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| CASE REPORT |
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| Year : 2022 | Volume
: 49
| Issue : 3 | Page : 356-357 |
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Maximal medical therapy in extensive subdural empyema of the brain and spinal cord
Fotis G Souslian1, Tariq Janjua2, Luis Rafael Moscote-Salazar3
1 Department of Neurosurgery, Banner Health Clinic, Greeley, CO, USA
2 Department of Research, Aneuclose LLC, Minneapolis, MN, USA
3 Department of Research, Colombian Clinical Research Group in Neurocritical Care, Bogota, Colombia
| Date of Submission | 06-Dec-2022 |
| Date of Acceptance | 28-Oct-2022 |
| Date of Web Publication | 27-Dec-2022 |
Correspondence Address:
Dr. Luis Rafael Moscote-Salazar
Colombian Clinical Research Group in Neurocritical Care, Bogota
Colombia
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jss.jss_116_22
Severe subdural empyema (SDE) involving both the brain and spinal cord can be a life-threatening condition if not treated properly. We describe a malnourished patient with extensive spinal and intracranial SDE, whose poor prognosis prompted palliative care consultation. Surgical options were not possible. However, following maximal medical therapy, the patient's condition resolved completely in 1 year. This case highlights the important relationship between neurocritical care medical management and infection when surgical options are not possible.
Keywords: Antibiotics, neurological infection, nutritional therapy, subdural empyema
How to cite this article:
Souslian FG, Janjua T, Moscote-Salazar LR. Maximal medical therapy in extensive subdural empyema of the brain and spinal cord. J Sci Soc 2022;49:356-7 |
| Introduction | |  |
Subdural empyema (SDE) rarely presents simultaneously in the brain and spinal cord. The high mortality rate (14%–28%) for SDE, in general, indicates that the presence of extensive SDE in both locations is a medical emergency.[1] We describe an undernourished patient with extensive spinal and intracranial SDE that resolved completely after treatment with broad-spectrum antibiotics and nutritional supplements, without surgery. Due to poor medical conditions, surgery risks were not accepted by the patient. This case suggests maximal medical therapy is an effective treatment strategy for advanced SDE.
| Case Report | | |
A 61-year-old female patient entered our hospital with a urinary tract infection and 1 week of worsening severe back pain, fevers, and chills. Medical history indicated a right middle cerebral artery aneurysm with a subarachnoid hemorrhage that was treated with coil embolization. Bilateral clonus indicated spinal cord compression with no other signs of neurological distress. The patient was hypotensive and in septic shock. Broad-spectrum antibiotics (vancomycin, ampicillin, and ceftriaxone) were started on arrival. Her laboratory investigations showed elevated white blood cells (WBC) – 12.2/nL, C-reactive protein (CRP) – 49.2 mg/L, and erythrocyte sedimentation rate (ESR) – 59 mm/h. Protein shakes were added to her diet due to low albumin (1.2 g/dL, normal: 3.5–5.0) and body mass index (BMI) – 19 kg/m2.
Magnetic resonance imaging showed early ventriculitis and extensive SDE throughout the cervical, thoracic, and lumbar levels causing spinal canal narrowing, stenosis, and discitis in multiple areas [Figure 1]. A palliative care specialist was consulted due to the severity of the infection. Surgical options were discussed, including multilevel laminectomies throughout the spine and lumbar drain displacement. Microorganism speciation revealed methicillin-sensitive Staphylococcus aureus. The patient's antibiotic regimen was changed to nafcillin to more effectively target the infection. Her ESR, CRP, and WBC normalized after 2 months on nafcillin. Imaging at 4 months showed minimal evidence of empyema in the cervical and lumbar/thoracic spine [Figure 2]. At 1 year of follow-up, the patient's condition improved dramatically, and she was discharged from her rehabilitation facility with a healthy BMI (2.1 kg/m2). Her SDE remains resolved. | Figure 1: Initial T2 sagittal MRI of the (a) cervical and (b) lumbar and thoracic spine showing extensive SDE collections causing spinal canal narrowing at C5–C7, T10–T11, and L2–L4, and severe stenosis at L1. MRI: Magnetic resonance imaging, SDE: Subdural empyema
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 | Figure 2: Resolved epidural and SDE 4 months postantibiotic and nutritional treatment. (a) Cervical spine T1 postcontrast sagittal MRI. (b) Lumbar T2 sagittal MRI. MRI: Magnetic resonance imaging, SDE: Subdural empyema
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| Discussion | | |
In this case, maximal medical therapy including antibiotic treatment and nutritional therapy led to a quick recovery. Surgical options were limited due to septic shock and the need for an extensive procedure. In underweight patients with an extensive infection, antibiotic therapy combined with nutritional supplementation may lead to positive outcomes, even in cases with an extremely poor outlook.
Only four cases of SDE presenting in both the brain and spinal cord have been reported in the literature, and each case differed in the treatment approach. Mortazavi et al. treated with a laminectomy, abscess evacuation, and intravenous administration of antibiotics.[2] The patient survived but developed quadriparesis, right third-nerve palsy, left facial palsy, and hoarseness. Pompucci et al. treated with a suboccipital craniectomy, drainage of empyema, and antibiotic treatment with vancomycin and rifampin.[3] The patient was discharged after 8 months with no neurological deficit. Baker et al. described a case of extensive cranial SDE that encircled the entire spinal cord. Due to the poor prognosis, no further intervention was undertaken and the patient succumbed.[4] Finally, Kamat et al. reported a 2-year-old patient with SDE along the entire neural axis treated with surgical drainage.[5] The patient was discharged with no neurological deficit.
Malnutrition is associated with immunodeficiency and increased susceptibility to infection and its associated severity. A 2010 study of 619 individuals found that a BMI of <20 was associated with an infection incidence hazard ratio of 1.62.[6] A 2015 meta-analysis of 19,538 geriatric patients revealed that underweight individuals had a 65% increased risk of infection-related mortality.[7] The successful outcome presented here highlights the importance of nutritional supplementation in conjunction with antibiotic treatment in undernourished patients with extensive and life-threatening infections such as spinal and intracranial SDE.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Le Beau J, Creissard P, Harispe L, Redondo A. Surgical treatment of brain abscess and subdural empyema. J Neurosurg 1973;38:198-203.  |
| 2. | Mortazavi MM, Quadri SA, Suriya SS, Fard SA, Hadidchi S, Adl FH, et al. Rare concurrent retroclival and pan-spinal subdural empyema: Review of literature with an uncommon illustrative case. World Neurosurg 2018;110:326-35. |
| 3. | Pompucci A, De Bonis P, Sabatino G, Federico G, Moschini M, Anile C, et al. Cranio-spinal subdural empyema due to S. intermedius: A case report. J Neuroimaging 2007;17:358-60. |
| 4. | Baker RP, Brown EM, Coakham HB. Overwhelming cranial and spinal subdural empyema secondary infected sacral decubitus ulcers. Br J Neurosurg 2003;17:572-3. |
| 5. | Kamat AS, Thango NS, Husein MB. Proteus mirabilis abscess involving the entire neural axis. J Clin Neurosci 2016;30:127-9. |
| 6. | Dorner TE, Schwarz F, Kranz A, Freidl W, Rieder A, Gisinger C. Body mass index and the risk of infections in institutionalised geriatric patients. Br J Nutr 2010;103:1830-5. |
| 7. | Veronese N, Cereda E, Solmi M, Fowler SA, Manzato E, Maggi S, et al. Inverse relationship between body mass index and mortality in older nursing home residents: A meta-analysis of 19,538 elderly subjects. Obes Rev 2015;16:1001-15. |
[Figure 1], [Figure 2]
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