P3C378: When a Seemingly Benign Finding Becomes a Dangerous Condition: Pott's Puffy Tumor Presenting as Frontal Head Swelling in an 8-year-old Boy

Introduction: Pott’s puffy tumor (PPT) is a rare complication of purulent rhinosinusitis with soft tissue swelling of the forehead, caused by underlying osteomyelitis of the frontal bone. Its presentation can bely the severity, as intracranial complications can result without prompt medical and surgical attention. We describe a case of PPT in an 8 y/o child.

Case Description: An 8-year-old male, with a history of recent viral sinusitis, presented with 2 days of severe frontal headache, photophobia, phonophobia, and left-sided orbital edema. He then developed swelling around his nasal bridge, hypersomnolence, and lower extremity weakness prompting him to go to the ED. CT scan of the orbits revealed frontal and sphenoidal sinusitis. Initial MRI revealed a subperiosteal abscess with a subjacent small frontal epidural fluid collection. He was empirically treated with IV triple broad-spectrum antibiotic therapy and functional endoscopic sinusotomy (FESS) with debridement. Streptococcus anginosus (SAG), Corynebacterium pseudodiphtheriticum. and Dolosigranulum pigrum grew from wound cultures. His hospital course was complicated by an acute seizure episode. Significant cerebral edema and subdural empyema were found on repeat MRI. He then underwent another FESS procedure, craniotomy, and subdural empyema evacuation. Post-operative MRI showed improvement in swelling and decrease in abscess size. His eye swelling and headache resolved afterwards. He was then discharged and completed a 6-week course of IV CTX, metronidazole, and oral linezolid, without signs of long-term sequelae.

Discussion: The incidence of PPT has increased predominantly in adolescent and young adult populations. PPT can be overlooked as a cause of frontal head swelling in children. Delayed management can be costly for these patients because intracerebral complications often occur with PPT.

CT or MRI imaging modalities can expedite the diagnosis of PPT and detection of intracranial involvement. Prompt surgical intervention and broad-spectrum antibiotic therapy can ensure good recovery and prevent long-term sequelae. Choice of antimicrobial agents should cover streptococci, staphylococcal species, anaerobes, and gram-negative rods. Polymicrobial growth from wound cultures occurs infrequently.

SAG is an emerging pathogen, correlated with several purulent infections such as brain abscess, bacteremia, pneumonia, and infective endocarditis. In reported PPT cases, SAG is often associated with epidural empyema. SAG has many adhesion factors and its complex polysaccharide capsule aids in phagocytosis evasion. Hyaluronidase and other proteins allow tissue destruction and can induce sepsis. C. pseudodiphtericum as well as D. pigrum are also nascent microbes implied in bacterial sinus infections. They are usually susceptible to B-lactams and vancomycin, but resistant to erythromycin.

Conclusion: PPT should be considered in patients of any age with frontal head swelling. While still rare, PPT may occur more often during a rise in viral infections. SAG is an emerging pathogen of PPT associated with high rates of intracranial complications and morbidity in both adults and children.