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Sanjay Gupta, Shobhan Vachhrajani, Abhaya V. Kulkarni, Michael D. Taylor, Peter Dirks, James M. Drake and James T. Rutka

Object

Extraaxial infections of the CNS, including subdural empyema and epidural abscess, are rare but potentially life-threatening conditions. Symptoms are usually progressive, and early diagnosis is therefore important. Early intervention with appropriate treatment offers the best opportunity for eradicating the infection and promoting maximal neurological recovery.

Methods

The medical records of children with extraaxial CNS infection over the last 24 years at the Hospital for Sick Children were analyzed. Only those patients with radiological and/or operative confirmation of the diagnosis of subdural empyema or epidural abscess were included in the study. Demographic and clinical data were collected to determine the outcomes after such infections and factors that predict for such outcomes.

Results

The authors identified 70 children who fulfilled the inclusion criteria. Sinusitis was the most common etiology and was seen in 38 patients. All of these patients were older than 7 years of age at diagnosis. Subdural empyemas were diagnosed in 13 patients following bacterial meningitis, and they were found primarily in infants within the 1st year of life. Other etiological factors included otogenic infection (4 cases), postneurosurgical infection (7 cases), and hematogenous spread of infection (7 cases including 6 cases of spinal epidural abscess). Streptococcus anginosus and Staphylococcus aureus were the most common pathogens identified. Sixty-four patients (91.4%) underwent at least 1 neurosurgical procedure. Seizures and cerebral edema from cortical vein thrombosis were the most common complications.

Conclusions

Due to variable etiology, identification of the responsible microorganism through neurosurgical drainage followed by long-term intravenous antibiotics remains the mainstay in treating extraaxial CNS infections. Optimal outcome is achieved with early diagnosis and therapy.

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David A. Herbert and Joel Ruskin

(brain abscesses) developed in association with meningitis. Three cases appeared to be precipitated by trauma or neurosurgery. Finally, three other cases (including ours) probably were late sequelae of an earlier typhoidal illness. These cases demonstrate not only that Salmonellae can cause focal CNS infections but that it is important to suspect these organisms as a cause of such infection in any patient with previous salmonellosis, regardless of how long the interval. TABLE 1 Focal central nervous system infections caused by Salmonella species

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Okezie Obasi Kanu, Efosa Ukponmwan, Olufemi Bankole, John Olutola Olatosi and Sarajudeen Oladele Arigbabu

Throat J 81 : 636 – 638 , 644 , 2002 58 Ziai WC , Lewin JJ III : Update in the diagnosis and management of central nervous system infections . Neurol Clin 26 : 427 – 468 , viii , 2008

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Rogier P. Schade, Janke Schinkel, Freek W. C. Roelandse, Ronald B. Geskus, Leo G. Visser, Marc C. van Dijk, Joan H. C. Voormolen, Hans van Pelt and Ed J. Kuijper

, then the positive CSF result was considered a contamination. Contamination was identified in 20 patients. Patients with negative cultures or contaminated cultures were defined as not having ED-BM. Excluded from the study were 30 patients with temporarily externalized internal CSF drains, such as malfunctioning ventriculoperitoneal or ventriculoatrial drains. Twenty patients with a central nervous system infection, such as cerebral abscess or tuberculosis, that was present before placement of the drain were also excluded. Therefore, 230 patients were included in the

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Liverana Lauretti, Quintino Giorgio D'Alessandris, Massimo Fantoni, Tiziana D'Inzeo, Eduardo Fernandez, Roberto Pallini and Giancarlo Scoppettuolo

, Kang HS , Sohn CH , Oh BM : Cauda equina syndrome misdiagnosed as aggravated hydrocephalus: neurological complication of intrathecal colistin in post-surgical meningitis . Acta Neurochir (Wien) 153 : 425 – 427 , 2011 10 Nau R , Sörgel F , Eiffert H : Penetration of drugs through the blood-cerebrospinal fluid/blood-brain barrier for treatment of central nervous system infections . Clin Microbiol Rev 23 : 858 – 883 , 2010 11 Pallotto C , Fiorio M , D'Avolio A , Sgrelli A , Baldelli F , Di Perri G , : Cerebrospinal fluid

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Bharat Guthikonda, Emilie Rouah, Bhuvanaswari Krishnan, Suzanne Z. Powell, J. Clay Goodman, Shankar P. Gopinath and Richard K. Simpson

MW , Homans AC , O'Shea PA : An unusual central nervous system infection in a young immunocompromised host . Arch Pathol Lab Med 110 : 497 – 501 , 1986 4 Antinori A : Evaluation and management of intracranial mass lesions in AIDS: report of the Quality Standards Subcommittee of the American Academy of Neurology . Neurology 51 : 1233 – 1234 , 1998 5 Autran B , Gorin I , Leibowitch M , Laroche L , Escande JP , Hewitt J , : AIDS in a Haitian woman with cardiac Kaposi's sarcoma and Whipple's disease . Lancet 1 : 767 – 768

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Rogier P. Schade, Janke Schinkel, Leo G. Visser, J. Marc C. van Dijk, Joan H. C. Voormolen and Ed J. Kuijper

pathogen, results of consecutive samples were negative, and no treatment had been started, then the CSF result was considered a contamination (20 patients). Patients with negative cultures or cultures considered to be contaminated were categorized as having no ED-BM. Thirty patients were excluded from the study with temporarily externalized internal CSF drains, such as malfunctioning ventriculoperitoneal or ventriculoatrial drains. Another 20 patients were also excluded because they demonstrated central nervous system infection (cerebral abscess or tuberculosis) prior

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Eric C. Raps, David H. Gutmann, James R. Brorson, Michael O'Connor and Howard I. Hurtig

✓ Central nervous system infections with Listeria monocytogenes result in varied clinical syndromes ranging from meningitis to rhomboencephalitis. A case of Listeria meningitis complicated by symptomatic communicating hydrocephalus and hydrostatic cervical cord compression is presented which clinically and radiographically improved with aggressive ventricular drainage.

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Ronald J. Ignelzi and Gary D. VanderArk

✓ The efficacy of chemoprophylaxis in the treatment of basilar skull fractures was studied in 129 patients over a 2-year period; antibiotics were found ineffective in preventing central nervous system infections, and in some cases may have proved harmful. It is suggested that a more rational approach to the treatment of basilar skull fractures includes close observation of the patient for early signs of meningitis, and if these should develop, treatment with antibiotics appropriate to the organism involved.

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S. Kwame Ofori-Kwakye, David G. Sidebottom, Joseph Herbert, Edwin G. Fischer and Govinda S. Visvesvara

✓ A case of a previously healthy 7-year-old girl with a left frontoparietal tumor identified as an Acanthamoeba-induced granuloma is reported, and the literature on Acanthamoeba meningoencephalitis is reviewed. Unlike most reported cases, the Acanthamoeba central nervous system infection presented in this girl as a discrete tumor without meningeal involvement or diffuse encephalitis. A favorable outcome was obtained following total excision of the mass and treatment with ketoconazole.