Case Presentation: Headache is one of the most common complaint of patients, yet over 65% of patients with tension-type headaches don’t present to their primary care doctor. When it’s not just a typical headache is when it’s imperative to make the diagnosis early to prevent detrimental complications. A 46-year-old-male presented with a chief complaint of headache, intractable nausea, and vomiting for 3weeks. He had a past medical history of hypertension, sinus bradycardia and tobacco abuse and had recently been diagnosed with frontal sinusitis by his primary care doctor via CT scan. Despite seven-days of amoxicillin, his headache worsened and was associated with intermittent fevers,a maximum temperature 103oF. Notably, patient has had tick-bite on the leg ~2-3 weeks prior that formed a blister and ruptured. On admission, he had fever of 101.2oF with leukocytosis, and was started on empiric vancomycin, ceftriaxone and metronidazole. A Head CT and a lumbar puncture were done. While getting CT-Head, patient experienced a generalized seizure.Patient worsened further with left sided weakness. CT revealed diffuse encephalitis with severe acute sinusitis. Tele-neurology started anti-epileptics. Repeat CT-head with contrast revealed right frontal subdural empyema, left-sided midline shift, patchy enhancement from cerebritis, with extensive opacification of paranasal sinuses. Labs were pertinent for WBC 22.8K with left shift and bandemia, Hgb 10.7, platelets 129k, lactate 2.6, ESR 79, CRP 90, negative lyme-titres, and EEG suggestive of structural lesions in the right hemisphere without any epileptiform discharges. Neurosurgery performed right craniotomy, subdural abscess drainage with a HVAC drain. Tissue and wound cultures were positive for Prevotella species. Patient was continued on broad-spectrum anaerobic antibiotics. Patient’s seizures resolved with craniotomy, but patient continued to have residual left sided weakness. ENT was consulted and suspected hematogenous osseous spread of infection from the frontal sinuses. Medical management was recommended. Patient subsequently was discharged to inpatient rehabilitation with improved clinical condition.

Discussion: Headache is a common presentation of rhinosinusitis. Complications of acute rhinosinusitis are rare and intracranial abscess is one of the most devastating.Approximately 10 % of brain abscesses are associated with paranasal sinusitis. Prevotella spp. are Gram-negative anaerobe members of oral, vaginal and gut microbiota. They can also be found in chronic respiratory and sinusitis related infections. In our case, it brought significant life-changing morbid events to a middle-aged healthy man in form of subdural abscess from his acute sinusitis.

Conclusions: Aggressive approach with appropriate broad spectrum antibiotics in such case with symptomatic sinusitis could prevent or minimize these unfortunate complications. It is a tough balancing act at times for antibiotic stewardship, high value care and optimally aggressive patient care. However, good clinical acumen can help augment this tricky balance effectively.