Case Report
A 73-year-old woman with a pertinent past medical history of diabetes and squamous cell carcinoma (SCC) of the scalp presented with her family to her primary care provider for her annual Medicare visit (2/2023). During the visit, her family reported increased confusion and falls over the course of two weeks as well as increased foul smelling, purulent drainage emanating from a surgical site wound on her scalp. Review of systems was negative for fever, chills, headaches, dizziness, hypoglycemia, or other infectious symptoms. She reported taking her medications as prescribed. In addition, her PHQ score was 18 (previous was one in December 2021).
Physical exam revealed normal vital signs and an intact cranial surgical mesh with an adjacent area of hypertrophied, hardened skin and purulent drainage. Bloodwork from the visit revealed a mild leukocytosis of 11.9k/cu mm (4.5 – 11k/cu mm), elevated ESR and CRP of 75 and 11.7 (<30 and <0.5 respectively), and an elevated hemoglobin A1c of 10.3% (6.2% six months prior). With these results, a prompt evaluation in the nearest emergency department (ED) was recommended to assess for a central nervous system (CNS) infection.
The SCC of her scalp had previously eroded through her cranium to the dura, resulting in craniectomy with placement of a titanium fenestrated mesh. To close the defect, she underwent two flap procedures (most recently 4/2022); however, both attempts were unsuccessful. Not wanting to undergo additional procedures, the defect had been treated for at least six months using Betadine 10% solution which was discontinued two weeks prior to her presentation to her primary care clinic.
In the ED, her vitals were: 97.9F, heart rate 69, respiratory rate 20, blood pressure 110/45, and O2 saturation 100% on room air. She was alert and oriented with an intact surgical mesh on her head. The surgical site had clean, dry dressing wrapped around it. The surgical site was surrounded by brown/gray material that appeared to be a mix of matted hair and dried discharge without any obvious purulence, foul smell, or tenderness (Figure 1 A & B).
After obtaining initial bloodwork (Table 1) and blood cultures, she underwent imaging, a lumbar puncture (Table 2), wound cleaning (Figure 1 C & D), and was started on intravenous antibiotics and supportive cares (vancomycin, cefepime, and metronidazole at CNS penetration dosing).
Magnetic resonance imaging (MRI) of her brain revealed left frontal cerebritis with associated bifrontal leptomeningitis and pachymeningitis without any intra- or extra-axial abscess. After discussing the case with Neuroradiology and comparing current imaging (Figure 2) to images obtained one year prior (Figure 2), there were no significant changes noted in the primary area of concern.