Multiple subdural empyema and deep vein thrombosis caused by Streptococcus constellatus after COVID-19: a case report

*Correspondence: [e-mail].

Abstract

Case Presentation: A thirteen-year-old patient was admitted to the emergency department with headache, fever and seizure. She did not have any relevant medical history, except for a history of COVID-19 infection two weeks prior. A brain CT scan revealed a sinusitis with parafalcine subdural empyema in the left frontal convexity and left cerebellar tentorium. Additionally, a hypodense area in the left frontal region was observed, possibly indicating cerebritis. The CSF analysis showed increased cellularity with neutrophilic predominance. A brain MRI also shows signs of recent venous thrombosis in the anterior portion of the superior sagittal, transverse and sigmoid sinus on the left side. A new parafalcine empyema was also observed on the right side. Neurosurgical and otolaryngology intervention were performed, followed by the initiation of anticoagulation. Streptococcus constellatus, identified through abscess fluid and blood culture, was the causative agent. The patient received prolonged antibiotic therapy for 52 days and underwent three additional neurosurgical interventions to control the infection, due to the emergence of new abscesses. She made a full recovery at the end of the treatment.

Discussion: S. constellatus is a commensal organism found in the oral, gastrointestinal, and genitourinary flora. It can be associated with various purulent infections, including odontogenic, pulmonary, intraabdominal, and, rarely, central nervous system infections. Typically, affected individuals have predisposing factors such as immunosuppression, a history of neurosurgery, oral and neck infections or dental procedures. However, in this case, no predisposing factors were identified that could be related to the development of the brain abscesses and thrombosis. This led us to believe that sinusitis might have been the predisposing factor. Pansinusitis is a well known risk factor to the development of subdural infection. It is also indicated that bacteria sinusitis and its potential complications as sinus thrombosis are known successors of viral infections but the complex features of COVID-19 may be especially related to them.

Final Comments: To our knowledge, this case is the fourth reported case of subdural empyema caused by S. constellatus following a COVID-19 infection in immunocompetent children. Despite the high risk of a fatal outcome, early and prolonged antibiotic treatment, along with surgical interventions, resulted in a complete recovery with no long-term sequelae.

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Artikel online veröffentlicht:
12. Mai 2025