Introduction An Illustrative Case1

History: While playing on a farmyard, a five years old boy accidentally was hit by a hayfork at his left eye. No injury was observed to the eye or surrounding tissue so that the true diagnosis was missed by a GP and an ophthalmologist the same evening1.

High temperatures up to 40° C (= 104° F) occurred during the following 24 hours and these were misdiagnosed as a summer flu. Another 24 hours later, the child was admitted to pediatric infirmary, now being in the state of a severe meningitis including sings of an orbital empyema (figure 2.2.5-1A).

Figure 2.2.5-1. Physical aspect and radiological findings (see text for details)

Diagnoses: Bacterial meningitis (cerebro-spinal-fluid culture: Clostridium perfringens). Gas formation of unknown origin in the basal parts of the left frontal cerebral lobe (figure 2.2.5-1B). Orbital empyema.

Course: Five days after the initial injury, the child was transferred to our facilities. Computed tomography revealed the penetrating injury of the leftside orbital roof (figure 2.2.5-1C). This established the link between the initial trauma, the meningitis, and the radiological signs of an early cerebritis.

Because of the localization of the cerebral process as well as its stage, the neurosurgical approach was limited to drainage only. In spite of effective drainage combined with broad-spectrum antibiotics, a large cerebral abscess emerged over the next three days. The abscess was adjacent to the Broca center, capsula interna, and A. cerebri media with resulting ventricular rupture (figure 2.2.5-1D).

Figure 2.2.5-2. Picture of the boy one year after treatment. Note the complete recovery in coordination and hand ability

HBO-Therapy: Because of the abscess being in a dominant location, the organism involved, and the progression in spite of standard therapy, adjuvant HBO was started (1 session of 60 minutes per day at 2.5 ata).

Continuous improvement followed: body temperatures, orbital empyema, subsided and systemic inflammatory parameters returned to normal within one week. The boy completely regained his alertness within three days.

Seventeen HBO-sessions were administered on 17 consecutive days. No complication resulted from the pressure or hyperoxygenation. At the end of HBO treatment, the child was discharged from the ICU following a total stay of 20 days. Close neurosurgical surveillance was maintained.

Outcome: There were no permanent neurological deficits and the boy was able to go to school at the age of six according to national regulations (figure 2.2.5-2).

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