Epidural abscess presenting as severe depression with suicidal ideations: Case report

Abstract

Background: Epidural abscess (EDA) is an uncommon form of intracranial infection that generally presents with fever, headache, and focal neurologic deficit. Imaging generally reveals a lentiform collection with diffusion restriction on diffusion weighted image. We present an interesting case in which a patient with EDA presented with three weeks of depression with suicidal ideations. The patient displayed no notable infectious signs and the imaging was suggestive of chronic subdural hematoma (SDH) rather than EDA.

Case description: The patient is a 57-year-old man with past medical history significant for epilepsy and left hemiplegia secondary to remote traumatic brain injury who presented with a three-week history of depression, anxiety, and active suicidal ideation, resulting in psychiatric admission to an outside hospital. He had undergone three previous craniotomies for SDH many years ago and had no significant psychiatric history. Magnetic resonance imaging was consistent with subacute right SDH. On presentation, patient was at neurologic baseline and was afebrile with unremarkable labs. Operative findings demonstrated frank purulence in the epidural space. The patient was treated with antibiotics and both depression and suicidal ideations resolved postoperative day 5.

Conclusions: EDA can present in atypical ways, especially in patients who have undergone previous cranial procedures. Depression is one possible atypical presentation.

Keywords: Depression; epidural abscess; subdural empyema; suicidal ideations.

Figure 1

Axial noncontrast CT head 3 years prior to presentation showing right isodense extraaxial fluid collection within bounds of previous craniotomy (Unfortunately, we don’t have any history as to why this scan was ordered. It was sent to use as part of the current workup for EDA)

Figure 2

MRI of the brain without contrast on the day of admission. (a) T1WI showing hyperintense extraaxial fluid collection within the bounds of previous craniotomy on the right side. (b) T2WI showing hyperintense extraaxial fluid collection within the bounds of previous craniotomy on the right side. Both of these findings were consistent with late subacute SDH. (c) DWI shows some diffusion restriction within the extraaxial fluid collection on the right side. This was felt to be nonspecific secondary to history of previous extraaxial blood