Pott's puffy tumor of the vertex years after trauma in a diabetic patient: case report

Pott's puffy tumor with intracranial extension in a child with incontinentia pigmenti: case based review of the eponymous disease

BACKGROUND

Pott's puffy tumor (PPT) is an uncommon infection involving the frontal bone, first described by Sir Percival Pott more than 250 years ago. It can present with intracranial extension and serious neurological morbidity. Incontinentia pigmenti (IP) is a rare inherited genodermatosis that is lethal prenatally in males and manifests clinically in females. IP is associated with recurrent infections and immune dysfunction/suppression.

METHODS

We report a case of Pott's puffy tumor presenting in a child with IP. We also performed a literature review of reported cases of PPT associated with immune dysfunction. We discuss the clinical presentation, diagnosis, and management of these lesions.

RESULTS

We identified 12 cases of PPT associated with immune dysfunction/suppression. Diabetes was the most commonly identified cause followed by iatrogenic immunosuppression. Surgery is the standard treatment for managing PPT and the management of PPT with and without intracranial involvement, particularly in the context of underlying immune dysfunction/suppression, is discussed.

CONCLUSION

PPT remains a rare but not infrequent diagnosis, often requiring neurosurgical intervention. Immune dysfunction/suppression is an additional risk factor that may predispose to PPT. Early and aggressive management should be instituted for optimal outcome.

A Systematic Review of Intracranial Complications in Adults with Pott Puffy Tumor over Four Decades

The purpose of this study is to investigate the risk factors of intracranial complications in adult patients with Pott Puffy Tumor (PPT). A systematic review was conducted of clinical studies from January 1983 to December 2022 that reported on PPT adult patients. The full-text articles were reviewed for the patients’ ages, sex, cultured organisms, surgical procedures, clinical sequalae, and underlying diseases that may affect the onset of intracranial complications in PPT adult patients. A total of 106 studies were included. Medical data were reviewed for 125 patients (94 males, 31 females). The median age was 45 years. A total of 52% had comorbidities, mostly head trauma (24.5%), sinus/neurosurgical operations (22.4%), immunosuppression conditions (13.3%), diabetes mellitus (9.1%), cocaine use (7.1%), or dental infections (6.1%). A total of 28 cultures revealed Streptococcus (22.4%), 24 contained staphylococci (19.2%), and 22 cultures contained other pathogens (17.6%). An amount of 30.4% developed intracranial complications, with the most common being epidural abscesses or empyemas (55.3%), as well as subdural (15.7%) and extradural lesions (13.2%). Age, DM, and immunosuppression conditions are significantly associated with intracranial complications (p < 0.001, p = 0.018 and p = 0.022, respectively). Streptococcus infection is associated with intracranial complications (p = 0.001), although Staphylococcus and other microorganisms are not. Surgical intervention, mainly ESS, and broad-spectrum antibiotics remain the cornerstones of treatment.

Pott's puffy tumour in an immunosuppressed adult: case report and systematic review of literature

This case is of a 34-year-old immunocompromised male with Pott’s puffy tumour, which was treated with antibiotics and endoscopic sinus surgery. Pott’s puffy tumour is typically a complication of frontal sinusitis in children and immunocompromise can be a precipitating factor.

A search was conducted of Embase, Medline, CINAHL, Cochrane, Google Scholar, Informit and Scopus of ‘Pott’s Puffy’ and variations of this phrase. Initial 804 records were reviewed by title, abstract and full text.

Of the unique papers identified, 155 only included paediatric patients and 128 included adult patients. After title, abstract and full-text review of 13 papers were identified describing Pott’s puffy tumour in immunocompromised patients.

Immunosuppression was noted as a risk factor in only a small number of cases, with diabetes mellitus being the most common. A few cases did note immunosuppression due to newer immunomodulatory agents being used for treatment of autoimmune conditions.

Pott's puffy tumor caused by Actinomyces naeslundii

Pott’s puffy tumor is characterized by forehead swelling from subperiosteal abscess and frontal bone osteomyelitis. It is encountered mainly in children; rarely in adults. When it does occur in the latter population, the most common risk factors include head trauma, sinusitis, or cocaine abuse. Generally, the organisms thought to be involved include streptococci, staphylococci and oral anaerobic flora. We present a case of a 53 year old female who presented with forehead swelling of 3 month duration after a dental procedure, found to be secondary to Actinomyces naeslundii. Actinomyces is a very rare etiology of this disease and has been reported only twice earlier in the literature. We present an uncommon infectious disease along with summary of clinical characteristics of this entity in the adult population.

Primary pyomyositis and disseminated septic pulmonary emboli: a reactivated staphylococcal infection?

Staphylococcal pyomyositis is a severe invasive soft tissue infection with high mortality rate that is increasingly being recognized even in temperate climates. In most cases predisposing factors are identified that include either source of skin penetration or/and impaired host immunocompetence. A case of primary, community-acquired pyomyositis of the left iliopsoas muscle in a 59-year-old immunocompetent woman, which was complicated with septic pulmonary emboli within 24h after hospital admission, is presented. The patient was subjected to abscess drainage under computed tomography guidance. Both pus aspiration and blood cultures revealed methicillin-susceptible Staphylococcus aureus. Given the absolute absence of predisposing factors and a remote history of staphylococcal osteomyelitis in the same anatomical region 53 years ago, reactivation of a staphylococcal soft tissue infection was postulated. Systematic review of the literature revealed a few interesting cases of reactivated staphylococcal infection after decades of latency, although the exact pathophysiological mechanisms still need to be elucidated.

[Pott's Puffy tumor: a forgotten complication of sinusitis]

Pott's puffy tumor is a rare entity characterized by a swelling of the scalp due to a subperiosteal abscess associated to osteomyelitis in the frontal bone. It is often associated with a complication of frontal sinusitis or trauma. Undiagnosed or partially treated frontal sinusitis can lead to Pott's puffy tumor, which requires rapid medical and surgical intervention to prevent complications that increase morbidity and mortality. Since the advent of antibiotics, Pott's puffy tumor has become rare to the point of almost being forgotten. We present a case of Pott's puffy tumor in a 15-year-old boy. This case is even more unusual because the tumor became complicated with orbital and intracranial involvement. The findings at computed tomography provided the key to the diagnosis in this patient.

Pott’s puffy tumor. A case report

Pott's puffy tumor is an infrequent entity characterized by a subperiosteal abscess associated with frontal bone osteomyelitis. It is usually seen as a complication of frontal sinusitis. This common condition is usually not diagnosed initially and is easily confused with neoplasms, skin and soft-tissue infection, and infected haematoma. Although Pott's puffy tumor is more commonly described in children, it should also be included in the differential diagnosis of swelling on the forehead in adults. This report describes the case of a 25-year-old man with Pott's puffy tumor resulting from frontal sinusitis, complicated by frontal brain abscess, and a subdural empyema. It was successfully treated with abscess drainage and prolonged use of antibiotics. To the best of our knowledge, only 13 cases of Pott's puffy tumor have been previously reported in adults. Particularities of this disease are reported here.