Kunii Misako, Okamoto Mitsuo, Takei Dan, Kubota Shun, Nakamura Haruko, Tanaka Fumiaki
Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine.
Rinsho Shinkeigaku. 2020 Aug 7;60(8):538-542. doi: 10.5692/clinicalneurol.60.cn-001418. Epub 2020 Jul 7.
A 78-year-old woman with bilateral fungal sinusitis, which resulted in right orbital apex syndrome, underwent endoscopic sinus surgery and optic nerve decompression. Two months after the operation, she complained of anxiety and insomnia. Head CT showed subdural hematoma-like effusion and burr hole drainage was conducted. The collected fluid was not hematoma, but bloody, xanthochromic effusion with no pathogenic bacteria. Ten days later, she underwent drainage and dural biopsy after craniotomy because of relapse of subdural hygroma and progression of hypertrophic pachymeningitis associated with aggravation of psychiatric symptoms. A sample of the dura mater showed dense fibrosis with thickening, and Pseudomonas aeruginosa (P. aeruginosa) was detected by culture. Although otitis or sinusitis secondary to P. aeruginosa infection has been reported as a leading cause of infectious pachymeningitis, psychiatric symptoms alone and concomitant refractory subdural hygroma are atypical and unreported manifestations. In patients with pachymeningitis and a history of transnasal endoscopic surgery, P. aeruginosa infection should be considered, irrespective of an atypical clinical course and negative blood or fluid culture. Additionally, dural biopsy might help in detection of pathogenic bacteria.
一名78岁患有双侧真菌性鼻窦炎并导致右眼眶尖综合征的女性接受了鼻内镜鼻窦手术和视神经减压术。术后两个月，她出现焦虑和失眠症状。头部CT显示硬膜下血肿样积液，遂进行了钻孔引流。引流收集的液体并非血肿，而是血性、黄变的积液，未检出病原菌。十天后，由于硬膜下积液复发以及肥厚性硬脑膜炎进展并伴有精神症状加重，她接受了开颅引流和硬脑膜活检。硬脑膜样本显示有致密纤维化及增厚，培养检测出铜绿假单胞菌。虽然铜绿假单胞菌感染继发的中耳炎或鼻窦炎已被报道为感染性硬脑膜炎的主要原因，但仅出现精神症状以及同时伴有难治性硬膜下积液是不典型且未被报道过的表现。对于有硬脑膜炎且有经鼻内镜手术史的患者，无论临床病程是否典型以及血液或液体培养结果是否为阴性，都应考虑铜绿假单胞菌感染。此外，硬脑膜活检可能有助于病原菌的检测。
