O2208: Pneumocephalus, a rare presentation of complicated sinusitis.

Introduction: Pneumocephalus is a rare medical condition characterized by the presence of gas or air within the cranial vault. While it most commonly occurs due to trauma or neurosurgical procedures, other causes can include congenital factors, neoplastic growths, and infections. Early recognition of pneumocephalus, particularly in cases involving infection, is crucial for preventing complications and guiding appropriate intervention. Though there is limited literature on pediatric cases of infectious pneumocephalus, it can present as an initial sign of acute sinusitis with intracranial involvement. Identifying pneumocephalus through imaging, especially in an urgent care or emergency setting, can help initiate timely management, potentially preventing delays in treatment.

Case Description: We present a case of a previously healthy 7-year-old African American boy diagnosed with sinogenic pneumocephalus and meningitis, who later developed dehiscence of the left sphenoid sinus wall, leading to central skull osteomyelitis and subdural empyema. The patient initially presented to our Urgent Care Clinic with a one-week history of nasal congestion, rhinorrhea, and fever. His condition worsened over the prior 24 hours, with the development of headache, vomiting, decreased urine output, and lethargy. His family attributed these symptoms to lack of sleep and poor appetite. Upon arrival, the patient was afebrile with normal vital signs, but he was difficult to arouse and could only respond to painful stimuli, with a Glasgow Coma Scale (GCS) 12. Based on these findings, meningitis complicating sinusits was suspected, parenteral antibiotics were administered and a transfer to the Emergency Department (ED) for further evaluation was organized.
Upon arrival at the ED, the patient's condition had improved significantly. He was awake, alert, and able to respond appropriately, though not immediately (GCS 14). The patient underwent a work-up for upper respiratory infection, which included a negative rapid Strep test, a positive result for Rhinovirus on the respiratory viral panel, and a normal chest X-ray. Given the clinical suspicion reported prior to transfer to the accepting physician, a head CT was also obtained. The imaging revealed two foci of pneumocephalus in the left anterior middle cranial fossa, one of which exerted mass effect on the anterior left temporal lobe, while the other extended into the left orbital apex. The pneumocephalus was associated with sinus disease. A multidisciplinary approach was initiated, involving ENT, neurosurgery, and pediatric intensive care specialists for comprehensive management.

Discussion: This case underscores the importance of timely, coordinated care across specialties in managing complex conditions such as sinusitis with intracranial complications. Symptoms can vary widely, and neurological signs may fluctuate, making early diagnosis challenging. Social and cultural factors can also influence parental perceptions of their child's health, complicating assessment.

Conclusion: Detailed history-taking is vital in raising suspicion for potential complications. Early intervention remains key to ensuring positive outcomes for patients with life-threatening conditions.