Meningoencephalitis With Subdural Supratentorial Pyogenic Abscess: A Case Report

Nawal B et al | DOI: 10.65188/nurexus.1080

Page 26

Journal of MedVerse Research & Practice

ISSN: 3107-4278

Meningoencephalitis With Subdural Supratentorial Pyogenic Abscess: A Case Report

B

Nawal

1

, Hisana Nazreen

2

, Hema Muralidharan

3

1

Pediatrics, Al Fujairah Hospital, Fujairah Hospital, ARE

2

Pediatrics, Jalila Children's Specialty Hospital, Dubai, ARE

3

Pediatrics, Al Qassimi Hospital, Sharjah, ARE Pediatrics

Email: jasminetvantony@gmail.com

Submission Date: 01.03.2026

Accepted Date:27.04.2026

Published Date: 30.04.2026

DOI: 10.65188/nurexus.1080

article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted

use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

Abstract

Meningoencephalitis is a serious infection involving both the meninges and the brain parenchyma, often associated

with significant morbidity and mortality, particularly in infants. Pyogenic abscess formation within the cranial cavity

is a rare but potentially life-threatening complication that requires prompt recognition and management. Subdural

abscesses, especially in the supratentorial region, are uncommon in early infancy and may present with non-specific

clinical features, making diagnosis challenging.

The case of a 2-month-old infant diagnosed with meningoencephalitis who subsequently developed a supratentorial

subdural pyogenic abscess. The patient presented with fever, irritability, and poor feeding, followed by neurological

deterioration. Neuroimaging played a crucial role in identifying the abscess, guiding timely surgical and medical

intervention. Early diagnosis, appropriate antimicrobial therapy, and neurosurgical management were key factors in

improving the clinical outcome.

This case underscores the importance of maintaining a high index of suspicion for intracranial complications in

infants with meningoencephalitis, particularly when clinical improvement is delayed or neurological signs worsen.

It also highlights the need for early imaging and multidisciplinary management to prevent adverse outcomes.

Keywords: subdural abscess, pyogenic abscess, pediatric neurology, meningoencephalitis, pediatric case report

Introduction

Subdural empyema (SDE) is characterized by the accumulation of purulent material between the arachnoid

and dura mater within the cranial cavity. This condition predominantly affects pediatric population, with

distinct etiologies according to age [1] . In infants, the primary cause is typically meningitis, whereas in

older children, otitis media and sinusitis are the primary sources, which may disseminate through

hematogenous spread or direct extension [2] . Notably, the mortality and morbidity rates associated with

supratentorial SDE is comparatively lower than in infratentorial locations [1]. This case report illustrates

the case of a 2-month-old boy who is diagnosed as meningoencephalitis. The main causative organisms

identified were Escherichia coli and Cytomegalovirus, leading to a cascade of events that subsequently lead

to the complication of subdural supratentorial pyogenic abscess. This case report provides information

about its occurrence, clinical course, and management. Publishing the same serves to expand the medical

literature, highlight the challenges in diagnosis and the importance of early intervention, share valuable

clinical experiences, contribute to better patient outcomes, and potentially influence changes in healthcare

systems' approaches to this condition.

CASE REPORT

Nawal B et al | DOI: 10.65188/nurexus.1080

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Case Presentation

A 2 months-old male baby presented to the hospital, with the complaint of high-grade fever for 3 days. It

was associated with abnormal movements, irritability, poor feeding and excessive cry. He had no other

symptoms like nasal congestion, cough, vomiting or diarrhea. He was brought to the emergency department

with fever and was advised admission, however, requested discharged against medical advice, and was

given prescription for home. At home, he was treated with oral cefixime (100 mg-5mL suspension) for 2

days.

There were no similar complaints in the family. He was born at full term via normal vaginal delivery with

hand presentation. His past medical history revealed a previously well baby with no known contact with

tuberculosis(TB). His vaccinations were up to date. He was on exclusive breast feeding. He had no known

allergies. No known travel history. Initial examination revealed an irritable infant with the following vitals:

temperature of 38 degree celsius, capillary refill time 3 s, heart rate 161/min, respiratory rate 36/min, and

oxygen saturation (SpO2) of 100% at room air. The patient weighed 5.3 kilo gram.

There was no pallor, icterus, cyanosis, clubbing or pedal edema. Neurological examination revealed intact

primitive reflexes, patent anterior fontanelle, non bulging, non pulsatile, no signs of meningeal irritation.

Rest of the systemic examination was unremarkable. On developmental assessment there was head lag, and

social smile. He responded to sound, could see, fix and follow objects. Blood workup was done (as shown

in the table 1). Blood investigation on admission had showed 8.7 g% hemoglobin. Total leukocyte count

was 4.2 x10(3)/mcL and the differential count revealed 79% lymphocytes, 12.7% neutrophils. C-reactive

protein (CRP)was 326mg/l. Cerebrospinal fluid (CSF) result was unremarkable. Chest X-Ray (CXR) and

abdominal X-Ray were normal.

Table 1:

Serial Blood Test Results

DATE

14

MA

R

2022

16

MAR

2022

18

MAR

2022

20

MAR

2022

21

MAR

2022

25

MAR

2022

30

MAR

2022

5

APR

2022

27

APR

2022

4

MAY

2022

HB

10.3

8.7

9.1 L

8.10 L

-

7.5 L

10.5

8.3 L

9.4 L

-

WBC

5.58

4.2L

16.7 H

16.61

H

-

15.19

19.3 H

11.5

17.27

-

NEUTRO%

42.3H

12.7 L

40.40

H

27.8

-

65.90

H

64 H

50.9

H

51.3 H

-

LYMPHO

%

51.6

79 H

36.9 L

51.3

-

19.9 L

24 L

32 L

51

-

MONO %

3.6

5

18 H

18.6 H

-

11.9 H

10.10

12.5

H

14.17

H

-

CRP

53 H

326.6

H

108.7

H

30.2H

-

143.1

H

169.6

H

73.8

H

0.2

-

PT

-

12.7

-

PTT

-

38.7

H

-

INR

-

1.12

-

CULTURE

-

CMV

reactiv

e

Nawal B et al | DOI: 10.65188/nurexus.1080

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A provisional diagnosis of meningoencephalitis was made based on septic workup. The patient was started

on cefotaxime, vancomycin and dexamethasone. After 48 hours of admission, he had right focal seizures

with secondary generalization followed by refractory seizure for around three hours. Then, he was started

on intravenous (IV) phenytoin 20mg/kg per day, phenobarbitone 30mg/kg per day and midazolam

(loading dose followed by infusion to a maximum dose of 18mg/kg/min). He was intubated, shifted to

high dependency unit (HDU) and put on ventilator support after thiopental sedation. The following day,

he was extubated as he was stable and was kept on phenobarbitone maintenance dose of 5mg/kg per day.

During the course of this period, the fever persisted.

On the eighth day, magnetic resonance imaging (MRI) brain with contrast revealed the presence of left

fronto-parieto-temporal extra axial pachymeningeal and to less extent leptomeningeal pathological

enhancement denoting meningitis. Bilateral subdural hygroma more on the left side was seen [Fig 1].

On the tenth day, lumbar puncture was repeated and CSF was sent for analysis. It showed no growth.Two

days later, US Neonatal Brain Scan was done that revealed a small fluid echogenicity below the level of

corpus callosum measuring about 1.3x1.5 cm. Second opinion from Infectious Diseases, concluded that

this is a complicated case of meningoencephalitis which went into stormy course of the illness, despite

maximum medical therapy, most likely due to microbial virulence rather than antibiotics failure. It was

advised to drain the subdural fluid collection immediately and then to send the drain for the following test

(gram stain/culture and sensitivity (c/s)/Acid Fast Bacillus (AFB)/TB Polymerase Chain Reaction (PCR)

and culture/ viral study for Herpes Simplex Virus (HSV) and enteroviruses). It was also recommended to

keep the child on meropenem alone. On the 15th day, the patient developed a brief generalized tonic clonic

convulsions. He was febrile with temperature39.5C. The convulsion was aborted after giving IV Diazepam

with loading dose of phenobarbital (10mg/kg) followed by 5mg/kg/BID. Hence 13 mg per dose was given

BID. He remained stable with no more convulsions.

FIGURE 1: Magnetic resonance imaging (MRI) brain study with contrast revealing left fronto-

parieto-temporal extra axial pachymeningeal and to less extent leptomeningeal pathological

enhancement denoting meningitis. Bilateral subdural hygroma more on the left side.

Nawal B et al | DOI: 10.65188/nurexus.1080

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A neurosurgical consultation was done to rule out any abscess which could be a complication of

meningoencephalitis. Close observation was ordered and computed tomography (CT) scan as needed was

advised for burr hole procedure if there is increase in size of the hygroma [fig 2].

On day 16, the infant underwent transfontanelle aspiration of the subdural collection, yielding

approximately 13 mL of pus for microbiological analysis. CSF examination revealed markedly elevated

protein, low glucose, and a WBC count of 24.146 × 10³/µL. Post-procedure, the patient developed a brief

right upper limb convulsion associated with a high-grade fever (39.5°C), which resolved following rectal

diazepam. Brain CT demonstrated a stable left fronto-temporo-parietal extra-axial subdural collection with

bilateral frontal hygroma/external hydrocephalus. The infant received intravenous meropenem for 42 days,

along with phenobarbital and levetiracetam, which were gradually tapered according to the clinical

response. Supportive therapy included multivitamins, vitamin D, and iron supplementation. Repeat lumbar

puncture on day 44 showed marked normalization of CSF parameters, while CBC, CRP, liver function, and

renal function tests were within normal limits. The child recovered well and was subsequently discharged

with follow-up advice.

TABLE 2: CSF RESULTS

DATE

16 MAR

2022

25 MAR

2022

27 MAR

2022

31 MAR

2022

02 APR

2022

28 APR

2022

Protein

651.3 C

1260.6 C

--

33,394.3 C

--

496.9 C

Glucose

2 L

2.1 L

--

0.2 C

--

2.7

Total WBC

1.581 X

10^3 uL

0.123 X

10^3 uL

--

24.146 X

10^3 uL

--

0.051 X

10^3 uL

IL-6

--

46.4 H

--

CSF

Culture

Negative

--

E.Coli

growth

E.Coli

growth

--

FIGURE 2: CT brain study done before burr hole

procedure to check if there is increase in size of the

hygroma.

Nawal B et al | DOI: 10.65188/nurexus.1080

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Serial blood test results are given in table 1 and CSF results in table 2. On day 44, the child was active, in

good general condition, vitally stable and maintaining oxygen saturation in room air. There was no fever

since the last 3 weeks. He was passing urine and stool normally and was tolerating feed.

Hence, the patient was discharged on the following home medications- Keppra 21 mg/kg/dose BID

[levetiracetam, 120 mg, Soln-Oral, q12hr, Oral] for 2 months and oral keppra at tapered doses, 6 mg twice

daily for 1 week, then 3 mg twice daily for 1 week , then to stop. The parents were also instructed that if

the child developed convulsion during tapering, they should resume previous dose. On discharge the plan

was to repeat CBC and High-Performance Liquid Chromatography after 1 month along with follow up in

the pediatric clinic and neurosurgical clinic. EEG and MRI brain appointment were given after 2 months,

which were concluded as normal.

Discussion

Brain abscess and subdural empyema (SDE) in pediatric patients are neurological emergencies with

significant morbidity and mortality. About one-quarter of brain abscesses occur in children, most

commonly between ages 4–7 years, with a male predominance. SDE, accounting for over half of

intracranial infections, involves pus accumulation between the dura and arachnoid mater. In infants, it

commonly follows meningitis, while in older children it is associated with sinusitis or otitis media. Risk

factors include infancy (<6 months) and male sex. Causative organisms vary by age: neonates are

commonly affected by group B streptococci, Enterobacteriaceae, and Listeria, whereas older children are

more often infected by Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis.

Clinical presentation is often nonspecific. Seizures are the most common symptom (≈40%), along with

fever, headache, altered consciousness, and focal neurological deficits. The classic triad (fever, headache,

focal deficits) appears in only a minority of cases. Laboratory findings may show elevated CRP, ESR, and

leukocytosis, but blood and CSF cultures often have low diagnostic yield.

Neuroimaging is critical for diagnosis. CT scans are widely available and used initially, but may be normal

in early stages. MRI with contrast is the gold standard, with higher sensitivity (~93%), especially for

detecting early or small lesions.

Management includes prompt initiation of broad-spectrum intravenous antibiotics (e.g.,

cefotaxime/ceftriaxone with metronidazole), followed by prolonged therapy. Supportive care includes

seizure prophylaxis and management of intracranial pressure. Surgical intervention (burr holes or

craniotomy) is indicated in cases of deterioration, sepsis, or poor response to antibiotics.

Early diagnosis and treatment significantly improve outcomes, with survival rates exceeding 90% when

managed promptly. However, survivors may experience long-term neurological deficits, emphasizing the

need for rapid recognition and intervention.

Summary

This case report describes a 2-month-old male infant with meningoencephalitis complicated by a

supratentorial subdural pyogenic abscess, a rare but potentially fatal intracranial complication in infancy.

The infant initially presented with high-grade fever, irritability, poor feeding, and seizures, followed by

neurological deterioration despite empirical broad-spectrum antibiotic therapy. Magnetic resonance

imaging (MRI) revealed bilateral subdural hygroma and features of meningitis, while subsequent aspiration

confirmed an Escherichia coli pyogenic abscess. The patient underwent prompt neurosurgical drainage,

received prolonged intravenous meropenem therapy along with anticonvulsants and supportive care, and

demonstrated gradual clinical recovery with normalization of laboratory, cerebrospinal fluid, EEG, and

Nawal B et al | DOI: 10.65188/nurexus.1080

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MRI findings before discharge. This case highlights the importance of maintaining a high index of suspicion

for intracranial complications in infants with persistent or worsening meningoencephalitis and emphasizes

that early neuroimaging, timely surgical intervention, multidisciplinary management, and prolonged

targeted antimicrobial therapy are essential for achieving favorable clinical outcomes.

Conclusion

In conclusion, the management of meningoencephalitis complicated by a subdural supratentorial pyogenic

abscess in this infant exemplifies the critical role of multidisciplinary care and timely surgical intervention.

Despite initial challenges in diagnosis and treatment, including the identification of ESBL-negative

Escherichia coli as the causative agent, early drainage and targeted antibiotic therapy led to a successful

clinical outcome. The case highlights the importance of vigilance in recognizing rare but serious

complications, such as convulsions and altered CSF dynamics, and underscores the necessity for thorough

post-treatment monitoring, including EEG and MRI evaluations. By sharing this experience, we aim to

contribute to improved awareness, diagnostic accuracy, and therapeutic strategies for similar cases in

pediatric neurology and infectious disease management.

Disclosures

Human subjects: Informed consent for treatment and open access publication was obtained or waived

by all participants in this study. Ministry of Health and Prevention Research Ethics Committee/RAK

Subcommittee issued approval MOHAP/REC/2024/67-2024 F-N. In regards to the above-mentioned

Study protocol, this is to confirm that on the meeting dated (04/06/2024) the Ministry of Health and

Prevention Research Ethics Committee has reviewed the Study protocol as well as all the documents

submitted in the Submission file from the ethical point of view and has approved the conduct of the

above-mentioned study.

Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the

following: Payment/services info: All authors have declared that no financial support was received from

any organization for the submitted work.

Financial relationships: All authors have declared that they have no financial relationships at present

or within the previous three years with any organizations that might have an interest in the submitted

work.

Other relationships: All authors have declared that there are no other relationships or activities that

could appear to have influenced the submitted work.

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