Meningitis and Subgaleal, Subdural, Epidural Empyema Due to Pasteurella Multocida

The Journal of Emergency Medicine, Vol. 39, No. 1, pp. 35–38, 2010 Copyright © 2010 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$–see front matter

doi:10.1016/j.jemermed.2008.04.008

Clinical Communications: Pediatrics

MENINGITIS AND SUBGALEAL, SUBDURAL, EPIDURAL EMPYEMA DUE TO PASTEURELLA MULTOCIDA Hüseyin Per,

MD,*

Sefer Kumandas¸, MD,* Hakan Gümüs¸, MD,* Mustafa K Öztürk, and Abdulhakim Ços¸kun, MD‡

MD,†

*Department of Pediatric Neurology, †Department of Pediatric Infection, and ‡Department of Radiology, Erciyes University Medical Faculty, Kayseri, Turkey Reprint Address: Hüseyin Per, MD, Department of Pediatric Neurology, Erciyes University Medical Faculty, Kayseri 38039, Turkey

e Abstract—Pasteurella is a Gram-negative coccobacillus found in 70 –90% of oral cavities of cats, and as well, is isolated from the digestive systems of dogs, rats, rabbits, monkeys, and other animals. Pasteurella multocida has been known to cause infections in humans, the most familiar being soft tissue infection after animal bites. However, this organism may affect a variety of systems, causing serious disease. Pasteurella multocida can cause septic arthritis, osteomyelitis, pneumonia, endocarditis, meningitis, and septicemia. We report a case of bacterial meningitis, subgaleal, subdural, and epidural empyema due to Pasteurella multocida by a rabbit licking that resulted in neurological complications and a prolonged recovery period. © 2010 Elsevier Inc.

cause of meningitis. Meningitis and epidural, subdural, and subgaleal empyema are rare forms of Pasteurella multocida infection. We report a previously healthy 15-year-old boy who developed Pasteurella meningitis and subdural, epidural, and subgaleal empyema secondary to a pet rabbit licking through kerion celci (a nodular, boggy, exudative circumscribed swelling covered with pustules secondary to tinea infections) at the occipital region.

CASE REPORT

e Keywords—Pasteurella multocida; meningitis; empyma; rabbit

A 15-year-old boy was admitted to our Pediatric Emergency service with complaints of headache, increased body temperature, weakness, and swelling of the head. The complaints started 1 week prior. First the left eye started to swell, and then it spread to the left half of his head. Additionally, he had increased body temperature, decreased appetite, and lethargy. His detailed history revealed that he had a pet rabbit, and it had died 3 days before from an unknown cause. On physical examination, he had confusion, lethargy and disorientation. He had a hyperemic fluctuating soft tissue swelling starting from the left of his eyelid and spreading to the left frontal and temporal region. There was a 4-cm kerion celsi on the occipital region and there was a squamous lesion on which the

INTRODUCTION Pasteurella multocida is a small Gram-negative coccobacillus, which is part of the normal flora of many animals including cats, dogs, and rabbits. It is a major pathogen in wound infections in humans due to an animal bite, most commonly causing local cellulitis or abscess formation, but may also cause bone and joint infections, respiratory tract infections, intra-abdominal infections, endocarditis, and meningitis (1–7). Pasteurella multocida is the commonest cause of local infection after an animal bite, but it is an unusual

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hair could be removed easily. Neurological examination revealed that there was neck stiffness. Kerning sign and Brudzinski sign were positive. Other systems were normal on physical examination. He had no previous history of any other disease and no use of any medication. The initial laboratory findings, including urinalysis, electrolytes, blood urea nitrogen, and creatine values, were normal. A chest X-ray study was normal. The complete blood count revealed white blood cell (WBC) count of 13,500/uL with 80% neutrophils and 15% band forms, a hematocrit of 40%, and platelets of 440,000/uL. Brain computed tomography (CT) scan showed edema. On the third day of admission, a lumbar puncture (LP) was performed and showed atypical meningitis with leukocytosis, low glucose, and elevated protein levels. Cerebrospinal fluid (CSF) microscopy revealed 180 WBC/uL with 90% neutrophils, and after 20 days of antibiotic therapy, the CSF findings normalized. On an initial cranial CT scan, an epidural empyema of the right frontal region, subcutaneous abscess of the left frontal region, and findings of cerebral edema are demonstrated (Figure 1). Seven days later, a cranial magnetic resonance imaging study showed a subgaleal abscess of the bilateral frontal regions, epidural and subdural abscesses localized to the frontoparietal region, and a midline shift from right to left (Figure 2).

Figure 1. Axial cranial CT scan shows epidural empyema at right frontal region (short arrow), subcutaneous abscess at left frontal region (long arrow), and brain edema.

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Figure 2. Axial T2-weighted cranial magnetic resonance study shows subgaleal abscess at bilateral frontal regions (thin arrows), epidural and subdural abscess localized at frontoparietal region (thick arrows), and midline shift from right to left.

Although subdural empyema was decreased, there was still evidence of it on cranial CT scan after 45 days (Figure 3).

Figure 3. Axial cranial CT scan shows subdural empyema (arrows), on 45th treatment day.

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Vancomycin, rifampin, and chloramphenicol antibiotherapics were initially started. Cefotaxime was started instead of chloramphenicol after the diagnosis of meningitis after the LP. Diphenylhydantoin was added on the same day for focal convulsions, and phenobarbital was needed due to uncontrolled convulsions. On the 7th day of admission, the patient was unconscious and there was left-sided hemiparesis and seizures, and after demonstration of a diffuse subdural empyema and shift from right to left, the patient was operated upon. After surgery the patient was conscious. The empyema was drained surgically (30 cc subdural and 60 cc subgaleal empyema). Pasteurella multocida was demonstrated in empyema cultures. After the 25th day of admission, the antibiotics were changed to cefazolin, penicillin, and chloramphenicol. After 4.5 years, the patient is on antiepileptic therapy and there are no neurological deficits.

DISCUSSION Pasteurella multocida was first noted in the blood of birds with fowl cholera in 1877. Kitt in 1878 isolated a Pasteurella species from wild hogs during an epidemic illness. Brugnatelli first described human infection by Pasteurella multocida in 1913 (8). The first documented case of Pasteurella multocida meningitis was noted in 1925 by Claudius (9). Pasteurella is a small, non-motile, bipolar staining, Gram-negative coccobacillus. Pasteurella multocida has been confused with Hemophilus influenza, Klebsiella, and Neissera. Pasteurella forms part of the normal flora in the nasopharynx of many domestic and wild animals. Typically, Pasteurella multocida is inoculated by animal contact, such as a scratch, lick, or bite, and will present to the Emergency Department several days later as a local cellulitis or abscess (1–9). In our case, there were also findings of hyperemic fluctuating soft tissue swelling starting from the left eyelid and spreading to the left frontal and temporal region. Mechanisms by which Pasteurella multocida may cause meningitis include: 1) direct penetration of the skull by a deep bite or trauma; 2) after surgical procedures involving the skull; 3) spread from infection of adjacent structures; and 4) bacteremia (10 –12). We think that Pasteurella multocida was inoculated when the child made contact with his hands to the kerion celsi on his head, or the rabbit licked the kerion celci. Pasteurella multocida, which got into the skull from the kerion celsi, developed into meningitis and subdural, epidural, and subgaleal empyma. After bites or exposure of mucous membranes to animal saliva, Pasteurella may cause local wound infec-

tion. Important complications have been reported after Pasteurella multocida cellulitis, including osteomyelitis sepsis and abscess. Bite wounds are most serious due to their propensity for deep tissue penetration. Tularemia, Yersiniosis, Dermatophyte infections and Ectoparasites have been reported from pet rabbits (13). Penicillin is the first-choice therapy in non-allergic individuals. Pasteurella is usually sensitive to penicillin and its derivates. There have been a few rare instances of penicillin resistance, therefore, chloramphenicol, thirdgeneration cephalosporins, or tetracycline can be substituted. Aminoglycosides, vancomycin, erythromycin, and clindamycin are poor choices in the case of penicillin allergy due to drug resistance (14). Vancomycin, rifampin, and chloramphenicol antibiotherapics were initially started in our case. Cefotaxime was started instead of chloramphenicol after the diagnosis of meningitis. A retrospective study of infections due to Pasteurella and related groups was performed between Pasteurella National Center and Nancy’s hospital from 1985 to 1991 by Escande and Lion (15). Among the 958 cases recorded, wound infections (bites, scratches, and punctures) were the common forms of pasteurellosis caused by Pasteurella multocida. They report that, of the 958 cases, 66% had cutaneous infections, 19% lung infections, and 11% bacteremia. Weber et al. review case reports of Pasteurella multocida meningitis, nine of which were in infants (1). Controni and Jones note 14 confirmed cases of Pasteurella meningitis; 11 occurred in adults and 3 in children. Eight of the 14 cases had a history of accidental or surgical trauma (10). There are reports of Pasteurella multocida related to post-traumatic meningitis by Schreckenbach et al. and Roberts et al., of meningitis in a 2-day-old newborn by Hillery et al., of a cerebellar abscess in a 14-year-old girl by Larsen et al., and of meningitis in a 7-week-old boy by Wade et al. (6,11,16 –18). Mortality in Pasteurella multocida meningitis is high. In the series by Kumar et al., overall mortality was 30%. (2). In another series of 17 cases, 7 of which were adults, 6 patients died within 72 h of hospital admission (1). The majority of Pasteurella multocida infections are related to wound infections, which are due to animal bites, scratches, and lickings. A rabbit licking caused this interesting condition in the present case. Cases such as this seem to be unusual. Although Pasteurella multocida meningitis is rare, it is a very serious condition with a high mortality and neurological sequelae. Therefore, where meningitis occurs in addition to a history of animal exposure, Pasteurella multocida infection should be considered. Children can be especially at risk to certain bacterial and parasitic zoonoses from the lack of hand washing after pet handling and fecal oral transmission prevalent in this age group. Due to the potential for

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serious complications, pediatric patients may be treated with prophylactic antibiotics after animal and human bites, scratches, and licking that occur on non-intact skin or other lesions. REFERENCES 1. Weber DJ, Wolfson JS, Swartz MN, Hooper DC. Pasteurella multocida infections. Report of 34 cases and review of the literature. Medicine (Baltimore) 1984;63:133–54. 2. Kumar A, Devlin HR, Vellend H. Pasteurella multocida meningitis in adult: case report and a review. Rev Infect Dis 1990;12:440 – 8. 3. Green BT, Ramsey KM, Nolan PE. Pasteurella multocida meningitis: case report and review of the last 11 years. Scand J Infect Dis 2001;34:213–7. 4. Stechenberg BW. Pasteurella multocida. In: Feigin R, Cherry JD, eds. Textbook of pediatric infections diseases. Philadelphia: Saunders; 1998:1361– 4. 5. Hirsh D, Farrell K, Reilly C, Dobson S. Pasteurella multocida meningitis and cervical spine osteomyelitis in a neonate. Pediatr Infect Dis J 2004;23:1063–5. 6. Wade T, Booy R, Teare EL, Kroll S. Pasteurella multocida meningitis in infancy (a lick may be as bad as a bite). Eur J Pediatr 1999;158:875– 8. 7. Layton TC. Pasteurella multocida meningitis and septic arthritis secondary to a cat bite. J Emerg Med 1999;17:445– 8.

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