Scientific letter
Acute mastoiditis with subperiosteal abscess due to emerging infectious agents
Mastoiditis aguda con absceso subperióstico por gérmenes emergentes
Marta Esther Vázquez Fernándeza,
, Rosalía Cebrián Fernándezb, Ana María Vegas Alvarezc
Corresponding author
a Centro de Salud Arturo Eyries, Gerencia de Atención Primaria Valladolid Oeste, Facultad de Medicina, Universidad de Valladolid, Valladolid, Spain
b Hospital Universitario Río Hortega de Valladolid, Valladolid, Spain
c Hospital Universitario Río Hortega, Facultad de Medicina, Universidad de Valladolid, Valladolid, Spain
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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 29,200<span class="elsevierStyleHsp" style=""></span>leukocytes/mm<span class="elsevierStyleSup">3</span> (neutrophils 76%, leukocytes 14.6%, monocytes 9.1%), with normal red and platelet series. CRP was 225<span class="elsevierStyleHsp" style=""></span>mg/dl. 2<span class="elsevierStyleHsp" style=""></span>h after admission he had abundant purulent suppuration through the left auditory canal. <span class="elsevierStyleItalic">Turicella otitidis</span> 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 (150<span class="elsevierStyleHsp" style=""></span>mg/kg/day) and vancomycin (60<span class="elsevierStyleHsp" style=""></span>mg/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. <span class="elsevierStyleItalic">Pantoea agglomerans and Fusobacterium</span> were isolated in the surgical exudate. The treatment was changed to meropenem (120<span class="elsevierStyleHsp" style=""></span>mg/kg/day) and finally received oral amoxicillin clavulanic 8/1 (40<span class="elsevierStyleHsp" style=""></span>mg/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.</p><p id="par0015" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">1</span></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"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Changes in the causes of AOM and its complications have been described since the pneumococcal vaccine was introduced.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleItalic">Turicella otitidis</span> is characterized by being a gram-positive bacillus confined to the ear or adjacent areas. It is possible that <span class="elsevierStyleItalic">Turicella otitidis</span><a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> and oropharyngeal anaerobic germs<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></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.</p><p id="par0025" class="elsevierStylePara elsevierViewall">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 48<span class="elsevierStyleHsp" style=""></span>h of treatment.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></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.</p><p id="par0030" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">5</span></a> In our patient, the poor response to parenteral antibiotic treatment determined the intervention.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">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.</p>" ] ] "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>. 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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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