRSA clones known as community-associated MRSA (CA-MRSA). CA-MRSA strains differ from the older, health care-associated MRSA strains; they infect a different group of patients, they cause different clinical syndromes, they differ in antimicrobial susceptibility patterns, they spread rapidly among healthy people in the community, and they frequently cause infections in health care environments as well. This review details what is known about the epidemiology of CA-MRSA strains and the clinical spectrum of infectious syndromes associated with them that ranges from a commensal state to severe, overwhelming infection. It also addresses the therapy of these infections and strategies for their prevention.

Clival osteomyelitis resulting from spread of infection through the fossa navicularis magna in a child

The fossa navicularis is a notch-like bone defect in the basiocciput that has been hitherto considered as an anatomical variant of the clivus and not previously described as a potential source of clival or skull base pathology. We report the imaging findings in a 5-year-old child who presented acutely with a retropharyngeal abscess and osteomyelitis of the clivus. Imaging after treatment revealed a "notch-like" defect in the anterior clivus consistent with a fossa navicularis. Based on these appearances, we postulate that the lymphoid tissue of the pharyngeal tonsil residing in the fossa navicularis served as a route through which infection spread and subsequently developed into clival osteomyelitis, which is a rare diagnosis. This case is unique, and we believe that the presence of this variant in young children may be important and is not merely an anatomical curiosity.

Role of methicillin-resistant Staphylococcus aureus in head and neck infections

The prevalence of infection with methicillin-resistant Staphylococcus aureus is increasing. Methicillin-resistant Staphylococcus aureus is also being recognised as an important pathogen in head and neck infections. This review summarises studies published over the past two decades which illustrate the growing prevalence of methicillin-resistant Staphylococcus aureus, and the current therapeutic approaches to head and neck infections caused by this bacterium. These infections include sinusitis, otitis, periorbital cellulitis, cervical lymphadenitis, tonsillitis, thyroiditis, retropharyngeal abscess, and abscesses and wounds of the neck. Treatment of head and neck infections associated with methicillin-resistant Staphylococcus aureus includes drainage and debridement, as well as administration of local and systemic antimicrobials that provide coverage against these organisms and against potential aerobic and anaerobic pathogens that may be present if the infection is polymicrobial.