Superimposed propionibacterium acnes subdural empyema in a patient with chronic subdural hematoma

Abstract

The authors present a case of subdural empyema in a macrocephalic patient. A 23-year-old male was admitted due to headache and fever. One month ago, he had mild head injury by his coworkers. Physical examination showed a macrocephaly and laboratory findings suggested purulent meningitis. Neuroimaging studies revealed a huge size of epidural space-occupying lesion. Under the impression of epidural abscess, operation was performed. Eventually, the lesion was located at subdural space and was proven to be subdural empyema. Later, histological examination of the specimen obtained by surgery demonstrated finings consistent with the capsule of the chronic subdural hematoma. Two weeks after operation, Propionibacterium acnes was isolated. The intravenous antibiotics were used for total of eight weeks under monitoring of the serum level of the C-reactive protein. Follow-up brain computed tomography (CT) scan showed the presence of significant amount of remaining subdural lesion. However, he has complained of minimal discomfort. It is suggested that the subdural empyema occurred with preexisting chronic subdural hematoma after head injury about one month prior to admission and it took a long time to treat Propionibacterium acnes subdural empyema with systemic antibiotics, at least over eight weeks.

Keywords: C-reactive protein; Chronic subdural hematoma; Propionibacterium acnes; Subdural empyema.

Fig. 1

The lateral view of the skull showing macrocephaly and multiple calcifications.

Fig. 2

Preoperative precontrast computed tomography scans revealing lentiform-shaped high density lesion at the left frontal area (A) and a large space-occupying lesion with isodensity over the left cerebral hemisphere (B).

Fig. 3

Immediate postoperative computerized tomography scans showing improvement of preoperative midline shifting (A) and new occurrence of a large amount of epidural hematoma at right cerebral convexity (B).

Fig. 4

Photomicrograph of the resected outer capsule of subdural empyema showing thick, fibrous membrane suggesting the membrane of the chronic subdural hematoma (A) (H & E, ×40) and revealing inflammatory changes with prominent neutrophil infiltration (B) (H & E, ×200).

Fig. 5

Computed tomography scan at postoperative one year demonstrating still remaining significant amount of subdural fluid collection at left cerebral convexity.