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      Fusobacterium necrophorum an Underrecognized Cause of Petrous Apicitis Presenting with Gradenigo Syndrome: A Case Report


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          Patient: Male, 21-year-old

          Final Diagnosis: Gradenigo syndrome • petrous apicitis • thrombosis of the cavernous sinus

          Symptoms: Cranial nerve palsy • facial numbness • headache • hearing loss • otalgia • otorrhea

          Clinical Procedure: Mastoidectomy

          Specialty: Infectious Diseases • Neurosurgery • Otolaryngology • Surgery


          Rare disease


          With the advent of antibiotics, petrous apicitis (PA), inflammation of the petrous temporal bone, has become a rare complication of otitis media. Even more uncommon is Gradenigo syndrome (GS), a result of PA, characterized by a triad of otitis media or purulent otorrhea, pain within the regions innervated by the first and second division of the trigeminal nerve, and ipsilateral abducens nerve palsy. Recent literature has demonstrated increasing reports of Fusobacterium necrophorum isolated in cases of GS.

          Case Report:

          A 21-year-old man presented with otalgia, reduced hearing, and severe headache. Examination revealed right-sided purulent otorrhea, anesthesia within the trigeminal nerve distribution, and an ipsilateral abducens nerve palsy. F. necrophorum was isolated from an ear swab and a blood culture. Computed tomography and magnetic resonance imaging (MRI) demonstrated otomastoiditis, PA, cavernous sinus thrombosis, and severe stenosis of the petrous internal carotid artery. He was treated with intravenous benzylpenicillin, underwent a mastoidectomy and insertion of a ventilation tube, and was started on a 3-month course of dabigatran. Interval MRI showed improved internal carotid artery caliber, persistent petrous apex inflammation, and normal appearance of both cavernous sinuses. Follow-up clinical review noted persistent abducens and trigeminal nerve dysfunction.


          We identified 190 cases of PA; of these, 80 presented with the classic Gradenigo triad. Fusobacterium sp. were cultured in 10% of GS cases, making them the most frequent isolates. Due to the fastidious nature of F. necrophorum, it may be underrepresented in the historical literature, and we recommend that empiric antibiotics cover anaerobic organisms.

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          Most cited references122

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          Surgical management of chronic osteomyelitis.

          Chronic osteomyelitis is a surgical disease that can require significant dedication from both patients and surgeons to eradicate. Osteomyelitis can result from a variety of etiologies but most often is a consequence of trauma to a long bone, frequently the tibia. It is important to understand the etiology of the infection, as well as the pathophysiology of its chronicity. Additionally, the surgeon must individualize treatment for each patient, because host morbidities often play an important role in propagation of infection. Treatment requires isolation of the pathogens, significant debridement for removal of all infective and necrotic material, and then bony and soft tissue reconstruction. We review the literature of surgical treatment of chronic osteomyelitis and discuss the numerous techniques available to the treatment team, including debridement, dead space management, Ilizarov techniques, and vascularized reconstruction. These patients often require a multimodality approach that incorporates a team approach involving orthopedic and plastic surgery, as well as infectious disease and general medicine.
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            Ceftriaxone. A review of its antibacterial activity, pharmacological properties and therapeutic use.

            Ceftriaxone is a new 'third generation' semisynthetic cephalosporin with a long half-life which has resulted in a recommended once daily administration schedule. It is administered intravenously or intramuscularly and has a broad spectrum of activity against Gram-positive and Gram-negative aerobic, and some anaerobic, bacteria. The activity of ceftriaxone is generally greater than that of the 'first' and 'second generation' cephalosporins against Gram-negative bacteria, but less than that of the earlier generations of cephalosporins against many Gram-positive bacteria. Although ceftriaxone has some activity against Pseudomonas aeruginosa, on the basis of present evidence it cannot be recommended as sole antibiotic therapy in pseudomonal infections. Ceftriaxone has been effective in treating infections due to other 'difficult' organisms such as multidrug-resistant Enterobacteriaceae. Ceftriaxone was effective in complicated and uncomplicated urinary tract infections, lower respiratory tract infections, skin, soft tissue, bone and joint infections, bacteraemia/septicaemia, and paediatric meningitis due to susceptible organisms. In most of these types of infections once-daily administration appears efficacious. Results were also encouraging in a few patients with ear, nose and throat, intra-abdominal, obstetric and gynaecological infections, and adult meningitis, but conclusions are not yet possible as to the efficacy of the drug in these indications due to limited experience. A single intramuscular dose of ceftriaxone has been compared with standard therapy for gonorrhoea due to non-penicillinase-producing and penicillinase-producing strains of Neisseria gonorrhoeae and shown to be highly effective. In a few small trials the comparative efficacy of ceftriaxone and other antibacterials has been assessed in other types of infections and in perioperative prophylaxis in patients undergoing surgery. Few significant differences in response rates were found between therapeutic groups in these comparative studies, but larger well-designed studies are needed to more clearly assess the comparative efficacy of ceftriaxone and other antimicrobials, especially the aminoglycosides and other 'third generation' cephalosporins, and to confirm the apparent lack of serious side effects with ceftriaxone. If more widespread use confirms the safety and efficacy of ceftriaxone, it will offer an important alternative, particularly for the treatment of serious infections due to multidrug-resistant Gram-negative bacteria and in situations where the long half-life of the drug could result in worthwhile convenience and cost benefits.
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              A Schuetz (2014)

                Author and article information

                Am J Case Rep
                Am J Case Rep
                The American Journal of Case Reports
                International Scientific Literature, Inc.
                06 February 2024
                : 25
                : e942652-1-e942652-30
                [1 ]Department of Neurosurgery, Auckland City Hospital, Auckland, New Zealand
                [2 ]Department of Microbiology, LabPlus, Auckland City Hospital, Auckland, New Zealand
                [3 ]Neurosurgery Research Unit, The Centre for Brain Research, The University of Auckland, Auckland, New Zealand
                Author notes
                Corresponding Author: Zaid Ibrahim, e-mail: zaid.ibrahim335@ 123456gmail.com

                Authors’ Contribution:


                Study Design


                Data Collection


                Statistical Analysis


                Data Interpretation


                Manuscript Preparation


                Literature Search


                Funds Collection

                Financial support: None declared

                Conflict of interest: None declared

                Author information
                © Am J Case Rep, 2024

                This work is licensed under Creative Common Attribution-NonCommercial-NoDerivatives 4.0 International ( CC BY-NC-ND 4.0)

                : 23 September 2023
                : 19 December 2023
                : 28 December 2023

                fusobacteria,fusobacteriaceae infections,fusobacterium necrophorum,otitis media,otitis media, suppurative,petrositis


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