A 75-year-old male was admitted to the emergency department in May 2019 presenting with oliguria and nocturnal psychomotor agitation over the past 24 hours. His medical history included mild cognitive impairment, chronic obstructive pulmonary disease, type 2 diabetes mellitus, coronary artery disease, and a third-degree atrioventricular block requiring pacemaker implantation. He had been previously hospitalized in January for recurrent falls with minor head trauma, during which brain CT revealed no abnormalities. In April, he was admitted for *Clostridium difficile* enteritis complicated by a urinary tract infection (UTI) caused by *Escherichia coli* and *Klebsiella pneumoniae*. At that time, a follow-up brain CT demonstrated a thin right fronto-parietal chronic subdural hematoma. Since discharge, his condition had progressively deteriorated with persistent low-grade fever and worsening general health.
On admission, vital signs showed blood pressure of 120/80 mmHg, heart rate 75 bpm, respiratory rate 16/min, oxygen saturation 100% on room air, and temperature 37.7°C. The patient was drowsy, opening eyes only to verbal stimuli, producing incomprehensible sounds, and withdrawing limbs to pain—Glasgow Coma Scale score of 9. Physical examination was unremarkable regarding cardiovascular, respiratory, and abdominal systems. An indwelling urinary catheter was in place, but no urine output was recorded in the last six hours. Bilateral lower limb edema was present. No meningeal signs or focal neurological deficits were observed. Chest X-ray showed no acute abnormalities.
Laboratory tests revealed severe leukocytosis with neutrophilia (WBC 34,880/µL, neutrophils 28,990/µL), platelet count 114,000/µL, C-reactive protein 3.62 mg/dL (normal <0.5 mg/dL), INR 2.02, creatinine 1.66 mg/dL, bilirubin 1.3 mg/dL, albumin 1.9 g/dL, pH 7.36, and lactate 3.8 mmol/L. These findings indicated systemic inflammation, renal dysfunction, and metabolic acidosis consistent with sepsis involving multiple organs—including hematological, renal, and central nervous system. Given his recent UTI and presence of an indwelling catheter, a relapse of UTI was considered the most likely source. Blood cultures were obtained, and empiric antibiotic therapy with meropenem was initiated due to concerns about multidrug-resistant organisms following recent hospitalization. After fluid resuscitation with 2000 mL crystalloids over two hours, spontaneous urination resumed, and a urine sample was sent for culture. Due to the history of chronic subdural hematoma and ongoing anticoagulation with fondaparinux, concern arose about potential hemorrhagic transformation into a subdural empyema.Cdc25C Antibody Protocol A non-contrast brain CT was performed (Fig.PDGFR-β Antibody medchemexpress 1), revealing an inhomogeneous right hemispheric subdural collection with adjacent parenchymal hypodensity suggestive of edema—features inconsistent with a simple chronic hematoma.PMID:34623476
Further imaging was urgently required. Because of the patient’s unstable clinical state and the contraindication to MRI due to implanted pacemaker, a contrast-enhanced CT scan was performed. It demonstrated intense rim enhancement of the extra-axial fluid collection, strongly suggestive of subdural empyema (Fig. 2). This finding prompted immediate neurosurgical consultation.
Neurosurgical evaluation confirmed the need for emergent craniotomy. The patient underwent surgery, during which a large purulent collection was found beneath a thickened parietal membrane—likely secondary to chronic hematoma organization. The brain surface was hyperemic, and widespread leptomeningeal exudates were evident. Multiple samples were collected for microbiology, and the cavity was irrigated with saline and vancomycin. A subdural drain was placed, and the skull was closed in standard fashion.
Postoperative CT showed successful evacuation of the empyema with significant reduction in mass effect and no complications. Neurological status improved markedly postoperatively—patient became responsive to commands, and left-sided weakness (3/5 BMRC) improved significantly.
Despite surgical intervention, the patient developed progressive multi-organ failure. On day 7, abdominal CT revealed acute bowel ischemia. Microbiological analysis from operative specimens identified *E. coli* (ESBL-positive). Despite aggressive ICU management including intubation and mechanical ventilation, the patient succumbed eight days after admission.
This case highlights the diagnostic challenge of sepsis in elderly patients with atypical presentations. While initial suspicion focused on a recurrent UTI, the presence of a chronic subdural hematoma and anticoagulant use necessitated further investigation. The radiological progression from chronic hematoma to subdural empyema underscores the importance of considering rare but life-threatening complications in patients with predisposing conditions. Early recognition via timely imaging—even when not initially suspected—is critical. This case also emphasizes that common explanations may be misleading; even in the face of typical septic signs, unusual diagnoses such as subdural empyema must be actively excluded, particularly in vulnerable populations.MedChemExpress (MCE) offers a wide range of high-quality research chemicals and biochemicals (novel life-science reagents, reference compounds and natural compounds) for scientific use. We have professionally experienced and friendly staff to meet your needs. We are a competent and trustworthy partner for your research and scientific projects.Related websites: https://www.medchemexpress.com
