Hypertrophic cranial pachymeningitis and skull base osteomyelitis by pseudomonas aeruginosa: case report and review of the literature

Abstract

Hypertrophic cranial pachymeningitis (HCP) is an uncommon disorder characterized by localized or diffuse thickening of the dura mater, and it usually presents with multiple cranial neurophaties. It has been associated with a variety of inflammatory, infectious, traumatic, toxic and neoplasic diseases, when no specific cause is found the process is called idiopathic. The infectious cases occur in patients under systemic immunosuppression, which have an evident contiguous source or those who have undergone neurosurgical procedures. We describe a case of a 62-year-old immunosuppressed woman with diabetes and rheumatoid arthritis, which had HCP and osteomyelitis of the skull base caused by pseudomonas aeruginosa, presenting with headache and diplopia. We believe this is the second documented case of pachymeningitis secondary to this microorganism. As a multifactorial disease, it is essencial to determine the specific causative agent of HCP before making treatment decisions, and great care is needed with immunocompromised patients.

Keywords: Pseudomonas aeruginosa; Hypertrophic pachymeningitis; Ophtalmoplegia, optical neuropathy; Osteomyelitis; Skull base.

Figure 1

(a-c) MRI images (coronal and horizontal cuts) showing a pachymeningeal thickening around the left anterior clinoid process and lesser wing of the sphenoid, that extends to the left anterior cranial fossa and the anterior part of the middle cranial fossa; it also extends to the orbitary apex through the left optic foramen and superior orbital fissure, affecting the extraocular orbitary muscles, compressing the optic nerve and infiltrating the bone marrow of the lesser wing of the sphenoid and the orbitary wall. This lesion was hypointense on both T1- and T2-weighted images and proeminently enhanced after administration of gadolinium.