(582) An Atypical Presentation of Mastoiditis Leading to Empyema, Meningitis, Subdural Empyema

Introduction: Mastoiditis, or inflammation of the mastoid air cells, frequently occurs due to otitis media. This condition is most common in children but rarely occurs in adults. Although typically treatable with antibiotics, here we present a refractory case leading to bacteremia, meningitis, subdural empyema, and status epilepticus.

Description: The patient is a 58-year-old female brought to the ER overnight for altered mental status and acute hypoxic respiratory failure, requiring High Flow Nasal Cannula with eventual intubation in the ER. Initial imaging included a CT Chest with bibasilar opacities, CT Head with mastoiditis, and respiratory biofiore positive for Parainfluenza Virus. She was admitted to the ICU for acute hypoxemic respiratory failure requiring mechanical ventilation and septic shock secondary to pneumonia on Levophed. The next day during a spontaneous awakening trial, the patient was noted to be encephalopathic. Blood and sputum cultures came back positive for Streptococcus Pneumoniae. She was already being treated with Ceftriaxone and Vancomycin at this time. Prompt LP was performed, and antibiotics were broadened to cover for meningitis.
Later that evening, she became febrile with a T max of 106.3 F and associated seizure. Repeat CT Head showed a subdural collection with leptomeningeal enhancement concerning for empyema. She underwent hemi-craniectomy and subdural empyema evacuation. Cultures grew Cutibacterium Acnes. Postoperatively, she remained in status epilepticus requiring high-dose antiepileptics.
The patient was evaluated for mastoid resection due to concern for mastoiditis eroding into the subdural space, but a multidisciplinary decision was made to continue medical therapy. Repeat neuroimaging showed multi-territorial ischemic infarcts in the pons and midbrain, secondary to meningitis. Her course was further complicated by obstructive hydrocephalus status post EVD and VP shunt.
Ultimately, the patient underwent tracheostomy and PEG tube placement and the family withdrew care in favor of comfort measures.

Discussion: This case underscores the importance of diligent and thorough workup of typically innocuous imaging findings such as mastoiditis, otitis media, etc. If left untreated, simple infections can progress to severe multisystem organ dysfunction and failure.