INFECTIOUS DISEASES

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INFECTIOUS DISEASES CASE CONFERENCE

• Pimpawan Boapimp, MD
• Wake Forest Baptist Medical Center
• October 18, 2004

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HPI

• 37 year old WM
• One month PTA, he had Lt-sided facial swelling,
  pain, and a knot on his Lt forehead
• Was diagnosed with acute sinusitis and was
  treated with antibiotics for 7 days.
• Symptoms resolved except a knot was still there
• One week PTA, he started having same symptoms
  with an intense left periorbital pain.

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HPI

• No F/C, night sweats
• Photophobia without visual changes
• No N/V
• Was seen in ED at OSH and had CT scan head done.
• Was referred to WFUBMC.

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Physical examination

• T 98.8 P 80 RR 18 BP 122/71 PO 96 RA
• GA AO X 3, afebrile, NAD
• HEENT 5 X 5 cms area of swelling at Lt forehead,
  tender at mass and Lt side of the face
• Chest CTA bilaterally
• Heart RSR, normal S1, S2, no murmur
• Abd Benign
• Ext No edema
• NS No focal deficit

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• Abscess from forehead
• PEPTOSTREPTOCOCCUS SPECIES
• SULBACTAM/AMP lt1 SUSCEPTIBLE
• CEFOXITIN lt2 SUSCEPTIBLE
• CEFOTETAN 4 SUSCEPTIBLE
  
• CEFTIZOXIME 4 SUSCEPTIBLE
• CEFOTAXIME lt2 SUSCEPTIBLE
• CEFTRIAXONE lt2 SUSCEPTIBLE
• CHLORAMPHENICOL 4 SUSCEPTIBLE
• PENICILLIN G lt0.06 SUSCEPTIBLE
• CLINDAMYCIN lt0.5 SUSCEPTIBLE
• METRONIDAZOLE gt16 RESISTANT
• TETRACYCLINE lt0.5 SUSCEPTIBLE
• IMIPENEM lt0.5 SUSCEPTIBLE
• PIPERACILLIN lt4 SUSCEPTIBLE
• TICAR/CLAVULANIC lt4 SUSCEPTIBLE
• MEZLOCILLIN lt4 SUSCEPTIBLE

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DIAGNOSIS ?
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• Ceftriaxone x 6 weeks
• F/U in IDSC

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Follow Up

• After 2 weeks of ceftriaxone, F/U with ENT

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2 week F/U Facial CT scan
Sub-galeal fluid collection
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2 week F/U Facial CT scan
Osteomyelitis
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2 week F/U Facial CT scan
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2 week F/U Facial CT scan
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Follow Up

• ENT did I and D of forehead abscess with penrose
  drain.
• Drain was removed one week after that.

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Follow Up

• After 4 weeks of ceftriaxone, F/U with ID.
• Clinically improved.

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6 week F/U Facial CT scan
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Potts Puffy Tumor

• Named after Sir Pervical Pott.
• An English surgeon who described it in 1760.
• Subperiosteal abscess and osteomyelitis of the
  frontal bone.

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Potts Puffy Tumor

• Sinus infection can easily spread to the orbit or
  to the orbital or intracranial cavity because of
  the anatomy.
• All sinuses share thin bony walls with the orbit
  and the cranium.
• Sinus veins also communicate with ophthalmic
  venous system

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Potts Puffy Tumor

• The ophthalmic venous system has no valves
  allow for an easy spread of infection.
• Lack of lymphatic system in the orbit also
  facilitates the spread of the infection.
• The cranial dura and galea derive blood supply
  from the same system.

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Potts Puffy Tumor

• Children have more diploic veins in the cranium
  than adults do.
• Allows infection to spread more deeply and more
  rapidly.

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• Meningitis is the most common complication of
  sinusitis.
• Frequently the result of sphenoiditis or
  ethmoiditis.
• HA, neck stiffness, fever
• CN palsy is frequently present.
• The most common abn. is a dysfunction of
  extraocular movement.
• Need CT brain before LP

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Trephination
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Intracranial complications of sinusitis

• Retrospective chart review of 82 adults and
  children
• From Jan 1, 1985 to Dec 31, 1999
• 39 pts (47.6) had intracranial complications
• 43 pts (52.4) had orbital complications

Ear Nose Throat J. 2002 Sep81(9)636-8, 640-2,
644. Intracranial complications of sinusitis a
15-year review of 39 cases. Younis RT, Lazar RH,
Anand VK.
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• 39 pts with intracranial complications
• 23 adults and 16 children
• most common complications
• - meningitis 21 pts (53.8)
• - epidural abscess 6 pts (15.4)
• - subdural abscess 5 pts (12.8)
• - intracerebral abscess 4 pts (10.3)
• - epidural abscess and Potts puffy tumor 1 pt
  (2.6)
• - Potts puffy tumor alone 1 pt

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• In pts with meningitis
• - most common bacteria S. pneumoniae (12/21
  pts)- CT showed that ethmoid and sphenoid
  sinuses were affected

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• Pansinusitis- predominant finding in the 16 pts
  with intracranial abscesses.
• All pts underwent surgical drainage.

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Types of local and distant complications of
sinusitis

• Local
• Intracranial complications
• Meningitis
• Epidural abscess
• Subdural abscess
• Intracerebral abscess
• Pott's puffy tumor
• Superior sagittal sinus thrombosis

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Types of local and distant complications of
sinusitis

• Local
• Orbital complications
• Periorbital cellulitis Extraconal
• Orbital cellulitis (preseptal)
• Subperiosteal abscess
• Orbital abscess Intraconal
• Cavernous sinus thrombosis (postseptal)
• Mucocele

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Types of local and distant complications of
sinusitis

• Distant
• Pulmonary (exacerbations of)
• Asthma
• Bronchitis
• Chronic obstructive pulmonary disease Cystic
  fibrosis
• Systemic diseases
• Sepsis
• Toxic shock syndrome