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PHYSICIANS’ FORUM SPONSORED BY BAYERS INDIA LTD 25 TH  Nov.2008 Case Review by Dr. K. K. Pateria, MD National Hospital, Bh...
History <ul><li>High grade fever with chills and rigors  - 2 months </li></ul><ul><li>Severe headache - 2 months </li></ul...
Presenting history <ul><li>Took anti-malarials and remained afebrile for 2 days. </li></ul><ul><li>Again had fever with ch...
Complaints on admission <ul><li>Vomiting, pain in abdomen, poor intake  </li></ul><ul><li>Along with altered sensorium </l...
Examination : <ul><li>O/E  : P = 76/min, R = 16/min, BP = 80/60 mm of Hg,    Afebrile. Mild pallor, </li></ul><ul><li>  No...
Exam : CNS <ul><li>Conscious slightly altered. </li></ul><ul><li>Pupils – BPNERL </li></ul><ul><li>NR – +/- </li></ul><ul>...
Investigations : <ul><li>CBP  : Hb  = 13.1 g% </li></ul><ul><li>: WBC = 15000/cumm </li></ul><ul><li>P 82  L 14  E 03  M 0...
Investigations : Contd… <ul><li>ADA = 26.3 U/L </li></ul><ul><li>HIV I & II = Negative </li></ul><ul><li>Urine R/M = 2-4 p...
Investigations : Contd… <ul><li>CXR = Normal </li></ul><ul><li>13. USG Abd. & Pelvis = Normal </li></ul><ul><li>Fundus exa...
??? <ul><li>? </li></ul>
Possibilities ? <ul><li>Bacterial/tubercular Meningitis </li></ul><ul><li>Encephalitis </li></ul><ul><li>Brain abscess </l...
Investigations : Contd… <ul><li>CSF : Qty = 2 ml </li></ul><ul><li>Color = Watery </li></ul><ul><li>Appearance = Clear </l...
 
 
 
video <ul><li>play </li></ul>
Investigations : Contd… <ul><li>MRI Brain : -  Large Right temporoparietal subdural  empyema </li></ul><ul><li>- Significa...
 
 
Diagnosis <ul><li>Neuroimaging  </li></ul><ul><li>MRI – better than CT in early stages, superior for abscess in posterior ...
Discussion - SDE <ul><li>Rare disorder </li></ul><ul><li>15-20 % of suppurative CND infection </li></ul><ul><li>Sinusitis ...
ETIOLOGY - SDE <ul><li>Aerobic or anaerobic bacteria </li></ul><ul><li>Staph, Strepto or enterococci </li></ul><ul><li>- A...
PATHOPHYSIOLOGY - SDE <ul><li>Spread  </li></ul><ul><li>  a).  Retrograde  – Sinusitis related SDE spreads from  septic th...
CLINICAL PRESENTATION-SDE <ul><li>Increasing headache and fever </li></ul><ul><li>Focal neurological deficit </li></ul><ul...
TREATMENT - SDE <ul><li>Neurosurgical evacuation </li></ul><ul><li>Empirical antibiotic treatment – Vancomycin, 3 rd  gen....
PROGNOSIS <ul><li>Depends on – </li></ul><ul><li>1. Level of consciousness on admission </li></ul><ul><li>2. Size </li></u...
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  1. 1. PHYSICIANS’ FORUM SPONSORED BY BAYERS INDIA LTD 25 TH Nov.2008 Case Review by Dr. K. K. Pateria, MD National Hospital, Bhopal
  2. 2. History <ul><li>High grade fever with chills and rigors - 2 months </li></ul><ul><li>Severe headache - 2 months </li></ul><ul><li>Vomiting off and on - 2 months </li></ul><ul><li>Altered sensorium - 3-4 days </li></ul>
  3. 3. Presenting history <ul><li>Took anti-malarials and remained afebrile for 2 days. </li></ul><ul><li>Again had fever with chills – took some treatment, details not available, but developed vomiting and fever. </li></ul><ul><li>Admitted in Hoshangabad in hospital for 20 days and had GTCS and unconsciousness on 4 th day of admission. Details of treatment and investigations not available, though CT was also done. </li></ul><ul><li>Hospitalised in PG hospital, Karond for 9 days but with no relief. Took DOR. Details of treatment not available. </li></ul><ul><li>Had Low grade fever, vomiting, GTCS 3 times followed by post ictal phase lasting 30 min. </li></ul>
  4. 4. Complaints on admission <ul><li>Vomiting, pain in abdomen, poor intake </li></ul><ul><li>Along with altered sensorium </li></ul>
  5. 5. Examination : <ul><li>O/E : P = 76/min, R = 16/min, BP = 80/60 mm of Hg, Afebrile. Mild pallor, </li></ul><ul><li> No icterus, clubbing or edema. </li></ul><ul><li> No lymphadenopathy, Mild dehydration +. </li></ul><ul><li>CVS : Normal </li></ul><ul><li>RS : Normal </li></ul><ul><li>P/A : Normal </li></ul>
  6. 6. Exam : CNS <ul><li>Conscious slightly altered. </li></ul><ul><li>Pupils – BPNERL </li></ul><ul><li>NR – +/- </li></ul><ul><li>Moving all 4 limbs Power grade IV-V. </li></ul><ul><li>Slight left side lateral rectus palsy. </li></ul><ul><li>Planters – B/L Flexor. </li></ul>
  7. 7. Investigations : <ul><li>CBP : Hb = 13.1 g% </li></ul><ul><li>: WBC = 15000/cumm </li></ul><ul><li>P 82 L 14 E 03 M 01 </li></ul><ul><li>ESR = 27 mm FHR </li></ul><ul><li>PS for MP = Negative </li></ul><ul><li>4. Malaria Antigen = Negative </li></ul><ul><li>Widal = Negative </li></ul><ul><li>LFT = Normal </li></ul><ul><li>RFT = Normal </li></ul><ul><li>8. Coagulation profile = Normal </li></ul>
  8. 8. Investigations : Contd… <ul><li>ADA = 26.3 U/L </li></ul><ul><li>HIV I & II = Negative </li></ul><ul><li>Urine R/M = 2-4 pc/hpf, otherwise normal </li></ul>
  9. 9. Investigations : Contd… <ul><li>CXR = Normal </li></ul><ul><li>13. USG Abd. & Pelvis = Normal </li></ul><ul><li>Fundus examination = bilateral papilloedema </li></ul><ul><li> with mild optic atrophy. </li></ul>
  10. 10. ??? <ul><li>? </li></ul>
  11. 11. Possibilities ? <ul><li>Bacterial/tubercular Meningitis </li></ul><ul><li>Encephalitis </li></ul><ul><li>Brain abscess </li></ul><ul><li>4. Subdural Hematoma </li></ul><ul><li>Superior Saggital thrombosis </li></ul><ul><li>Disseminated encephalomyelitis </li></ul><ul><li>Tuberculoma </li></ul><ul><li>SOL </li></ul>
  12. 12. Investigations : Contd… <ul><li>CSF : Qty = 2 ml </li></ul><ul><li>Color = Watery </li></ul><ul><li>Appearance = Clear </li></ul><ul><li>Coagulum = Not seen </li></ul><ul><li>Blood = Absent </li></ul><ul><li>Proteins = 17 mg % </li></ul><ul><li>Pandy’s test= Negative </li></ul><ul><li>Sugar = 61 mg % </li></ul><ul><li>Cells = 05 / cumm, All mononuclear </li></ul><ul><li>ADA = 4.6 </li></ul>
  13. 16. video <ul><li>play </li></ul>
  14. 17. Investigations : Contd… <ul><li>MRI Brain : - Large Right temporoparietal subdural empyema </li></ul><ul><li>- Significant surrounding mass effect </li></ul><ul><li>- Trans-tentorial herniation </li></ul>
  15. 20. Diagnosis <ul><li>Neuroimaging </li></ul><ul><li>MRI – better than CT in early stages, superior for abscess in posterior fossa. </li></ul><ul><li>Nuchal rigidity – unusual in abscess and epidural empyema, but if present suggest Subdural empyema (SDE). </li></ul><ul><li>4. In meningitis – No focal deficit usually. </li></ul>
  16. 21. Discussion - SDE <ul><li>Rare disorder </li></ul><ul><li>15-20 % of suppurative CND infection </li></ul><ul><li>Sinusitis esp. frontal, most common predisposing factor, 1-2 % can complicating to SDE </li></ul><ul><li>Young male preponderance </li></ul><ul><li>70 % occurring in 2 & 3 rd decade of life </li></ul><ul><li>- May be complication of head trauma, neurosurgery or subdural effusion </li></ul>
  17. 22. ETIOLOGY - SDE <ul><li>Aerobic or anaerobic bacteria </li></ul><ul><li>Staph, Strepto or enterococci </li></ul><ul><li>- Anaerobic bacteria – most common in SDE associated with sinusitis </li></ul>
  18. 23. PATHOPHYSIOLOGY - SDE <ul><li>Spread </li></ul><ul><li> a). Retrograde – Sinusitis related SDE spreads from septic thrombophlebitis of mucosal veins draining sinuses </li></ul><ul><li> b). Contiguous – From osteomyelitis of posterior wall of frontal and other sinuses </li></ul><ul><li> c). Direct – Due to neurosurgery </li></ul><ul><li>Association </li></ul><ul><li>- Epidural empyema (40 %) </li></ul><ul><li>- Cortical thrombophlebitis (35 %) </li></ul><ul><li>- Cerebritis (25 %) </li></ul>
  19. 24. CLINICAL PRESENTATION-SDE <ul><li>Increasing headache and fever </li></ul><ul><li>Focal neurological deficit </li></ul><ul><li>Seizures, partial motor becoming secondary generalized </li></ul><ul><li>Nuchal rigidity </li></ul><ul><li>Signs of raised ICP </li></ul><ul><li>6. Contra lateral hemiplegia – most common deficit, direct or due to venous infarct </li></ul>
  20. 25. TREATMENT - SDE <ul><li>Neurosurgical evacuation </li></ul><ul><li>Empirical antibiotic treatment – Vancomycin, 3 rd gen. Cephalosporin, Metronidazole. </li></ul><ul><li>Specific antibiotic – according to c/s. </li></ul><ul><li>4. Duration of treatment – 4 weeks of parenteral antibiotic treatment </li></ul>
  21. 26. PROGNOSIS <ul><li>Depends on – </li></ul><ul><li>1. Level of consciousness on admission </li></ul><ul><li>2. Size </li></ul><ul><li>Long term Neurological Sequele – </li></ul><ul><li>1. Seizures and hemiparesis in 50 % </li></ul>

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