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Table of Contents    
LETTERS TO EDITOR
Year : 2019  |  Volume : 67  |  Issue : 3  |  Page : 915-918

Spontaneous skull osteomyelitis with subgaleal abscess due to Kocuria rosea


1 Department of Neurosurgery, Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
2 Department of Microbiology, Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India

Date of Web Publication23-Jul-2019

Correspondence Address:
Dr. Mathew Abraham
Department of Neurosurgery, Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.263238

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How to cite this article:
Rangnekar RD, Jamaluddin MA, Raja K, Abraham M. Spontaneous skull osteomyelitis with subgaleal abscess due to Kocuria rosea. Neurol India 2019;67:915-8

How to cite this URL:
Rangnekar RD, Jamaluddin MA, Raja K, Abraham M. Spontaneous skull osteomyelitis with subgaleal abscess due to Kocuria rosea. Neurol India [serial online] 2019 [cited 2019 Aug 19];67:915-8. Available from: http://www.neurologyindia.com/text.asp?2019/67/3/915/263238




Sir,

A 35-year old healthy male, without any comorbidity, presented with mild left frontal dull aching headache for 2 months. The patient had sustained a trivial fall at the age of 8 years. On examination, the patient was neurologically stable with most of the scalp being doughy and edematous. A fluctuant 6 × 4 cm swelling was felt over the left frontal region. A healed scar was found at the glabella, due to old trauma, without any signs of inflammation. Examination of the eyes, ear, nose, and airway were unremarkable.

The blood investigations were within normal limits. The computed tomographic (CT) imaging showed a 25 × 10 mm sized right parietal bone lytic lesion, adjacent to the sagittal suture, with erosion of the outer and inner table as well as a diffuse subgaleal collection with specks of air [Figure 1]. Magnetic resonance (MR) imaging revealed two small discrete expansile lesions of size 16 × 9 and 13 × 9 mm, involving the diploic space of right parietal bone with thinned remodeled inner and outer table along with a diffuse subgaleal collection [Figure 2] and [Figure 3].
Figure 1: (a) CT bone window imaging showing a parietal bone lytic lesion with increased scalp thickness. (b) CT 3D reconstruction showing a right parietal bone lytic lesion

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Figure 2: MR T2 weighed imaging showing a discrete expansile hyper-intense lesion involving the diploic space of right parietal bone with a diffuse hyper-intense subgaleal collection. (a) Sagittal view (b) Coronal View

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Figure 3: MR diffusion weighed imaging showing restricted diffusion in the subgaleal planes suggestive of an abscess

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Aspiration of the frontal collection revealed frank pus, and hence, the patient was taken up for evacuation of the subgaleal abscess via a bicoronal skin flap. The abscess was found at bilateral fronto-parietal regions extending posteriorly. Osteomyelitic bone was found in the right parietal bone near the sagittal suture 5 cm behind the coronal suture. 3 × 3 cm of outer and inner cortices were nibbled out [Figure 4]. No intracranial extension or foreign body was seen. Debridement was done followed by insertion of a large subgaleal drain. The pus culture grew Kocuria rosea sensitive to erythromycin, cefotaxime, vancomycin, clindamycin, and penicillin [Figure 5]. The patient received intravenous cefotaxime for 3 weeks followed by oral clindamycin for 3 weeks, according to sensitivity. Histological examination revealed an acute inflammatory exudate and organizing inflammatory granulation. No fungi or acid-fast bacilli was found. The patient was discharged with a healthy wound after ruling out the possibility of any immunosuppressive state or infective focus elsewhere.
Figure 4: Intraoperative photograph, after evacuation of the subgaleal abscess and removal of the osteomyelitic bone, showing the unhealthy scalp tissue and skull defect

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Figure 5: Gram stain of the growth obtained from culture of the pus aspirate showing gram positive diplococci – Kocuria Rosea

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Subgaleal abscess, although uncommon, occurs secondary to trauma, surgical interventions, scalp monitoring, sinusitis, scalp infection, contiguous infections, or septicemia.[1] There is a high predilection in neonates where scalp hematomas develop secondary infection. Subgaleal abscess has also been reported after blunt head injury, even without any definite macroscopic scalp wound, after a short lag period.[1],[2] There is a high chance of the sub-galeal inflammation disseminating within the closed space as well as intracranially through the emissary veins or the foramina. This may lead to osteomyelitis, intracranial abscess or scalp necrosis. Spontaneous subgaleal abscess with skull osteomyelitis has been reported only thrice in children but not in adults [Table 1].[3],[4],[5]
Table 1: Reported cases of spontaneous/cryptogenic skull osteomyelitis in literature and their management

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Kocuria genus organisms are gram-positive coccoid bacteria belonging to the Micrococcaceae family and are now emerging as the cause of different infections, especially in immuno-compromised hosts.[6] These low virulence organisms are found as commensals in the oropharynx and skin and are obligate aerobes. They are nitrate reductase negative, catalase positive and coagulase negative, hence showing a close diagnostic resemblance to coagulase-negative Staphylococci (CoNS). It seems, at this point, that misidentification of Kocuria as CoNS is possible and it feels prudent to speculate that cases earlier diagnosed as CoNS might have needed further characterization.[6] Diagnosis of Kocuria species may be difficult biochemically and may require genomics. Purty et al., attributed most cases to immuno-compromised states, in-dwelling devices presenting as blood stream infections, dialysis catheter related peritonitis and allied infections.[6],[7] Only a few cases of well-defined abscesses, such as brain abscess, have been reported due to Kocuria species [Table 2].[8],[9],[10] Only two case reports of non-catheter-related bacterial meningitis due to Kocuria rosea in otherwise healthy adults have been reported [Table 2].[7],[11],[12]
Table 2: Reported cases of Intra-cranial infections due to Kocuria species in literature and their management

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Detailed investigations should be done to rule out the presence of immunosuppression and any other infective focus. Since there are no definite guidelines on the best treatment required for the Kocuria species, it is imperative to follow the susceptibility pattern and previously successfully treated cases. A patient with an occipital brain abscess was reported to be successfully treated with surgical excision along with removal of the capsule and postoperative antibiotics; while the other case of parietal abscess was treated with only sensitive antibiotics after confirming the diagnosis with a stereotactic biopsy.[8],[9] First line antibiotics include amoxicillin/clavulanate with amikacin, doxycycline, ceftriaxone, or cefuroxime.[6] Extrapolating from the experience of improvement seen with catheter removal in catheter related infections due to Kocuria, foreign body removal might be helpful in these cases.[6]

Surgical treatment consists of an appropriate large flap with evacuation of any abscess, a thorough debridement of all non-viable tissue, followed by a subgaleal drain placement. Systemic and later oral antibiotic regime, for a duration depending on the type of intracranial extension and bony involvement, along with treatment of the source of infection and immunosuppression, if any, is of prime importance.

The present case is the fourth ever-reported patient who spontaneous developed skull osteomyelitis, the first adult case of spontaneous skull osteomyelitis, and the first case of subgaleal abscess or osteomyelitis due to Kocuria species. The remote history of trauma and the distant location of scar away from the skull lesion, as well as no definite foreign body or implantation dermoid found intraoperatively, ruled out the possibility of trauma as the etiology. There was also no underlying immunosuppression, no sinus infection nor any infective focus found.

With effective vaccines against meningitis in place, newer neuropathogens like Kocuria rosea have emerged, and that too, in the absence of any risk factors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Schaefer JP, Clein LJ, Conly JM. De novo subgaleal abscess. Can J Infect Dis Med Microbiol 1992;3:30-2.  Back to cited text no. 1
    
2.
Wiley JF, Sugarman JM, Bell LM. Subgaleal abscess: An unusual presentation. Ann Emerg Med 1989;18:785-7.  Back to cited text no. 2
    
3.
Prasad A, Madan VS, Suri ML, Buxi TB. Cryptogenic osteomyelitis of the skull and intracerebral abscess. Child's Nerv Syst 1992;8:142-3.  Back to cited text no. 3
    
4.
Arana E, Vallcanera A, Santamaría JA, Sanguesa C, Cortina H. Eikenella corrodens skull infection: A case report with review of the literature. Surg Neurol 1997;47:389-91.  Back to cited text no. 4
    
5.
Arnold PM, Govindan S, Anderson KK. Spontaneous cranial osteomyelitis in an otherwise healthy ten-year-old male. Pediatr Neurosurg 2009;45:407-9.  Back to cited text no. 5
    
6.
Purty S, Saranathan R, Prashanth K, Narayanan K, Asir J, Devi CS, et al. The expanding spectrum of human infections caused by Kocuria species: A case report and literature review. Emerg Microbes Infect 2013;2:e71.  Back to cited text no. 6
    
7.
Sipahi OR, Mermer S, Aydemir S, Ozgiray E, Cilli F, Oner K. Kocuria rosea meningitis. Surg Infect 2014;15:659.  Back to cited text no. 7
    
8.
Tsai CY, Su SH, Cheng YH, Chou YL, Tsai TH, Lieu AS. Kocuria varians infection associated with brain abscess: A case report. BMC Infect Dis 2010;10:102.  Back to cited text no. 8
    
9.
Montoya JE, Moran MÁ, Ardila JA, Henao PG, Rodriguez EE, Meza GA. Brain abscess by Kocuria rosea: Case report and literature review. Interdisciplinary Neurosurg 2017;7:59-61.  Back to cited text no. 9
    
10.
Nguyen A, Allison RZ, Maynard K, Patterson J. Kocuria rhizophila intracerebral abscess in diabetic ketoacidosis. J Neuroinfect Dis 2018;9:2.  Back to cited text no. 10
    
11.
Paul M, Gupta R, Khushwaha S, Thakur R. Kocuria rosea: An emerging pathogen in acute bacterial meningitis-Case report. Antimicrobial Agents 2015;1. Available from: http://jmaa.co.uk/o.js-2.4.7-1/index.php/JMAA/article/view/9. [Last accessed on 2019 Jun 15].  Back to cited text no. 11
    
12.
Behera B, Naik V, Mathur P, Agarwal D. Identification of Kocuria rosea by Vitek 2 GP card. Inter J Med Inform 2007;3:2.  Back to cited text no. 12
    


    Figures

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