J Neurocrit Care.  2020 Nov;13(2):119-122. 10.18700/jnc.200017.

Central skull base osteomyelitis due to nasopharyngeal Klebsiella infection

• Woo KN
• Roh J
• Baik SK
• Shin DH
• Park KS
• Park MG
• Park KP
• Ahn SH

• KMID: 2509943
• DOI: http://doi.org/10.18700/jnc.200017

Abstract

Background
Skull base osteomyelitis (SBO) is a rare but life-threatening disease occurring as a complication of malignant otitis externa, and accompanied by venous sinus thrombosis, meningitis, abscess, cranial neuropathies, and carotid invasion as complications. Central SBO may originate from a paranasal infection, such as sphenoidal or ethmoidal sinusitis without associated external otitis.
Case Report
We describe a 36-year-old Sri Lankan male with central SBO presenting with multiple embolic infarctions and meningitis caused by a nasopharyngeal Klebsiella infection that had invaded the left internal carotid artery. Despite complications, such as endogenous endophthalmitis, abscesses in the brain parenchyma, and mycotic aneurysms in cerebral vessels, the patient recovered after 8 weeks of intensive antibiotics treatment except for a remnant mycotic aneurysmal dilatation in the internal carotid artery.
Conclusion
This is the first report of central SBO caused by a nasopharyngeal Klebsiella infection, which invaded the left internal carotid artery and led to multiple complications.

Keyword

Skull base osteomyelitis; Infarction

Figure

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  Fig. 1. Brain magnetic resonance imaging (MRI) and computed tomography angiography (CTA) findings at admission (A, B), at 2 weeks of hospitalization after the onset of endogenous endophthalmitis (C), and at 8 weeks of hospitalization after completion of the antibiotic treatment (D). (A) Baseline MRI revealed multiple embolic infarctions on diffusion weighted image sequence in the region of the left middle cerebral artery. (B) Baseline MRI revealed an increased gadolinium enhancement in the left infratemporal fossa and skull base (red lines) and sulcal enhancement in the hemispheres (left), and baseline CTA (right) revealed a narrowing in the left petrous portion of the internal carotid artery (ICA; blue arrow), compatible with osteomyelitis due to the extension of a deep neck infection into the ICA. (C) Follow-up MRI revealed an increased enhancement in the left infratemporal fossa and skull base (red lines) and newly developed ring enhancement in the infarct area (suspicious of brain abscess formation; red arrows), and follow-up magnetic resonance angiography (MRA) revealed an interval improvement of the left distal ICA stenosis with a newly developed aneurysmal formation (mycotic aneurysm, blue arrow). (D) Follow-up MRI revealed an improvement in the inflammation in the left skull base and neck (red lines) and brain abscess (red arrow), and follow-up MRA revealed an increased size of the aneurysm in the ICA (blue arrow).

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