Hoofbeats, Zebras, and a Child with Vomiting

A 2-year-old child presented with a 2-day history of fever, irritability, and vomiting. At physical examination, he was alert with a presumptive body weight loss of 5%. No infective focus was identified. Blood test showed leukocytosis (15,270/mmc leukocyte), C-reactive protein elevation (53.81 mg/L), and mild hypoglycemia (58 mg/dL). Despite fluid correction, the child became drowsy rising suspicion of acute meningoencephalitis. Twenty-four hours after admission left otorrhea appeared. Given rapid neurological deterioration, Ceftriaxone and Acyclovir were started. Cerebral computed tomography (CT) showed opacification of the mastoid air cells and middle ear, a hyperdense appearance of the left sigmoid and transverse sinuses consistent with otomastoiditis, and cerebral venous sinus thrombosis (CVST). Conventional and venous magnetic resonance imaging (MRI) confirmed the diagnosis demonstrating also ipsilateral jugular vein thrombosis and epidural abscess ([Figs. 1] [2] [3]). After drainage of the abscess, low molecular weight heparin was administered for 2 months with complete neurological recovery. CSVT and epidural abscess are recognized complication of acute otitis media (AOM) and mastoiditis.[1] [2] Rarely otalgia could be lacking.[3] Although vomiting and drowsiness are common findings in acute gastroenteritis, one should also suspect intracranial hypertension.

Fig. 1 Coronal multiplanar reconstruction of fat-suppressed T1-weighted magnetic resonance (MR) images obtained using a 1.5-T superconductive MR scanner (Magnetom Aera, Siemens, Erlangen, Germany) with a standard head coil, after injection of 0.2 mL/kg of gadoteric acid. Omogeneous, hypointense epidural collect with peripheral enhancing wall is visible posteriorly to the left petrous bone.

Fig. 2 Same sequence as [Fig. 1]. A filling defect in the left sigmoid and transverse sinuses is more evident when compared with the omogeneous, hyperintense right sigmoid sinus.

Fig. 3 Maximum intensity projection (MIP) reconstruction obtained from a two-dimensional (2D) time-of-flight (TOF) magnetic resonance (MR) venography. Asymmetry between the left distal transverse sinus, the sigmoid sinus, and the left inner jugular vein (right in the picture), which are not visible, and the other hyperintense viable brain venous sinuses is highlighted.

CT scan is the first line investigation in emergency but its diagnostic sensitivity is low compared with MRI.[4]

The work was performed in Udine, Italy.

• References

• 1 Mattos JL, Colman KL, Casselbrant ML, Chi DH. Intratemporal and intracranial complications of acute otitis media in a pediatric population. Int J Pediatr Otorhinolaryngol 2014; 78 (12) 2161-2164
• 2 Bales CB, Sobol S, Wetmore R, Elden LM. Lateral sinus thrombosis as a complication of otitis media: 10-year experience at the children's hospital of Philadelphia. Pediatrics 2009; 123 (02) 709-713
• 3 Voudouris C, Psarommatis I, Nikas I, Kafouris D, Chrysouli K. Pediatric masked mastoiditis associated with multiple intracranial complications. Case Rep Otolaryngol 2015; 2015: 897239
• 4 Ghosh PS, Ghosh D, Goldfarb J, Sabella C. Lateral sinus thrombosis associated with mastoiditis and otitis media in children: a retrospective chart review and review of the literature. J Child Neurol 2011; 26 (08) 1000-1004