Objective:

To report a case of a 19-year-old man who presented with two weeks of fever and lethargy with a rapid decompensation requiring decompressive hemicraniectomy and intensive care unit admission due to a subdural empyema from Lemierre syndrome.

Background:

Subdural empyema is a neurological condition that accounts for approximately 20% of intracranial infections. The rapid accumulation that can occur is a neurologic emergency as it can result in neurologic deficits, herniation, and death.

Design/Methods:

N/A

Results:

The patient presented to the hospital due to concern for increasing lethargy. He was admitted to the neurology service after developing right-sided ptosis during initial evaluation. Baseline computed tomography imaging was significant for pansinusitis without other intracranial abnormalities.  A lumbar puncture was planned due to leukocytosis and fever, but was ultimately deferred due to acute anisocoria and witnessed seizure, resulting in intubation. Emergent head imaging revealed a right frontal hyperdense subdural collection with midline shift and basal cistern effacement concerning for herniation, and the patient was taken for emergent decompressive hemicraniectomy. Fusobacterium species were dentified in blood and intra-op cultures. Further investigation revealed cavitary lesions in the chest, raising concern for Lemierre Syndrome. Bilateral carotid ultrasounds did not reveal septic thrombophlebitis, but it is possible there was resolution by the time of evaluation.

Conclusions:

Lemierre Syndrome presents as a rare complication of pharyngeal and other infections of the head and neck including sinusitis, otitis and mastoiditis. The initial concern was that either previous trauma to the sinuses or septic emboli from an unrecognized source were the nidus for subdural empyema accumulation in this patient. Our case underscores the importance of serial imaging and neurological exams in patients who present with suspected intracranial infection, as re-evaluation of initial imaging showed early signs of increased intracranial pressure, which progressed over a twelve-hour period and resulted in significant neurologic injury.