Rapid evolution of acute mastoiditis: three case reports of otogenic meningitis in adults

Probable fatal mastoiditis by the around 2300 year old Heidelberg's Egyptian mummy Djed-Hor

The universal use of computed tomography (CT) has opened up new possibilities in the noninvasive examination of human mummies, and particularly the detailed study of the fine structures of the temporal bone. The aim of this study was to describe the morphological changes, as seen on CT, found in the right temporal bone of Djed-Hor, an around 2300 year old Heidelberg's Egyptian mummy, and to discuss their possible causal relation to his death. Here we showed the presence of a compress on the auricle, and of probable pus in the mastoid, middle ear, and external ear with erosion of the tegmen tympani probably related to a fatal acute mastoiditis. These typical morphological changes of such a disease were demonstrated in the same way as in living patients of today. This would be the first depiction of a compress on an auricle associated with pus in the ear of an Egyptian mummy.

Meningitis and endocarditis as a sequela of streptococcus pneumonia mastoiditis: A case report

Key Clinical Message

Austrian Syndrome classically consists of meningitis, endocarditis, and pneumonia due to Streptococcus pneumonia bacteremia. A literature review, however, does not show variants of this triad. Our case highlights a unique variant of Austrian Syndrome with mastoiditis, meningitis, and endocarditis which requires immediate recognition and treatment to prevent devastating patient outcomes.

Abstract

Streptococcus pneumonia is responsible for more than 50% of all bacterial meningitis and has a case fatality rate of 22% in adults. In addition, Streptococcus pneumonia is also one of the most common causes of acute otitis media, a known cause of mastoiditis. However, in conjunction with bacteremia and endocarditis, limited evidence is able to be identified. This sequence of infections also closely relates to Austrian syndrome. Otherwise known as Osler's triad, Austrian syndrome is a rare phenomenon of meningitis, endocarditis, and pneumonia secondary to Streptococcus pneumonia bacteremia that was first delineated by Robert Austrian in 1956. The incidence of Austrian syndrome is reported to be less than <0.0001% per year and has decreased significantly since the initial usage of penicillin in 1941. Despite this, the mortality rate of Austrian syndrome is still around 32%. Despite an extensive literature review, we were unable to find any reported cases of variants of Austrian syndrome that include mastoiditis as the primary insult. As such, we present a unique presentation of Austrian syndrome with mastoiditis, endocarditis, and meningitis with complex medical management that led to resolution for the patient. To discuss the presentation, progression, and complex medical management of a previously undiscussed triad of mastoiditis, meningitis, and endocarditis occurring in a patient.

An unusual presentation of hemiparesis: Rapidly progressing Streptococcal pneumoniae meningitis secondary to acute mastoiditis

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Acute bacterial meningitis should be included in the differential diagnosis when considering stroke mimics.

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Potential for rapid progression highlights the importance of hourly neurological exams and early intervention.

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Antimicrobials, steroids, and myringotomy with tympanostomy tube are effective interventions in treating meningitis secondary to mastoiditis.

A sixty-three year-old male who arrived to our emergency department with signs and symptoms of an acute left middle cerebral artery cerebrovascular accident. Initial neurovascular imaging failed to demonstrate any abnormalities that explained his symptoms. His neurologic status rapidly deteriorated in conjunction with the development of severe sepsis. The patient required endotracheal intubation and was transferred to our intensive care unit. After an extensive diagnostic work-up, the etiology of his condition was determined to be due to bacterial meningitis originating from acute mastoiditis. Cultures of cerebrospinal fluid and peripheral blood grew Streptococcus pneumoniae. The patient improved with intravenous antimicrobials, intravenous dexamethasone and a left sided myringotomy with tympanostomy tube. The patient made a complete neurological recovery following this treatment.

A case series of complicated infective otitis media requiring surgery in adults

INTRODUCTION

With the advent of antibiotics, complications of otitis media have become less common. It is crucial for physicians to recognise otitis media and treat its complications early. Herein, we present our institution's experience with patients who required emergency surgical intervention for complications of otitis media.

METHODS

Data on patients who underwent emergency surgery for complications of otitis media from 2004 to 2011 was retrieved from the archives of the Department of Otolaryngology, Changi General Hospital, Singapore.

RESULTS

A total of 12 patients (10 male, two female) underwent emergency surgery for complications of otitis media. The median age of the patients was 25 years. Otalgia, otorrhoea, headache and fever were the main presenting symptoms. Extracranial complications were observed in 11 patients, and six patients had associated intracranial complications. The primary otologic disease was acute otitis media in six patients, chronic otitis media without cholesteatoma in three patients and chronic otitis media with cholesteatoma in three patients. Mastoidectomy and drainage of abscess through the mastoid, with insertion of grommet tube, was the main surgical approach. Two patients required craniotomy. The mean length of hospital stay was 16.2 days and the mean follow-up period was 16.3 months. Five patients had residual conductive hearing loss; two patients with facial palsy had full recovery.

CONCLUSION

Otitis media can still result in serious complications in the post-antibiotic era. Patients with otitis media should be monitored, and prompt surgical intervention should be performed when necessary to attain good outcomes.

Otogenic pneumococcal meningitis with pneumocephalus

Streptococcus pneumoniae accounts for approximately 50% of bacterial meningitis cases in the United States annually. Since the advent of antibiotics, pneumococcal meningitis as a complication of a primary otogenic focus has been rare in the United States. The widespread use of immunosuppressants and increasing bacterial resistance to commonly prescribed antibiotics may contribute to a higher incidence of complications of otitis media in the future, similar to that of the pre-antibiotic era. We report a case of otogenic pneumococcal meningitis with pneumocephalus in an adult male on chronic immunosuppressant therapy. A 33-year-old man with Crohn's disease and azathioprine use presented to our Emergency Department with progressive headache while taking antibiotics for otitis media. Initial computed tomography scan of the brain revealed pneumocephaly, and cerebrospinal fluid analysis and culture diagnosed pneumococcal meningitis. The patient continued to have fevers while receiving intravenous antibiotics and underwent bilateral myringotomies; his clinical course subsequently improved significantly. Meningitis is a rare complication of Streptococcus pneumoniae infections since the advent of antibiotics; however, it may become more frequent with increasing antibiotic resistance and a growing population of immunocompromised patients. Additionally, pneumocephalus in the setting of meningitis and otitis media should raise the suspicion for mastoiditis (even without overt clinical findings) and early consultation with an otolaryngologist is warranted.