Acute mastoiditis with subperiosteal abscess due to emerging infectious agents

Vázquez Fernández, Marta Esther; Cebrián Fernández, Rosalía; Vegas Alvarez, Ana María

doi:10.1016/j.medcle.2017.12.036

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Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus aureus are frequently isolated germs in children and, more rarely, anaerobic germs.<a class="elsevierStyleCrossRef" href="#bib0030">1</a>Turicella otitidis is a bacillus that is also found in the ear and has been recently associated to cases of AOM and mastoiditis.<a class="elsevierStyleCrossRef" href="#bib0035">2</a> We report a case of polymicrobial mastoiditis and subperiosteal abscess caused by Turicella otitidis and anaerobic germs.A 13-month-old male with no personal history of interest (breastfeeding until age 7 months, day-nursery from 8 months onwards and no previous episodes of otitis), properly vaccinated, who presented with a 7-day history of excess mucus and fever for 36h. A good general condition was observed on examination, with inflammation and erythema in the left retroauricular area and detachment of the auricle. The left eardrum was hyperaemic and bulging. He was hospitalized when mastoiditis was suspected. The blood count showed 29,200leukocytes/mm3 (neutrophils 76%, leukocytes 14.6%, monocytes 9.1%), with normal red and platelet series. CRP was 225mg/dl. 2h after admission he had abundant purulent suppuration through the left auditory canal. Turicella otitidis susceptible to beta-lactams, cephalosporins, aminoglycosides, macrolides and quinolones was isolated in the ear exudate. Blood culture was negative. Intravenous antibiotic treatment with cefotaxime was prescribed (150mg/kg/day) and vancomycin (60mg/kg/day), in addition to otic ciprofloxacin. Given the persistence of fever and worsening of the general condition, a cranial CT scan was performed, observing bilateral complicated mastoiditis with subperiosteal abscess on the left side. Given this situation, the patient underwent simple mastoidectomy, drainage of the abscess and transtympanic drainage tube in the left ear, and tympanocentesis in the right ear. Pantoea agglomerans and Fusobacterium were isolated in the surgical exudate. The treatment was changed to meropenem (120mg/kg/day) and finally received oral amoxicillin clavulanic 8/1 (40mg/kg/day). The inflammation and suppuration progressively decreased following 3 weeks of antibiotic treatment. In addition, the immunological study (GAME Ig, subclasses of IgG, lymphocyte populations, C3, C4, CH50) was normal for his age.Mastoiditis, as well as subperiosteal abscess, are rare processes whose incidence varies between 1.2 and 4.2 per 100,000 under the age of 14.<a class="elsevierStyleCrossRef" href="#bib0030">1</a> It mainly affects children under 2 years of age. It has been linked to immunological factors, as well as to an increased difficulty in the diagnosis of AOM (narrow external auditory canal, sometimes with ear wax). However, the absence of AOM does not rule out the diagnosis of these complications, nor is the treatment of AOM with antibiotics a protection.<a class="elsevierStyleCrossRef" href="#bib0035">2</a>Changes in the causes of AOM and its complications have been described since the pneumococcal vaccine was introduced.<a class="elsevierStyleCrossRef" href="#bib0040">3</a>Turicella otitidis is characterized by being a gram-positive bacillus confined to the ear or adjacent areas. It is possible that Turicella otitidis<a class="elsevierStyleCrossRef" href="#bib0035">2</a> and oropharyngeal anaerobic germs<a class="elsevierStyleCrossRef" href="#bib0045">4</a> could play a role in ear infections under favourable conditions (local immunological alterations and/or imbalances in the accompanying flora caused by the inflammatory process and/or the administration of antimicrobials). However, the exact role of these germs is difficult to determine due to the difficulties involved in their isolation and identification in previous studies.Mastoiditis is a serious disease that requires early diagnosis and treatment. It should be suspected in the presence of inflammation and protrusion in the mastoid area, usually accompanied by fever, headache and AOM symptoms. The indication of cranial CT scan is controversial. It is indicated when there are neurological signs, recurrent acute mastoiditis, in atypical presentations that generate doubts and when no clinical improvement is observed within 48h of treatment.<a class="elsevierStyleCrossRef" href="#bib0040">3</a> Our case demonstrates that the indication of cranial CT should be performed whenever there are clear severe infection lab parameters and/or when no improvement is observed.The results are good if treated without delay. A conservative treatment with antibiotics alone or associated with myringotomy is indicated in cases of acute mastoiditis without complications, while those who do not respond or develop complications should undergo mastoid surgery as soon as possible.<a class="elsevierStyleCrossRef" href="#bib0050">5</a> In our patient, the poor response to parenteral antibiotic treatment determined the intervention." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Vázquez Fernández ME, Cebrián Fernández R, Vegas Alvarez AM. Mastoiditis aguda con absceso subperióstico por gérmenes emergentes. Med Clin (Barc). 2018;151:292–293." ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Larrú Martínez B. Mastoiditis (v.3/2014). Guía ABE. Infecciones en Pediatría. Guía rápida para la selección del tratamiento antimicrobiano empírico. Available from: <a id="intr0010" class="elsevierStyleInterRef" href="http://www.guia-abe.es/temas-clinicos-mastoiditis">http://www.guia-abe.es/temas-clinicos-mastoiditis</a>. [Accessed 1 October 2017]." ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Alloiococcus otitidis y Turicella otitidis: gérmenes emergentes como causa de mastoiditis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.A. Sánchez" 1 => "M.J. Carbonero" 2 => "M.C. Cuadrado" 3 => "N. Batista" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Vox Paediatrica" "fecha" => "2014" "volumen" => "21" "paginaInicial" => "69" "paginaFinal" => "70" "itemHostRev" => array:3 [ "pii" => "S0161642014000487" "estado" => "S300" "issn" => "01616420" ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mastoiditis aguda en la época de la vacuna antineumocócica" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A.I. Navazo-Eguía" 1 => "D. Conejo-Moreno" 2 => "G. de-la-Mata-Franco" 3 => "A. Clemente-García" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.otorri.2010.09.005" "Revista" => array:7 [ "tituloSerie" => "Acta Otorrinolaringol Esp" "fecha" => "2011" "volumen" => "62" "paginaInicial" => "45" "paginaFinal" => "50" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21112578" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S016164201100950X" "estado" => "S300" "issn" => "01616420" ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anaerobic bacteria in upper respiratory tract and head and neck infection: mycrobiology and treatment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "I. Brook" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.anaerobe.2011.12.014" "Revista" => array:7 [ "tituloSerie" => "Anaerobe" "fecha" => "2012" "volumen" => "18" "paginaInicial" => "214" "paginaFinal" => "220" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22197951" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S000293940700863X" "estado" => "S300" "issn" => "00029394" ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of paediatric acute mastoiditis: systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R. Loh" 1 => "M. Phua" 2 => "C.L. Shaw" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1017/S0022215118001810" "Revista" => array:5 [ "tituloSerie" => "J Laryngol Otol" "fecha" => "2017" "paginaInicial" => "1" "paginaFinal" => "9" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30322420" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015100000007/v1_201810260641/S2387020618303267/v1_201810260641/en/main.assets" "Apartado" => array:4 [ "identificador" => "43311" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015100000007/v1_201810260641/S2387020618303267/v1_201810260641/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020618303267?idApp=UINPBA00004N"]

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Vol. 151. Issue 7.

Pages 292-293 (October 2018)

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