(565) Subgaleal Abscess in an Immunosuppressed Patient: A Rare and Urgent Condition

Introduction: Subgaleal abscess (SGA) is a rare and potentially serious condition characterized by formation of a pus-filled collection in the subgaleal space (SGS). The SGS is a potential space between the skull periosteum and scalp galea aponeurosis. This condition often arises from localized infection or trauma. Once microorganisms infiltrate the SGS, inflammation can spread with alarming rapidity posing significant threat to the patient.

Description: A 56-year-old male with diabetes presented with a 2-week history of worsening occipital to frontal scalp pain after persistent excoriations. These excoriations led to the development of fluctuance, edema, and drainage of purulent fluid. On the day of presentation, patient noticed facial and periorbital edema causing inability to open his eyes. Physical examination showed diffuse scalp and sinus tenderness along with marked occipital edema and fluctuance. A posterior fistulous tract was identified, draining from the scalp, face, and periorbital regions. The extensive swelling resulted in obstructed vision, although the rest of the neurological examination was unremarkable. CT revealed a subcutaneous abscess with dermal connection and diffuse periorbital soft tissue swelling consistent with cellulitis. Subsequently, Otolaryngology was consulted leading to incision and drainage with debridement of the abscess. A small drain was left packed with twice daily dressing changes and Bactroban ointment. Cultures of the exudate revealed trace Streptococcus agalactiae, Staphylococcus epidermidis, and methicillin-sensitive Staph aureus. Broad-spectrum antibiotics were tailored to linezolid 600 mg twice daily based on culture sensitivities. Patient's condition improved significantly with resolution of abscess drainage and cellulitis.

Discussion: SGA is rare and clinical presentation can be subtle leading to diagnostic challenges. The swift progression of symptoms, including facial and periorbital edema leading to obstructed vision, highlights the severity of the infection and raises concerns about complications such as cellulitis and osteomyelitis. This case illustrates the complexity SGAs in immunocompromised individuals, such as diabetics, and highlights the critical importance of prompt recognition and management given its proximity to vital structures.