708 - When Commensal Becomes Catastrophic: Brain Injury from Streptococcus constellatus Sinusitis

Case Diagnosis: Subdural empyema with associated cerebritis, pneumocephalus, and hydrocephalus as a complication of Streptococcus constellatus sinusitis.

Case Description: A 27-year-old left-handed Marine without prior medical history presented with fever and altered mental status after several days of sinusitis. Brain imaging revealed pansinusitis with frontal sinus dehiscence, pneumocephalus, cerebritis, and a large left subdural empyema with midline shift. Despite empiric antibiotics, he deteriorated, requiring intubation and emergent craniectomy with empyema evacuation. His course was complicated by recurrent subdural collections requiring external ventricular drain placement and occipitotemporal abscess drainage, as well as hypothermia, intracranial hypertension, and prolonged airway compromise necessitating tracheostomy. Follow-up MRI ultimately showed resolution of empyema with a small noninfectious residual collection. After six weeks of intravenous antibiotics, he underwent ventriculoperitoneal shunt placement for hydrocephalus. Upon transfer to inpatient rehabilitation, he was awake, able to follow commands, and motivated for therapy. During rehabilitation, he demonstrated functional gains including improved speech and sitting balance, highlighting the potential for meaningful recovery despite severe infection-related brain injury.

Discussions: This case demonstrates the fulminant intracranial complications that may follow untreated or refractory sinusitis from commensal bacteria. Subdural empyema, brain abscess, and hydrocephalus pose significant morbidity, often requiring multiple neurosurgical interventions. Early recognition, broad-spectrum antimicrobial therapy, and close collaboration between neurosurgery, infectious disease, and rehabilitation teams are critical to survival and recovery.

Conclusions: Subdural empyema secondary to sinusitis remains a life-threatening neurosurgical emergency. Prompt diagnosis, aggressive surgical management, and prolonged antibiotics can lead to meaningful neurologic recovery, even in critically ill patients. Rehabilitation plays a vital role in functional restoration following stabilization.