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. 2016;2016:9252361.
doi: 10.1155/2016/9252361. Epub 2016 Aug 11.

A Case of Skull Base Osteomyelitis With Multiple Cerebral Infarction

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Free PMC article

A Case of Skull Base Osteomyelitis With Multiple Cerebral Infarction

Haruka Miyabe et al. Case Rep Otolaryngol. .
Free PMC article

Abstract

Skull base osteomyelitis is classically documented as an extension of malignant otitis externa. Initial presentation commonly includes aural symptoms and cranial nerve dysfunctions. Here we present a case that emerged with multiple infarctions in the right cerebrum. A male in his 70s with diabetes mellitus and chronic renal failure presented with left hemiparesis. Imaging studies showed that blood flow in the carotid artery remained at the day of onset but was totally occluded 7 days later. However, collateral blood supply prevented severe infarction. These findings suggest that artery-to-artery embolization from the petrous and/or cavernous portion of the carotid artery caused the multiple infarctions observed on initial presentation. Osteomyelitis of the central skull base was diagnosed on the basis of the following findings taken together: laboratory results showing high levels of inflammation, presence of Pseudomonas aeruginosa in the otorrhea and blood culture, multiple cranial nerve palsies that appeared later, the bony erosion observed on CT, and the mass lesion on MRI. Osteomyelitis was treated successfully by long-term antibiotic therapy; however, the patient experienced cefepime-induced neurotoxicity during therapy. The potential involvement of the internal carotid artery in this rare and life-threatening disease is of particular interest in this case.

Figures

Figure 1
Figure 1
Diffusion-weighted MRI taken on the day of onset indicated multiple infarcts in the right cerebral cortex (a, arrowheads). MR angiography performed on the same day revealed blood flow in the internal carotid artery (b, arrowhead), but CT-angiography conducted 7 days after onset of the disease showed complete occlusion of the artery.
Figure 2
Figure 2
(a) T1-weighted MRI displayed a low-signal intensity lesion at the right skull base (arrowhead), replacing the high-signal intensity area of fatty tissues in the bone marrow and extending to the soft tissues inferior to the skull base. (b) CT showed erosion of the cortical bone in the right central skull base (arrowhead). Opacification of the right mastoid air cells was also noted.
Figure 3
Figure 3
Summary of the course of clinical signs, CRP, and antibiotic therapy. On day 1, the patient was admitted to our hospital with left upper limb paresis, right otorrhea, and high levels of inflammation. Empiric antibiotic treatment () was initiated, followed by targeted treatment against Pseudomonas aeruginosa. The patient was discharged on day 19 of antibiotic therapy, but because of the subsequent appearance of cranial nerve (CN) palsy affecting multiple nerves, he had to be retreated with antibiotics for an extended duration. Details have been provided in the text.

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