Clival osteomyelitis and hypoglossal nerve palsy--rare complications of Lemierre's syndrome

Case report: Metagenomics next-generation sequencing in the diagnosis of septic shock due to Fusobacterium necrophorum in a 6-year-old child

Fusobacterium necrophorum (F. necrophorum) infection is rare in pediatrics. In addition, the detection time of F. necrophorum by blood culture is long, and the positive rate is low. Infection with F. necrophorum bacilli usually follows rapid disease progression, resulting in high mortality. In previous reports of F. necrophorum-related cases, the most dangerous moment of the disease occurred after the appearance of Lemierre's syndrome. We report an atypical case of a 6-year-old female patient who developed septic shock within 24 h of admission due to F. necrophorum infection in the absence of Lemierre's syndrome. F. necrophorum was identified in a blood sample by metagenomics next-generation sequencing (mNGS) but not by standard blood culture. The patient was finally cured and discharged after receiving timely and effective targeted anti-infection treatment. In the present case study, it was observed that the heightened virulence and invasiveness of F. necrophorum contribute significantly to its role as a primary pathogen in pediatric septic shock. This can precipitate hemodynamic instability and multiple organ failure, even in the absence of Lemierre's syndrome. The use of mNGS can deeply and rapidly identify infectious pathogens, guide the use of targeted antibiotics, and greatly improve the survival rate of patients.

The Hypoglossal nerve

The hypoglossal nerve is the 12th cranial nerve, exiting the brainstem in the preolivary sulcus, passing through the premedullary cistern, and exiting the skull through the hypoglossal canal. This is a purely motor nerve, responsible for the innervation of all the intrinsic tongue muscles (superior longitudinal muscle, inferior longitudinal muscle, transverse muscle, and vertical muscle), 3 extrinsic tongue muscles (styloglossus, hyoglossus, and genioglossus), and the geniohyoid muscle. Magnetic resonance imaging (MRI) is the best imaging exam to evaluate patients with clinical signs of hypoglossal nerve palsy, and computed tomography may have a complementary role in the evaluation of bone lesions affecting the hypoglossal canal. A heavily T2-weighted sequence, such as fast imaging employing steady-state acquisition (FIESTA) or constructive interference steady state (CISS) is important to evaluate this nerve on MRI. There are multiple causes of hypoglossal nerve palsy, being neoplasia the most common cause, but vascular lesions, inflammatory diseases, infections, and trauma can also affect this nerve. The purpose of this article is to review the hypoglossal nerve anatomy, discuss the best imaging techniques to evaluate this nerve and demonstrate the imaging aspect of the main diseases that affect it.

Isolated hypoglossal nerve neuropathy in vertebral dolichoectasia: Microvascular decompression by vessel transposition with Teflon cuff

Background:

A clinical case of isolated unilateral hypoglossal nerve (HN) neuropathy, which spontaneously occurred from vertebral artery dolichoectasia and was cured by a new method of microvascular decompression by transposition of the vertebral artery using the Teflon cuff.

Case Description:

A young patient with an anamnesis of the disease for more than 4 years and complaints of a deviation of the tongue to the right and dysarthria was examined. MRI of the brain revealed compression of the medulla oblongata by an elongated, dilated, and deformed right vertebral artery. Compression of the medulla oblongata and HN was confirmed during surgery. A transposition of the vertebral artery was performed using a Teflon cuff in the ventral direction to the clivus. Three months after surgery, positive dynamics was noted in the form of regression of dysarthria and improvement of mobility and trophic language.

Conclusion:

Thus, isolated HN neuropathy as a result of compression by an elongated, dilated, and deformed vertebral artery is a rare neurological disease that can be successfully treated by transposition using a Teflon cuff.

Erosion of the sella turcica and pituitary expansion secondary to polymicrobial brain abscesses: a case report

Introduction

Brain abscesses can lead to a diverse array of complications, especially when they are polymicrobial in nature. Multiple underlying pathogens may present with a unique set of clinical symptoms which require an early identification and treatment. Skull base osteomyelitis with sellar floor erosion and pituitary involvement with SIADH are such rare complications of brain abscesses which have never been reported previously in the literature.

Case Presentation

We report the case of an immunocompetent 38-year-old male with altered mental sensorium and left hemiparesis due to polymicrobial brain abscess which required surgical evacuation. The post-operative recovery was complicated by severe hyponatremia secondary to SIADH which was treated uneventfully. Radiological imaging demonstrated pituitary enlargement with herniation through an eroded sella turcica without active CSF leak. Patient responded well to the antibiotic therapy based on microbiological susceptibility testing with a complete resolution of the pituitary enlargement on radiological follow-up.

Conclusion

Conservative treatment with targeted antibiotics can lead to the resolution of pituitary enlargement secondary to a brain abscess. However, a close clinical follow-up is required to look for a CSF leak considering the sellar floor erosion due to osteomyelitis.

A rare life-threatening complication of acute mastoiditis: Case report and literature review

Severe complications may not always present with "classic" signs and symptoms. In the setting of recent mastoiditis, complications including cerebral venous sinus thrombosis, skull base osteomyelitis, and retropharyngeal abscess should be considered, particularly with persistent or worsening symptoms. A broad differential can lead to prompt diagnosis and treatment, thereby reducing the likelihood of morbidity and mortality.

Cavernous sinus thrombosis caused by Streptococcus constellatus-associated Lemierre syndrome presenting as an isolated abducens nerve palsy

Purpose

To describe a patient with Streptococcus constellatus-associated Lemierre syndrome complicated by eventual cavernous sinus thrombosis (CST) that manifested as an isolated abducens nerve palsy.

Observations

A patient with a history of heavy alcohol use presented with Lemierre syndrome caused by an odontogenic infection due to Streptococcus constellatus. Despite initiation of intravenous antibiotics and eventual eradication of her bacteremia, she developed an isolated abducens nerve palsy on hospital day 7 due to associated CST.

Conclusions and Importance

CST is a rare complication of odontogenic infection and Lemierre syndrome. This case demonstrates the potential for primary odontogenic infections to progress to life- and sight-threatening diseases. This case also illustrates the importance of considering uncommon pathogens as the etiology of CST based on the suspected source of primary infection.

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.

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.