When to Think of Zebras

• Published in: The American journal of medicine Vol. 122; no. 5; pp. 424 - 426
• Main Authors: Ho, Roger S., MS, Kohli, Rahul M., MD, PhD, Maragakis, Lisa L., MD, MPH
• Format: Journal Article
• Language: English
• Published: New York, NY Elsevier Inc 01.05.2009; Elsevier; Elsevier Sequoia S.A
• Subjects: Adult; Anti-Bacterial Agents - therapeutic use; Biological and medical sciences; Brain Abscess - diagnosis; Brain Abscess - etiology; Brain Abscess - therapy; Chronic Disease; Diagnostic tests; Disease management; Drainage - methods; Ear diseases; Follow-Up Studies; General aspects; Humans; Internal Medicine; Magnetic Resonance Imaging; Male; Medical diagnosis; Medical sciences; NMR; Nuclear magnetic resonance; Otitis Externa - complications; Otitis Externa - diagnosis; Otitis Externa - therapy; Otitis Media, Suppurative - complications; Otitis Media, Suppurative - diagnosis; Otitis Media, Suppurative - therapy; Pseudomonas aeruginosa - isolation & purification; Pseudomonas Infections - diagnosis; Pseudomonas Infections - etiology; Pseudomonas Infections - therapy; Temporal Lobe; Medicine; Vertebrata; Mammalia; Perissodactyla; Zebra; Ungulata
• ISSN: 0002-9343; 1555-7162
• DOI: 10.1016/j.amjmed.2009.01.008

Ho et al present a case study where in a 44-year-old man whose chronic otitis eventually evoked throughts of zebras. Magnetic resonance imaging (MRI) revealed a 1-cm rim-enhancing fluid collection at the right petrous apex with associated dural enhancement. Suspecting malignant otitis externa, the otolaryngology team performed a radical mastoidectomy with temporalis flap reconstruction. Despite extensive surgical debridement, the fluid could not be accessed. The patient's antimicrobial therapy was changed to vancomycin, cefepime, metronidazole, and liposomal amphotericin B to enhance central nervous system penetration and broaden treatment for potential pathogens involved in brain abscess. However, an MRI scan taken 2 days later revealed extension of the fluid collection and new abscesses in the temporal lobe and along the inferior margin of the petrous bone (Figure 1). This progression of disease despite ongoing therapy with broad-spectrum antimicrobial agents prompted an emergent procedure to drain and determine the etiology of the intracerebral fluid collections.