Subdural Empyema, Brain Abscess, and Sinus Venous Thrombosis Secondary to Streptococcus Anginosus in a 13-Year-Old Patient

Background: Streptococcus anginosus, a normal flora of the oral cavity, gastrointestinal and urogenital system, is one of the viridans group streptococci. It can be frequently isolated from brain abscesses but is a rare cause of the liver, lung, and deep tissue abscesses.

Case Report: A 13-year-old female patient was referred to our pediatric intensive care unit(ICU) with altered mental status, aphasia, and behavioral change. On the brain computed tomography(CT) examination, subdural empyema extending from the left frontal sinus to the frontal interhemispheric area and to left hemispheric dura was detected with purulent collections in the right frontal, ethmoidal, maxillary sinuses. Intravenous ceftriaxone, vancomycin and metronidazole treatments were started. Subdural empyema was surgically drained. Postoperative brain magnetic resonance imaging(MRI) and venography showed severe cerebritis and superior sagittal sinus thrombosis. Enoxaparin was started. Cultures obtained from purulent empyema material revealed Streptococcus anginosus. On follow-up, brain CT examination was repeated after the symptoms of increased intracranial pressure syndrome and it showed brain edema and recurrence of subdural empyema that had been previously drained. Decompressive craniectomy was performed. Partial epileptic seizures occured. Phenytoin was added to levetiracetam treatment that had been started at the admission. Brain MRI showed a brain abscess on the interhemispheric area. Antibiotherapy was changed to vancomycin and meropenem. Immunoglobulin levels, lymphocyte subgroups, dihydrorhodamine test, galactomannan, and complement 50 were normal in our patient who had lymphopenia since the admission. After the recovery of consciousness, she was transferred to pediatric ward on day 10. The MRI findings of cerebritis and abscess formation improved in a month. The patient was discharged after six weeks of vancomycin treatment.

Conclusion: It should be kept in mind that rhinosinusitis caused by Streptococcus anginosus has a worse prognosis compared to other pathogens and may cause complications such as subdural empyema, brain abscess, and venous sinus thrombosis.