Subdural Empyema Presenting with Seizure, Confusion, and Focal Weakness
A 16-year-old male presented to the ED with 1 day of a reported fever, a right temporal headache, and a witnessed tonic-clonic seizure. He arrived confused with left arm weakness noted as well. He had no past history of seizures. For the preceding week, he had complained of sinus congestion and received an antibiotic from his primary care provider several days prior.\nHis review of systems was negative for rash, emesis or dyspnea. His medical history was unremarkable, and his immunizations were up to date. He lived at home with his family, none of whom were ill, and he took no medications or over-the-counter medications. He denied any allergies. Physical examination revealed a drowsy, but arousable, black male who was only oriented to person. His vital signs included a temperature of 36.6°C, pulse of 108, respiratory rate of 18, blood pressure of 118/54 mmHg, and an oxygen saturation of 100% on room air. His head and neck examination demonstrated only rhinorrhea but no meningismus, sinus tenderness, nystagmus or pupillary irregularity. His neurologic examination revealed isolated 0/5 weakness in the left upper extremity and confusion to time and place. His leg strength and reflexes were normal, but his gait was not tested. The remainder of his examination was normal. Diagnostic testing included an initial computed tomography (CT) that showed a right, frontal subdural hypodensity. His complete blood count was remarkable only for a white blood cell count of 17,300 cells/mm with a left shift. His basic metabolic panel showed normal electrolytes, glucose, and renal function. A magnetic resonance imaging (MRI) was obtained showing right frontal sinusitis with right subdural space extension (). A subsequent lumbar puncture demonstrated no organisms on gram stain and 3 white blood cells per high power field.\nHe was diagnosed with a subdural empyema and started on intravenous ceftriaxone and vancomycin. He received supportive care and pain control, and he was admitted to the pediatric intensive care unit (PICU) with neurosurgical consultation. His empyema was surgically drained on the day of presentation. The patient slowly recovered in the PICU without any further seizure activity. At the time of discharge, his left arm strength was 4/5 and he had a normal mental status. He was kept on anti-seizure prophylaxis for 6 months without recurrent seizures, and his strength returned to normal with physical therapy over the subsequent 6 months.