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A common complaint… a rare disease!
  1. Mary-Beth Toner1,
  2. Seana Molloy1,
  3. Peter Mallett1,2,
  4. Andrew Thompson1,
  5. Lynne Speirs1,2
  1. 1 Department of Paediatrics, Royal Belfast Hospital for Sick Children, Belfast, UK
  2. 2 Paediatric Infectious Diseases, Royal Belfast Hospital for Sick Children, Belfast, UK
  1. Correspondence to Dr Mary-Beth Toner, Paediatrics, Royal Belfast Hospital for Sick Children, Belfast, N.Ireland; mtoner13{at}


A 2-year-old previously well child presented to the emergency department with temperatures and lethargy. He was pale and looked unwell. He received a fluid bolus and was commenced on intravenous ceftriaxone. Pus was discharging from his left ear with postauricular swelling and erythema. Given clinical concerns, urgent neuroimaging was arranged.

Question 1 What does the CT scan of head show (figure 1)?

Figure 1

Enhanced CT showing external and middle ear infection with skull base osteomyelitis.

  1. Acute subdural collection

  2. Acute mastoiditis secondary to sinusitis

  3. Enhanced cerebral lesions

  4. Meningitis with abscess formation

  5. Middle ear infection with skull base osteomyelitis

A subsequent MRI scan was performed (figure 2).

Figure 2

MRI shows thrombus in left jugular vein, and MRA demonstrates occlusion of left internal carotid artery secondary to carotid sheath infection.

Question 2 What do these two images show?

  • Left jugular vein dissection with subdural haematoma

  • Left jugular vein thrombus and carotid artery occlusion

  • Posterior fossa tumour

  • Right sided posterior communicating artery aneurysm

  • Skull base abscess

Question 3 What is the most likely diagnosis?

  1. Acute mastoiditis secondary to chronic sinusitis

  2. Cerebral tuberculosis (TB)

  3. Hereditary thrombophilia (protein S deficiency)

  4. Lemierre’s syndrome

  5. Non-accidental head trauma (NAI)

Question 4 What is the most commonly identified organism in this syndrome?

  1. Candida albicans

  2. Fusobacterium necrophorum

  3. Haemophilus influenza

  4. Staphylococcus aureus

  5. Streptococcus pyogenes

Answers can be found on page XX.

  • microbiology
  • neurosurgery
  • rehabilitation
  • therapeutics

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  • Contributors M-BT, SM, LS and AT were involved in concept, manuscript design and serial draft reviews. M-BT, SM, LS and PM were involved in patient management.

  • 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.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.