A unique presentation: Bezold’s abscess and glomerulonephritis

Abstract

In the era of antibiotics, Bezold’s abscess is a rare complication of otitis media. We report a unique case of a patient with Bezold’s abscess and lateral sinus thrombosis, who initially presented with post-streptococcal glomerulonephritis. To our knowledge, this is the only documented case in the literature of such an unusual presentation. A previously healthy 14-year-old boy was admitted under the care of the paediatricians with 5-day history of frank haematuria, abdominal pain, pyrexia, nausea and vomiting. Two days prior to the presentation, he complained of left-sided earache, neck stiffness and reduced hearing of this ear. He has no previous otologic history and was not on any regular medication. He had elevated serum creatinine (125 μmol/L) and urea (11 mmol/L) levels as well as gross haematuria and protenuria as revealed by the urinary dipstick test. Renal ultrasound showed increased cortical echogenicity, consistent with glomerulonephritis. While being investigated for his haematuria, he complained of increasing earache and neck pain. Four days after admission, he developed mastoid tenderness and was referred to the on-call otolaryngologist. On clinical examination, he was pyrexial. He was noted to have protrusion of his left pinna, an erythematous left mastoid region and also a firm mass in the neck above the anterior border of his left sternocleidomastoid muscle. His left tympanic membrane was bulging and suggestive of acute otitis media. The tuning fork test and audiometry showed a conductive hearing loss in his left ear, and he had a type B tympanogram on that side. His right ear was normal. There was no sign of papilloedema, and neurological examination was unremarkable. He had a mild leucocytosis of 12.9×10/L, elevated creatinine of 155 μmol/L and elevated C-reactive protein (170 mg/L). A computed tomography (CT) scan showed extensive left mastoid opacification with secondary Bezold’s abscess at the tip of the mastoid process (Fig. 1a,b) and thrombosed sigmoid sinus, with a small extradural collection adjacent to it. There was a posterior fossa extradural collection, contiguous with the defect in the mastoid. He was started on intravenous ceftriaxone and metronidazole as well as topical ciprofloxacin eardrops. He had a mastoidectomy and drainage of the extradural collection on the same day. The microbiology revealed a profuse growth of Streptococcus milleri. The patient was discharged home 8 days post-operatively, with a 6-week course of intravenous ceftriaxone and oral metronidazole. When he was reviewed 3 weeks later he was well with normal hearing level and had an intact left tympanic membrane. Although his creatinine has returned to normal, he still had mild proteinuria and haematuria at his 4-month follow up. With respect to the otological situation he remained asymptomatic with normal audiometry at his final 6-month follow up.