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Objective:To determine the aetiologies and clinical characteristics of infants with fever and a bulging fontanelle.Design:The medical records of all febrile infants with a bulging fontanelle who underwent a lumbar puncture from January 2000 to February 2008 in Assaf Harofeh Medical Center, a university affiliated hospital in central Israel, were identified.Results:153 patients met the inclusion criteria. The male to female ratio was 100:53; age range was 3–11 months with a mean age of 5.6 (SD 1.8) months and a median age of 5 months. Cerebrospinal fluid pleocytosis was found in 42 cases (27.3%), including one case of bacterial meningitis (0.6%). Other leading diagnoses were aseptic meningitis (26.7%), upper respiratory tract infection (18.3%), viral disease not otherwise specified (15.6%), roseola infantum (8.5%) and acute otitis media (6.5%). Appearance on admission was described as good to excellent in 113 (73.8%) infants, none of whom had bacterial meningitis. 32 had aseptic meningitis and 17 had other bacterial disease (pneumonia, acute otitis media, pyelonephritis, bacteraemia, shigella or salmonella gastroenteritis). All the latter had, upon admission, symptoms, signs, laboratory tests or imaging studies suggesting a bacterial aetiology.Conclusions:In this large cohort, all infants who appeared well on admission and had normal clinical, laboratory and imaging studies had benign (non-bacterial) disease. In an infant who appears well and has no evidence of bacterial disease, it is reasonable to observe the infant and withhold lumbar puncture. Prospective studies should be carried out to confirm this approach.

Purpose Ureaplasma species are associated with urogenital infections, infertility and adverse pregnancy outcomes as well as neonatal infections. Involvement of the central nervous system in adults is extremely rare. We report an unusual case of a brain abscess secondary to otitis media with Ureaplasma parvum in a patient with granulomatosis with polyangiitis (GPA). Methods Imaging and laboratory findings, treatment decisions, and outcome of this case are explicated. Results A young adult with GPA presented with progredient earache after ambulant diagnosis of otitis media. Despite different courses of broad-spectrum antibiotic therapy, she developed meningoencephalitis due to mastoiditis following temporal abscess formation. Mastoidectomy and neurosurgical abscess removal were performed. Standard cultures of cerebrospinal fluid, blood and intracranial abscess material, as well as polymerase chain reaction (PCR) for common bacterial and viral meningitis pathogens remained negative. Only eubacterial PCR of intracranial abscess material returned positive for Ureaplasma parvum. The patient finally improved under antibiotic therapy with moxifloxacin and doxycycline. Conclusion Ureaplasma species are rare causative pathogens in immunocompromised patients. They should be considered in patients with humoral immunodeficiencies with culture-negative infections failing standard therapy. Eubacterial PCR should be performed in early states of infection in these patients for immediate diagnosis and initiation of appropriate treatment to prevent adverse outcomes.

Objectives: We evaluated the results of cases of chronic otitis media treated with mastoid obliteration surgery using bioactive glass S53P4. Methods: Twenty-five patients with chronic otitis media and 1 patient with cerebrospinal fluid leakage without chronic infection were treated with bioactive glass S53P4. Twenty patients had had previous surgery because of chronic otitis media with or without cholesteatoma. A mastoid obliteration was performed with bioactive glass S53P4 granules and a musculoperiosteal flap with or without bone paté. In 2 patients with a bony dehiscence at the middle cranial fossa, a bioactive glass plate was used to support the protruding dura. In addition, in 3 patients, occlusion of a dural fistula was needed. The median follow-up period was 34.5 months (range, 1 to 182 months). Results: Excluding the 2 patients with only 1 month of follow-up at our department, 96% of the patients had a dry, safe ear or only intermittent otorrhea. In 92% of the patients, the objective of achieving a smaller or nonexistent cavity was achieved. Conclusions: Bioactive glass S53P4 is a noteworthy material in mastoid obliteration surgery.

This case report describes the successful diagnosis and surgical management of a cerebellar subdural empyema in a 14-year-old Domestic Shorthair cat. The patient presented with a left-sided head tilt and right-sided hemiparesis. Magnetic resonance imaging (MRI) revealed a right-sided extra-axial cavitated lesion in the cerebellum, and mild right-sided otitis media without evidence of otitis interna. Surgical decompression was performed, guided by the use of a 3D-printed model, and purulent material was evacuated. Bacterial culture identified Peptostreptococcus canis , Filifactor villosus, and a Gram-negative rod population; all were suspectible to amoxicillin-clavulanic acid. Cerebellar subdural lesion histopathologic analysis confirmed a pyogranulamatous to lymphoplasmocytic inflammatory process. The patient showed rapid postoperative neurological improvement and was discharged with targeted antimicrobial therapy. Follow-up MRI at 2 months revealed resolution of the cerebellar lesion but progression of right-sided otitis media without evidence of otitis interna. A ventral bulla osteotomy was subsequently performed, and tympanic mucosa biopsy confirmed chronic inflammation with cholesterol granuloma formation. To our knowledge, this is the first report of successful surgical treatment of a cerebellar subdural empyema in a feline patient.

Background Syringomyelia is a spinal cord cavity containing cerebrospinal fluid (CSF)-like fluid. If syringomyelia asymmetrically involves the dorsal horn grey matter of the spinal cord, affected dogs show increased signs of dysesthesia and neuropathic pain, like increased itching behaviour. In the dorsal horn, amongst others, receptors for Interleukin-31 (IL-31) can be found. IL-31 is one of the main cytokines involved in the pathogenesis of pruritus in atopic dermatitis in different species. This study investigates suspected elevated levels of IL-31 in serum and CSF of dogs showing signs of pain or increased itching behaviour related to syringomyelia. The IL-31 were measured in archived samples (52 serum and 35 CSF samples) of dogs with syringomyelia (n = 48), atopic dermatitis (n = 3) and of healthy control dogs (n = 11) using a competitive canine IL-31 ELISA. Results Mean serum IL-31 level in dogs with syringomyelia was 150.1 pg/ml (n = 39), in dogs with atopic dermatitis 228.3 pg/ml (n = 3) and in healthy dogs 80.7 pg/ml (n = 10). Mean CSF IL-31 value was 146.3 pg/ml (n = 27) in dogs with syringomyelia and 186.2 pg/ml (n = 8) in healthy dogs. Individual patients with syringomyelia (especially dogs with otitis media or otitis media and interna or intervertebral disc herniation) showed high IL-31 levels in serum and CSF samples, but the difference was not statistically significant. IL-31 serum and CSF levels did not differ significantly in dogs with syringomyelia with or without itching behaviour and with or without signs of pain. Conclusion Based on this study, increased IL-31 levels seem not to be correlated with itching behaviour or signs of pain in dogs with syringomyelia, but might be caused by other underlying diseases.

To recount experience with cerebrospinal fluid otorrhoea and temporal bone meningoencephalocele repair in a tertiary care hospital. A retrospective review was conducted of 16 cerebrospinal fluid otorrhoea and meningoencephalic herniation patients managed surgically from 1991 to 2016. Aetiology was: congenital (n = 3), post-traumatic (n = 2), spontaneous (n = 1) or post-mastoidectomy (n = 10). Surgical repair was undertaken by combined middle cranial fossa and transmastoid approach in 3 patients, transmastoid approach in 2, oval window plugging in 1, and subtotal petrosectomy with middle-ear obliteration in 10. All patients had successful long-term outcomes, except one, who experienced recurrence after primary stage oval window plugging, but has been recurrence-free after second-stage subtotal petrosectomy with middle-ear obliteration. Dural injury or exposure in mastoidectomy may lead to cerebrospinal fluid otorrhoea or meningoencephalic herniation years later. Congenital, spontaneous and traumatic temporal bone defects may present similarly. Middle cranial fossa dural repair, transmastoid multilayer closure and subtotal petrosectomy with middle-ear obliteration were successful procedures. Subtotal petrosectomy with middle-ear obliteration offers advantages over middle cranial fossa dural repair alone; soft tissue closure is more robust and is preferred in situations where hearing preservation is not a priority.

BackgroundGroup A streptococcal(GAS) meningitis is a severe disease with a high case fatality rate. In the era of increasing GAS meningitis, our understanding about this disease is limited.PurposeTo gain a better understanding about GAS meningitis.MethodsFive new cases with GAS meningitis were reported. GAS meningitis related literatures were searched for systematic review in PUBMED and EMBASE. Case reports and case series on paediatric cases were included. Information on demographics, risk factors, symptoms, treatments, outcomes, and emm types of GAS was summarized.ResultsTotally 263 cases were included. Among 100 individuals, 9.9% (8/81) had prior varicella, 11.1% (9/81) had anatomical factors, and 53.2% (42/79) had extracranial infections. Soft tissue infections were common among infants (10/29, 34.5%), while ear/sinus infections were more prevalent in children ≥ 3 years (21/42, 50.0%). The overall case fatality rate (CFR) was 16.2% (12/74). High risk of death was found in patients with shock or systemic complications, young children(< 3 years) and cases related to hematogenic spread. The predominate cause of death was shock(6/8). Among the 163 patients included in case series studies, ear/sinus infections ranged from 21.4 to 62.5%, while STSS/shock ranged from 12.5 to 35.7%, and the CFR ranged from 5.9 to 42.9%.ConclusionsA history of varicella, soft tissue infections, parameningeal infections and CSF leaks are important clinical clues to GAS in children with meningitis. Young children and hematogenic spread related cases need to be closely monitored for shock due to the high risk of death.

This retrospective study aimed to assess the accuracy of neurological examination in identifying intracranial extension of ear infection in dogs and to investigate the clinical data that may potentially aid in its diagnosis and prognosis. Dogs diagnosed with meningitis or meningoencephalitis due to an intracranial extension of otitis media-interna were included, and the relationship of MRI findings with neurological examination, clinical data, and outcome was studied. Thirty dogs were included, with 96% corresponding to brachycephalic breeds and a mean age of 7.5 years. The neurological examination was accurate in localizing the lesion in the central nervous system in 33% of dogs. Dogs with brainstem parenchymal involvement in magnetic resonance imaging (MRI) had a longer recovery (21 days). Recovery was complete in 28% of cases, with dogs more likely to have persistent neurological deficits when parenchymal and/or meningeal involvement was observed on imaging. MRI did not show intracranial extension in 20% of cases despite inflammatory cerebrospinal fluid (CSF). This study supports the conclusion that intracranial extension of otogenic infection is possible in dogs without central nervous system signs. When otitis media-interna is diagnosed, MRI and CSF studies should be recommended, especially for chronic or recurrent cases and in brachycephalic breeds.

Background: Otogenic meningitis represents the most common and life-threatening complication of infective middle ear diseases. However, no guidelines are available to describe the optimal management strategy and the role of surgical intervention. Methods: A six-year multicenter retrospective study on consecutive patients treated for otogenic meningitis caused by acute otitis and re-exacerbation of chronic otitis at the University Hospital of Verona and Modena was performed, and a systematic review regarding acute otitis media-related meningitis in accordance with the PRISMA 2020 statement was then conducted. Results: From the clinical chart analysis, 16 patients with surgical indications according to our decision-making flow chart were reviewed, with most of them undergoing surgery within 7 days of admission (n = 13, 81%). The systematic review ultimately utilized 24 studies (16 case reports and 8 case series) published between 1990 and 2023, with the overall analysis involving a total of 181 patients. Conclusion: The primary treatment for acute bacterial meningitis relies on antibiotic therapy, with surgical intervention being employed in the event of complications and when the initial treatment is not effective within 48 h. The objective of surgery is to sterilize the tympanic and mastoid cavity, thereby eradicating the suspected infective foci and managing any eventual intracranial complications.

The goal of this work is to develop an innovative method that combines bioprinting and endoscopic imaging to repair tympanic membrane perforations (TMPs). TMPs are a serious health issue because they can lead to both conductive hearing loss and repeated otitis media. TMPs occur in 3–5% of cases after ear tube placement, as well as in cases of acute otitis media (the second most common infection in pediatrics), chronic otitis media with or without cholesteatoma, or as a result of barotrauma to the ear. About 55,000 tympanoplasties, the surgery performed to reconstruct TMPs, are performed every year, and the commonly used cartilage grafting technique has a success rate between 43% and 100%. This wide variability in successful tympanoplasty indicates that the current approach relies heavily on the skill of the surgeon to carve the shield graft into the shape of the TMP, which can be extremely difficult because of the perforation's irregular shape. To this end, we hypothesized that patient specific acellular grafts can be bioprinted to repair TMPs. In vitro data demonstrated that our approach resulted in excellent wound healing responses (e.g., cell invasion and proliferations) using our bioprinted gelatin methacrylate constructs. Based on these results, we then bioprinted customized acellular grafts to treat TMP based on endoscopic imaging of the perforation and demonstrated improved TMP healing in a chinchilla study. These ear graft techniques could transform clinical practice by eliminating the need for hand-carved grafts. To our knowledge, this is the first proof of concept of using bioprinting and endoscopic imaging to fabricate customized grafts to treat tissue perforations. This technology could be transferred to other medical pathologies and be used to rapidly scan internal organs such as intestines for microperforations, brain covering (Dura mater) for determination of sites of potential cerebrospinal fluid leaks, and vascular systems to determine arterial wall damage before aneurysm rupture in strokes.