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Images in Neurology |

Metastatic Epidural Bacterial Abscess in a 4-Year-Old Boy

Seth DeVries, MD
JAMA Neurol. 2013;70(5):648. doi:10.1001/jamaneurol.2013.1942.
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A 4-year-old boy with community-acquired pneumonia unresponsive to outpatient antibiotics was admitted to the hospital for intravenous treatment. Chest computed tomography revealed left lower lobe pulmonary empyema (Figure 1), which led to the placement of a chest tube. After 1 week of intravenous antibiotics, the chest tube was removed and the patient was to be discharged home. Unexpectedly, the patient's clinical condition deteriorated. He became encephalopathic and had evidence of tonic eye deviation to the right. While undergoing an emergency computed tomographic scan of the head, the patient had a generalized tonic-clonic seizure. Head computed tomography revealed osteomyelitis of the left anterior, medial, and inferior frontal bone as well as left anterior, inferior, and medial epidural fluid collection suggestive of an epidural abscess. Brain magnetic resonance imaging with and without contrast confirmed the findings (Figure 2). The neurosurgeon performed an emergency hemicraniotomy and abscess evacuation; the surgical procedure was not associated with complications. Six months later, at a follow-up appointment, the patient had no evidence of neurological deficit.

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Figure 1. Chest computed tomographic image reveals air-fluid levels (arrows) concerning for left-sided lung abscesses and empyema.

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Figure 2. Brain magnetic resonance images without and with contrast. A, Axial T2-weighted image without contrast shows hyperintense areas in the left frontal lobe representing multiple loculated fluid-filled regions (arrows) with surrounding edema. B, Axial T1-weighted postcontrast image shows ring-enhancing lesions representing abscesses (arrows).

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