Cerebral haemorrhagic infarction associated withacute otitis media in a 4-­year-­old boy
Yuji Fujita ‍ ‍,1 George Imataka,1 Misako Ohkusu,2 Shigemi Yoshihara1
1

Department of Pediatrics,
Dokkyo Medical University,
Shimotsuga, Tochigi, Japan2
Department of Infectious
Diseases, Medical Mycology
Research Center, Chiba
University, Chiba, Japan
Correspondence toDr Yuji Fujita;​fujitay@​dokkyomed.​ac.​jp
Accepted 5 May 2021

© BMJ Publishing Group
Limited 2021. No commercial
re-­use. See rights andpermissions. Published by BMJ.
To cite: Fujita Y, Imataka G,Ohkusu M, et al. BMJ Case
Rep 2021;14:e242098.
doi:10.1136/bcr-2021242098

DESCRIPTION
A 4-­
year-­
old boy had cough and purulent nasal
discharge 2 days before admission; he also had
fever, headache, vomiting and left ear pain. He
received amoxicillin (40 mg/kg/day) and was diagnosed with left acute suppurative otitis media(AOM) by an otorhinolaryngologist, the sameday. The next day, he developed right clonus of
the upper and lower limbs and was administeredmidazolam. He was immediately referred to ourhospital; he was sedated at the time of admission
due to midazolam. Physical examination revealed
redness on the left eardrum and pus in the left
ear canal, without a heart murmur, stiff neck or
Kernig’s sign. Blood examination showed a whitecell count of 12.2×109/L cells/µL, C-­reactive
protein level of 16.54 mg/dL, procalcitonin levelof 0.32 pg/mL, prothrombin time international
normalised ratio of 1.11, activated partial thromboplastin time of 32.3 s, fibrinogen level of 524 mg/dL and D-­dimer level of 0.6 µg/mL. Cerebrospinal
fluid (CSF) examination showed a CSF pressureof 50 mm Hg, a cell count of 21 cells/µL, glucose
level of 99 mg/dL (CSF/serum glucose ratio of 0.77)
and protein level of 29.7 mg/dL. Brain diffusion-­weighted and T2-­star-­weighted MRI showed twolesions of haemorrhagic infarctions in the left
hemisphere (figure 1A–C). Brain T2-­
weighted
MRI showed a high signal in the mastoid part andtympanic cavity (figure 1D). Brain magnetic resonance angiography (MRA) showed no abnormal
findings in the cerebral artery. Head CT showed noanatomical abnormalities indicating direct central
nervous system spread, including bone destruction.
Echocardiography showed no signs of underlying
cardiogenic-­embolism-­causing diseases, including
infectious endocarditis. He was administered cefotaxime, ampicillin and corticosteroid. Blood andcerebrospinal cultures at admission were negative.
Haemophilus influenzae was detected via CSF PCR.
Transient aphasia, right facial nerve paralysis andright hemiplegia were observed. Although he had
difficulty moving his right hand, he was discharged
independently.
AOM can occasionally cause cerebral complications, including bacterial meningitis, brain abscesses
and lateral sinus thrombosis.1 Haemorrhagic infarction caused by AOM is extremely rare. Massive ischaemic stroke after cerebral artery infarction caused
by AOM has been reported.2 In the case, haemorrhagic infarctions were not considered arterial
infarctions because MRA showed no abnormal findings and haemorrhagic infarctions were observed indifferent areas of the artery. Therefore, haemorrhagic

Figure 1 (A) Brain diffusion-­weighted (b=1000 s/mm2) MRI showing reduced diffusivity, manifested ashigh intensity in the left parietal lobe. (B) Brain T2-­
star-­weighted MRI showing low intensity around theperiphery of the infarction. (C) Brain diffusion-­weightedMRI showing small infarction in the left basal ganglia. (D)T2-­weighted MRI showing high signal in the left mastoidpart, left tympanic cavity and bilateral paranasal cavities.
infarctions were believed to be caused by venous
infarctions. Cerebral venous infarction due to AOM
is extremely rare,3 and a massive haemorrhagic
infarction, as in our case, has not been reported.
In our case, H. influenzae was detected via CSF
by PCR; however, we believe that the haemorrhagic
infarction in our case was not caused by bacterial meningitis because it was observed on the side

Patient’s perspective
We are glad that our son’s life was saved, although
he had some neurological sequelae.

Learning points►► Causative organism can be identified by

PCR of cerebrospinal fluid even with prioradministration of antibiotics.
►► Acute otitis media rarely causes cerebrospinal
complications such as haemorrhagic infarction.
►► It is important to empirically administer
antibiotics in cases of haemorrhagic infarction.

Fujita Y, et al. BMJ Case Rep 2021;14:e242098. doi:10.1136/bcr-2021-242098

1

BMJ Case Rep: first published as 10.1136/bcr-2021-242098 on 21 May 2021. Downloaded from http://casereports.bmj.com/ on May 21, 2021 at Dokkyo Medical University. Protected bycopyright.

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with otitis media, and the cell count in the CSF was inadequate
for bacterial meningitis. It was speculated that the infarction wascaused by the embolism of haematogenously spreading bacteria;
the secondary bleeding after the infarction might have caused theleakage of bacteria into the CSF.
Paediatricians should remember that AOM rarely causes cerebrospinal complications.
Acknowledgements We would like to thank Editage (​www.​editage.​com)for English language editing. We would like to thank Dr Shigeko Kuwashima,
Department of Radiology, Dokkyo Medical University and Professor Jun-­ichi
Takanashi, Department of Paediatrics, Tokyo Women’s Medical University Yachiyo
Medical for advising us regarding the diagnosis in our case.
Contributors Dr YF collected and analysed the data, drafted and revised the initialmanuscript. Dr GI, Dr MO and Professor SY interpreted all the data and criticallyrevised the manuscript for important intellectual content. All the authors read andapproved the final manuscript.

Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Disclaimer Case reports provide a valuable learning resource for the scientificcommunity and can indicate areas of interest for future research. They should not be
used in isolation to guide treatment choices or public health policy.
Competing interests None declared.
Patient consent for publication Parental/guardian consent obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
ORCID iD
Yuji Fujita http://​orcid.​org/​0000-​0001-​6440-​9110

REFERENCES

1 Penido NdeO, Borin A, Iha LCN, et al. Intracranial complications of otitis media: 15years of experience in 33 patients. Otolaryngol Head Neck Surg 2005;132:37–42.
2 Pasha HM, Mirsky DM, Streubel SO. Massive ischemic stroke as a complication of otitis
media. Int J Pediatr Otorhinolaryngol 2015;79:1771–3.
3 Özer E, Sıvaslı E, Bayazıt YA, et al. Otogenic cerebral venous infarction: a rarecomplication of acute otitis media. Int J Pediatr Otorhinolaryngol 2003;67:1019–21.

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2Fujita Y, et al. BMJ Case Rep 2021;14:e242098. doi:10.1136/bcr-2021-242098

BMJ Case Rep: first published as 10.1136/bcr-2021-242098 on 21 May 2021. Downloaded from http://casereports.bmj.com/ on May 21, 2021 at Dokkyo Medical University. Protected bycopyright.

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