The Case Files

Abstract

Figure: CT scan of the head illustrating possible cribriform penetration.FigureFigureInitial symptoms of cerebritis are nonspecific, making it difficult to diagnose A 34-year-old man presented with a frontal headache and two syncopal episodes over 24 hours. The patient had had URI symptoms—sore throat, rhinorrhea, and mild shortness of breath—for three weeks. He had no history of headaches or fevers, he hadn't traveled recently, and he didn't use drugs or take any medications. The patient's first syncopal episode occurred a day earlier while at work. It happened suddenly, without any prodromal symptoms. He did not seek medical care, and he finished his shift. The second episode occurred at home suddenly, without any prodromal symptoms, and prompted him to go to the ED. The patient had normal vitals and was alert. His physical exam showed no abnormalities. Lab work was ordered, including CBC, CMP, ECG, chest x-ray, and head CT. The CT identified extensive paranasal sinus disease with penetration of the cribriform plate and a small epidural collection, raising concern for an epidural abscess or cerebritis. The patient was treated in the ED with IV fluids and broad-spectrum antibiotics, including vancomycin and piperacillin-tazobactam, and he was made NPO. ENT recommended the patient be transferred to a tertiary care center for ENT and neurosurgery consultation. An MRI showed extensive sinus disease without a frank intracranial abscess. The patient underwent nasal septoplasty, inferior turbinate submucous resection, left maxillary antrostomy with tissue removal, left frontal sinusotomy, and left total ethmoidectomy. The patient's headache improved significantly following the procedures, and he had no more episodes of syncope. Blood cultures revealed Bacillus species. He was transitioned off IV antibiotics and discharged with a seven-day course of amoxicillin and clavulanate at home after a four-day hospital course. This was a rare form of syncope brought on by extensive sinus disease with early penetration into the CNS. Cerebritis is inflammation of the cerebrum with nonspecific findings on CT scan. It develops in response to pyogenic bacteria, most commonly Staphylococcus and Streptococcus. This infection develops typically from otogenic and odontogenic sources, recent procedures, penetrating head trauma, or via hematogenous spread. It's difficult to diagnose cerebritis early because initial symptoms are nonspecific and patients do not present until late findings such as headache, altered mental status, syncope, and seizures are present. Labs may show leukocytosis, but that is also not specific. Diagnosis is made by imaging with CT or MRI. Acute treatment in the ED includes managing the patient's symptoms, NPO status, broad-spectrum antibiotics, and admission with ENT and neurosurgery consults. Syncope is a common presentation in the ED, but cerebritis as a cause is rarely seen. Prompt evaluation and management likely prevented further complications and progression of the disease.