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Fulminant Bacterial Meningitis ComplicatingSphenoid SinusitisAkihiko Saitoh, MD,* Bernard Beall, PhD,y and Victor Nizet, MD*Key Words: sphenoid sinus, Streptococcus pneumoniae, sinusitis,Streptococcus pyogenes, meningitisIntracranial complications of sinusitis, including meningitis,are uncommon in childhood. Among pediatric patientsadmitted for treatment of sinusitis, 3.2% were found to havean intracranial complication.1Conversely, among pediatricpatients with intracranial infections, only 2.4% had infectionssecondary to sinusitis.2Infection of the sphenoid sinuses,however, merits particular concern. These thin-walled sinusesdevelop late in childhood, and their deep location places themadjacent to the dura mater and other critical structures. Herewe describe 2 previously healthy adolescent boys who de-veloped fulminant bacterial meningitis as a complication ofsphenoid sinusitis.CASESPatient 1 is a previously healthy 14-year-old African-American male with sickle trait who presented to an outside emer-gency department after 5 days of headache and fatigue, 2 days offever and nasal congestion, and sudden worsening of headache withdecreased level of consciousness. On arrival, he was disorientatedand agitated with Glasgow Coma Scale (GCS) = 6 and markedhypertension (180/120 mm Hg). Lumbar puncture found an elevatedopening pressure = 52 cm H2O and yielded turbid fluid with aleukocyte count of 14,000/mm3(95% neutrophils, 2% lymphocytes,3% monocytes), glucose < 20 mg/dL, protein 1,293 mg/dL, andabundant Gram-positive diplococci. The patient was intubated,treated with antihypertensives, and transported to our ICU. Van-comycin (60 mg/kg/d) and ceftriaxone (100 mg/kg/d) were begun.Admission CBC revealed WBC 23,700/mm3(46% neutrophils, 39%bands), normal hemoglobin, and platelets. Serum electrolytes, bloodurea nitrogen, creatinine, and serum aminotransferases were normal.Computerized tomography scan of head showed fluid and mucoper-iosteal thickening in the left ethmoid sinus and both sphenoid sinuses(Fig. 1A). CSF culture and blood cultures grew Streptococcuspneumoniae sensitive to penicillin (MIC  0.03 mg/mL); vancomy-cin was discontinued. The initial hypertension quickly resolved andthe patient remained hemodynamically stable throughout the hos-pitalization. He experienced steady improvement in his level ofconsciousness and was extubated on hospital day 6. Audiogram wasnormal. The patient was discharged in good condition uponcompleting 10 days of ceftriaxone therapy.Patient 2 is a previously healthy 12-year-old African-Americanmale who presented to our emergency department following 3 days ofproductive cough, greenish nasal discharge and headache, 2 days offever, nausea and vomiting, then sudden worsening of headache withphotophobia and neck discomfort. He had normal vital signs andclear mental status, but meningismus was appreciated on examina-tion. A lumbar puncture found opening pressure of 41 cm H2O, andyielded clear fluid with a leukocyte count of 144/mm3(88% neu-trophils, 5% lymphocytes, and 7% monocytes), glucose 88 mg/dL,protein 32 mg/dL, and negative Gram stain. CBC showed WBC14,700/mm3(40% neutrophils, 51% bands), normal hemoglobin, andplatelets. Serum electrolytes, blood urea nitrogen, creatinine, andserum aminotransferases on admission were normal. Within a 3-hourobservation period in the emergency department, he rapidly dete-riorated with GCS dropping to 6, and then suffered a right-sided focalseizure with periodic breathing. Blood pressure and pulse remainedstable. The patient was intubated and admitted to the ICU, van-comycin and ceftriaxone treatment initiated, and an intracranialpressure monitor was placed. Computerized tomography scan ofhead revealed total opacification of right ethmoid, maxillary andsphenoid sinuses (Figure 1B). CSF culture yielded Streptococcuspyogenes while blood culture was sterile; vancomycin therapy wasdiscontinued. On hospital day 3, the patient’s condition worsened,with development of adult respiratory distress syndrome, inotropicsupport requirements, and appearance of a scarletiniform rash overthe entire body. Clindamycin therapy was added and he ultimatelyexperienced widespread epidermal desquamation. The patient re-ceived prolonged ventilatory support and intracranial pressuremonitoring, but was ultimately discharged in good conditionfollowing 2 weeks of antibiotic therapy and an additional 3 weeksof rehabilitative care. Audiogram was normal.DISCUSSIONSphenoid sinusitis is identified in approximately 3% ofcases of acute sinusitis, typically in the context of pansinu-sitis.3Significant development of the sphenoid sinuses doesnot begin until age 4 to 6, thus, sphenoid sinusitis is restrictedIllustrative CasePediatric Emergency Care Volume 19, Number 6, December 2003 415*Division of Pediatric Infectious Diseases, University of California, SanDiego, La Jolla, CA; yRespiratory Diseases Branch, National Centerfor Infectious Diseases, Centers for Disease Control and Prevention,Atlanta, GA.Address correspondence and reprint requests to Victor Nizet, MD, Division ofPediatric Infectious Diseases, MC 0687, University of California, SanDiego, La Jolla, CA 92093. E-mail: [email protected] n 2003 by Lippincott Williams & WilkinsISSN: 0749-5161/03/1906-0415Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is older children and adolescents. Likewise, intracranial com-plications of sinusitis appear predominantly in older children.Pooling 4 published pediatric series,1,2,4,5we calculated amedian age of 13 years and a male proponderance of 3:1.Approximately 80% of pediatric patients with intracranialcomplications of sinusitis have sphenoid involvement.2,4–7Table 1 summarizes the features of pediatric sphenoid si-nusitis with intracranial complications from those cases inwhich sufficient clinical data were provided.2,5–7The anatomic location of the sphenoid sinus places itadjacent to the optic canals, dura mater, cavernous sinuses,cranial nerves III to VI, and the internal carotid arteries. Thebony walls of the sphenoid are thin or sometimes absent,leaving the sinus separated from intracranial structures by anarrow mucosal barrier. Diagnosis of sphenoid sinusitis isoften difficult.8Located deep in the apex of the nasal cavity,the sphenoid sinuses are not amenable to percussion nortransillumination and may be indistinct on routine radio-graphs.3Early symptoms are usually nonspecific,

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