Subgaleal abscess

Subgaleal abscess

Subgaleal abscesses and skull osteomyelitis are rarely encountered today.

Etiology

Reports of these entities usually describe an underlying pathology such as trauma or puncture wounds which account for direct inoculation or contiguous spread of microorganisms.

Acute bacterial sinusitis 1) Surgical correction of craniosynostosis 2)

Treatment

Although the diagnosis and management of a secondary subgaleal abscess may be straightforward, the same cannot be said for a primary or de novo subgaleal abscess 3).

Case series

Goodman SJ, Cahan L, Chow AW. Subgaleal abscess: a preventable complication of scalp trauma. West J Med. 1977 Aug;127(2):169-72. PubMed PMID: 898950; PubMed Central PMCID: PMC1237748.

Case reports

Spontaneous subgaleal abscess associated with lung adenocarcinoma: first description of this unusual association 4).


Spontaneous skull osteomyelitis with subgaleal abscess due to Kocuria rosea 5).


A 47-year-old immunosuppressed woman presented with fever, altered level of consciousness, dysphasia, and a left occipital subgaleal fluctuant mass after acupuncture for headaches in the same area. Imaging demonstrated subgaleal and epidural collection localized in the left occipital region. She underwent urgent surgical evacuation of both collections. Cultures from intraoperative specimens grew Streptococcus anginosus. The patient started targeted antibiotic treatment leading to complete recovery.

This is the first report of intracranial abscess after acupuncture. Given the worldwide application of this alternative treatment, physicians, acupuncturists, and the general public should be aware of the possibility of this rare but serious complication 6).


A case of a 64-year-old Sri Lankan Sinhalese man with prolonged fever and constitutional symptoms with a neglected swelling over the back of the scalp who was found to have an abscess in the subgaleal space of the scalp during surgical drainage. Burkholderia pseudomallei was isolated in pus culture, and melioidosis serology was highly positive. The patient was treated with ceftazidime for 2 weeks, followed by co-trimoxazole for another 3 months. He made a complete clinical recovery with normalization of inflammatory markers. This is the first case of subgaleal abscess following melioidosis infection reported in the literature.

Abscesses in anatomically unusual locations should raise suspicion for melioidosis infection, particularly among patients with risk factors such as diabetes mellitus 7).


A case of an infected SGH in an 8-month-old following closed skull fracture. The patient presented with scalp swelling 1 day after falling 3 feet. Initial evaluation found a nondisplaced skull fracture on computed tomography. She was discharged following an uneventful 23-hour observation. Three days later, she developed symptoms concerning for a viral upper respiratory tract infection and received symptomatic treatment. Nine days after injury, she returned with continued fevers, irritability, and significant increase in scalp swelling. Magnetic resonance imaging showed a subgaleal abscess with osteomyelitis. Needle aspiration revealed an infected hematoma with cultures positive for Streptococcus pneumoniae, treated with intravenous ampicillin. Purulent drainage from an enlarging necrotic needle aspiration site required subsequent surgical debridement of the subgaleal abscess with drain placement. She recovered well following surgery and intravenous antibiotics. Physicians should be aware that SGH carries a risk of serious morbidity and mortality. SGH can serve as a nidus for infection, typically from skin barrier breakdown or, as in this case, hematogenous spread. Early recognition, appropriate antibiotic therapy, and surgical debridement are critical in treating infected SGH 8).


Chang et al. reported an infected SGH with abscess formation as a complication of early-onset Escherichia coli sepsis in a term neonate. The patient was discovered to have SGH soon after birth. Early-onset E. coli sepsis developed on Day 3 of life. The SGH became infected, with abscess formation 1 week later. The infected SGH was probably due to direct hematogenous spreading of sepsis. The patient was successfully treated without complications. Clinicians should be aware that SGH is a potential site of infection and infection may be caused either by direct hematogenous extension or from traumatic scalp lesions. Appropriate antibiotic treatment and surgical debridement are necessary when an infected SGH occurs 9).


Chou et al. reported on an elderly female who suffered from forehead carbuncle with intractable headache, later confirmed as having subgaleal abscess. Physicians should pay special attention to elderly and immune-compromised patients with carbuncles located in the middle of the face, especially when accompanied by intractable headache, to avoid poor outcome 10).


A 14-year-old boy with a rare combination of periorbital cellulitis, subgaleal abscess and superior sagittal sinus thrombosis following a late presentation of unilateral frontal sinusitis.

Following multiple surgical procedures, and antimicrobial and anticoagulation therapy, the patient made a full recovery.

Serious sinusitis complications still occur and can do so in unusual combinations with minimal clinical signs. Systemic anticoagulation therapy is considered safe practice in the management of cerebral venous sinus thrombosis and may reduce morbidity and mortality 11).


A 5-year-old child presented to the emergency department with a three-week history of fever associated with drowsiness and left parietal headache, and a week’s history of swelling on the left frontoparietal soft tissue. He had suffered a penetrating scalp injury four month ago. On physical examination, there was a tender swelling with purulent stream on the lateral half of his scalp. His vital signs are within normal limits. Plain X-ray of the skull showed a lytic lesion on the left frontoparietal bone. A cranial computed tomography (CT) scan demonstrated a large subgaleal abscess at the left frontoparietal region. SBO possesses a high morbidity and mortality; therefore, prompt diagnosis and appropriate treatment are mandatory to prevent further complications and to reduce morbidity and mortality significantly 12).


A case of bacterial meningitis, subgaleal, subdural, and epidural empyema due to Pasteurella multocida by a rabbit licking that resulted in neurological complications and a prolonged recovery period 13).


A preterm infant who developed scalp abscess and E. coli sepsis following a scalp electrode. Onyeama et al. recommend a careful examination of babies with a history of fetal electrode monitoring as this could be a nidus for local and generalised infection 14).


A 12-year-old girl presented with a swollen right eye with three days of pain and a diffused swollen frontal region and head lasting for one day. On the computed tomography with contrast, diffused collection was detected in the subgaleal regions and subperiosteal of the right orbita. It was observed that she had bilateral maxillary, ethmoidal, and frontal sinusitis and an infected bilateral middle concha bullosa in the right side. No symptoms of intracranial complication and osteomyelitis in the frontal or other calvarial bones were determined. This case presentation is thought to be the first one in literature that is an acute sinusitis without an intracranial complication and osteomyelitis, but with a diffused subgaleal abscess resulting from a subperiosteal abscess 15).

References

1)

Stokken J, Gupta A, Krakovitz P, Anne S. Rhinosinusitis in children: a comparison of patients requiring surgery for acute complications versus chronic disease. Am J Otolaryngol. 2014 Sep-Oct;35(5):641-6. doi: 10.1016/j.amjoto.2014.05.008. Epub 2014 Jun 5. PubMed PMID: 25069389.
2)

Zakhary GM, Montes DM, Woerner JE, Notarianni C, Ghali GE. Surgical correction of craniosynostosis. A review of 100 cases. J Craniomaxillofac Surg. 2014 Dec;42(8):1684-91. doi: 10.1016/j.jcms.2014.05.014. Epub 2014 Jun 4. PubMed PMID: 24969768.
3)

Schaefer J, Clein L, Conly J. De novo subgaleal abscess. Can J Infect Dis. 1992 Jan;3(1):30-2. PubMed PMID: 22451760; PubMed Central PMCID: PMC3307424.
4)

Umana GE, Scalia G, Fagone S, Strano G, Tranchina MG, Raudino G, Cicero S. Spontaneous subgaleal abscess associated with lung adenocarcinoma: first description of this unusual association. World Neurosurg. 2019 Aug 7. pii: S1878-8750(19)32149-7. doi: 10.1016/j.wneu.2019.07.233. [Epub ahead of print] PubMed PMID: 31400523.
5)

Rangnekar RD, Jamaluddin MA, Raja K, Abraham M. Spontaneous skull osteomyelitis with subgaleal abscess due to Kocuria rosea. Neurol India. 2019 May-Jun;67(3):915-918. doi: 10.4103/0028-3886.263238. PubMed PMID: 31347589.
6)

Priola SM, Moghaddamjou A, Ku JC, Taslimi S, Yang VXD. Acupuncture-Induced Cranial Epidural Abscess: Case Report and Review of the Literature. World Neurosurg. 2019 Feb 8. pii: S1878-8750(19)30300-6. doi: 10.1016/j.wneu.2019.01.189. [Epub ahead of print] PubMed PMID: 30743042.
7)

Dalugama C, Tennegedara A, Gawarammana IB. De novo subgaleal abscess – a rare presentation of melioidosis: a case report. J Med Case Rep. 2018 Apr 30;12(1):115. doi: 10.1186/s13256-018-1643-x. PubMed PMID: 29706135; PubMed Central PMCID: PMC5925829.
8)

Barry J, Fridley J, Sayama C, Lam S. Infected Subgaleal Hematoma Following Blunt Head Trauma in a Child: Case Report and Review of the Literature. Pediatr Neurosurg. 2015;50(4):223-8. doi: 10.1159/000433442. Epub 2015 Jun 13. Review. PubMed PMID: 26088299.
9)

Chang HY, Cheng KS, Liu YP, Hung HF, Fu HW. Neonatal infected subgaleal hematoma: an unusual complication of early-onset E. coli sepsis. Pediatr Neonatol. 2015 Apr;56(2):126-8. doi: 10.1016/j.pedneo.2013.03.003. Epub 2013 Apr 13. PubMed PMID: 23597516.
10)

Chou PY, Chen YC, Huang P. Forehead carbuncle with intractable headache. Neuropsychiatr Dis Treat. 2015 Mar 20;11:793-5. doi: 10.2147/NDT.S79349. eCollection 2015. PubMed PMID: 25848276; PubMed Central PMCID: PMC4376302.
11)

Jones H, Trinidade A, Jaberoo MC, Lyons M. Periorbital cellulitis, subgaleal abscess and superior sagittal sinus thrombosis: a rare combination of complications arising from unilateral frontal sinusitis. J Laryngol Otol. 2012 Dec;126(12):1281-3. doi: 10.1017/S0022215112002228. Epub 2012 Oct 1. PubMed PMID: 23020898.
12)

Sayhan MB, Kavalci C, Sogüt O, Sezenler E. Skull base osteomyelitis in the emergency department: a case report. Emerg Med Int. 2011;2011:947327. doi: 10.1155/2011/947327. Epub 2011 May 29. PubMed PMID: 22046552; PubMed Central PMCID: PMC3200088.
13)

Per H, Kumandaş S, Gümüş H, Oztürk MK, Coşkun A. Meningitis and subgaleal, subdural, epidural empyema due to Pasteurella multocida. J Emerg Med. 2010 Jul;39(1):35-8. doi: 10.1016/j.jemermed.2008.04.008. Epub 2008 May 16. PubMed PMID: 18486411.
14)

Onyeama CO, Srinivasan H, Lotke M, Vickers DL. Subgaleal abscess and E. coli septicemia following scalp electrode in a preterm newborn: a case report. J Matern Fetal Neonatal Med. 2009 Dec;22(12):1201-3. doi: 10.3109/14767050903042553. PubMed PMID: 19916718.
15)

Celik H, Islam A, Felek SA, Yüksel D. A very rare complication of acute sinusitis: subgaleal abscess. Kulak Burun Bogaz Ihtis Derg. 2009 May-Jun;19(3):155-8. PubMed PMID: 19857195.

Update: Intramedullary spinal cord abscess

Intramedullary spinal cord abscess

Intramedullary spinal cord abscess due to congenital dermal sinus (CDS) is rare and often co-exists with an inclusion tumor such as dermoid/epidermoid cyst.

CDS are the commonest cause of intramedullary spinal cord abscess (IMSCA) 1).

Prasad et al. did a literature review to analyze all cases of pediatric IMSCA secondary to CDS by searching online databases starting from the oldest case reported.

Only 50 cases have been reported and were analyzed. Mean age was 22.6 months (range 1 month-15 years). Fever, acute flaccid lower limbweakness, and urinary disturbances were the most common presenting features. Dermal sinus was commonest in lumbosacral region. Inclusion cysts were observed in 50% of cases. Staphylococcus aureus was the most the common organism. Mean follow-up duration was 18.2 months (range 1 week-156 months). Majority of the cases underwent multilevel laminectomy with myelotomy and drainage of abscess. Outcome was good-to-excellent in around 60% cases with four deaths. Presence of fever and limb weakness was significantly associated with poor outcomes.

Intramedullary abscess secondary to CDS is very rare. Complete sinus tract excision, myelotomy and drainage of abscess, and decompression of co-existent inclusion cysts with prolonged antibiotic therapy remain the standard treatment. Approximately 60% cases achieve good outcomes. Fever and limb weakness portend poorer outcomes than those without 2).

1)

Kanaheswari Y, Lai C, Raja Lope RJ, Azizi AB, Zulfiqar MA. Intramedullary spinal cord abscess: The result of a missed congenital dermal sinus. J Paediatr Child Health. 2014 Aug 7. doi: 10.1111/jpc.12707. [Epub ahead of print] PubMed PMID: 25099316.

2)

Prasad GL, Hegde A, Divya S. Spinal Intramedullary Abscess Secondary to Dermal Sinus in Children. Eur J Pediatr Surg. 2018 Jun 1. doi: 10.1055/s-0038-1655736. [Epub ahead of print] PubMed PMID: 29857348.

Update: Steroids for brain abscess

Steroids for brain abscess

Steroids for Brain Abscess is controversial.
Reduces edema, but may reduce antibiotic penetration into abscess 1).
It seems to only partially inhibit adequate concentrations of antibiotics in brain tissue dependent upon the antibiotics used 2).
Immune supression may also be deleterious.
There is no well-controlled, randomized clinical study evaluating the use of corticosteroids for controlling the cerebral edema surrounding BA; nevertheless, corticosteroids are recommended perioperatively for reducing intracranial pressure and avoiding acute brain herniation 3) but only in those patients that demonstrate signs of meningitis or disproportionate cytotoxic edema posing a life-threatening problem 4).
Steroids can retard the encapsulation process, increase necrosis, reduce antibiotic penetration into the abscess, increase the risk of ventricular rupture, and alter the appearance on CT scans because of contrast reduction. Steroid therapy can also produce a rebound effect when discontinued. Corticosteroids are used when a significant mass effect is visible on imaging and the patient’s mental status is depressed. When used to reduce cerebral edema, therapy should be of short duration. The appropriate dosage, the proper timing, and any effect of steroid therapy on the course of the disease are unknown 5).

Case reports

A case of acute brain abscess in a 59-year-old man is presented. The primary CT findings were misinterpreted as a brain infarct or possibly a tumour. Under steroid therapy an activation of the brain abscess was observed in only nine days and in spite of an immediate operation the patient died 6).
1)

Rosenblum ML, Hoff JT, Norman D, Edwards MS, Berg BO. Nonoperative treatment of brain abscesses in selected high-risk patients. J Neurosurg. 1980 Feb;52(2):217-25. PubMed PMID: 7351561.
2)

Kourtópoulos H, Holm SE, Norrby SR. The influence of steroids on the penetration of antibiotics into brain tissue and brain abscesses. An experimental study in rats. J Antimicrob Chemother. 1983 Mar;11(3):245-9. PubMed PMID: 6841306.
3)

Lee TH, Chang WN, Su TM, Chang HW, Lui CC, Ho JT, Wang HC, Lu CH. Clinical features and predictive factors of intraventricular rupture in patients who have bacterial brain abscesses. J Neurol Neurosurg Psychiatry. 2007 Mar;78(3):303-9. Epub 2006 Sep 29. PubMed PMID: 17012340; PubMed Central PMCID: PMC2117635.
4)

Muzumdar D, Jhawar S, Goel A. Brain abscess: an overview. Int J Surg. 2011;9(2):136-44. doi: 10.1016/j.ijsu.2010.11.005. Epub 2010 Nov 16. Review. PubMed PMID: 21087684.
6)

Strohecker J, Kollmann H, Piotrowski W, Grobovschek M. Exacerbation of brain abscess during exclusive treatment with steroids, demonstrated by computerised tomography. Neurochirurgia (Stuttg). 1985 Jan;28(1):20-1. PubMed PMID: 3974790.
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