675: A RARE CASE OF BILATERAL SUBDURAL EMPYEMA SECONDARY TO ESCHERICHIA COLI IN AN IMMUNOCOMPETENT INFANT

Abstract

Learning Objectives: Subdural empyema remains the life-threatening condition and requires neurosurgical emergencies. We present an extremely rare case of bilateral subdural empyema secondary to Escherichia Coli (E.Coli) requiring prompt surgical drainage in an immunocompetent infant. Method(s): 5-month old male, previously healthy who was transferred with meningitis and large bilateral subdural collections. He presented with one day history of fever, irritable, and bulging anterior fontanelle. Cultures from cerebrospinal fluid and blood were positive for E. coli. Initially stated on broad spectrum antibiotics including intravenous vancomycin, gentamicin and ceftriaxone. Later switched to monotherapy with ceftriaxone based on susceptibilities. Head CT and MRI showed large bilateral holohemispheric subdural complex fluid collections, concern of intracranial bleed or empyema. His empyema was surgically drain on admission and again on hospital day 15 secondary to persistent fevers and elevated inflammatory markers. Extensive work-up did not show osteomyelitis or endocarditis. In addition to repeat drainage, antibiotics switched to meropenam and ciprofloxacin for 2 weeks with improvement in inflammatory markers and fever curve. Extensive immunology work-up was negative for immunodeficiency syndrome. He was kept on levetiracetam anti-seizure prophylaxis for 7 days without any seizure. He had no neurologic complications after discharge from the hospital. Result(s): Subdural empyema is a known complication of bacterial meningitis. The mechanism is possible from bacterial seeding of the meninges which usually occurs through hematogenous spread and then progress to subdural empyema. Recent large nationwide study from Dutch hospitals demonstrated incidence of 2.7% with Streptococcus being a predominant organism. However, reported cases secondary to E.Coli are very rare. Post infection neurological squeale (paresis, focal seizures, dysesthesia) in Streptococcal empyema were very common. In our case, infant made complete neurological recovery at discharge and on 6-months follow-up. Surgical evacuation is the treatment of choice either craniotomy or the burr holes as untreated subdural empyema may lead to intracranial hypertension, herniation and death. Placement of surgical drainage can be left up to 72 hours. In conclusion, subdural empyema is a rare complication of infant with E. coli meningitis. Surgical evacuation is mandatory with prolonged systemic antibiotics.