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. 2021 Mar;42(3):404–413. doi: 10.3174/ajnr.A7015

FIG 10.

FIG 10.

Progressive left-sided skull base osteomyelitis. A 65-year-old man with multiple comorbidities, including poorly controlled diabetes, presented with a relatively long-standing history of chronic sinusitis and bilateral otitis media. He was recently treated for otitis media of the left ear and presented with new headache and left-sided hearing loss. Culture from the left EAC was negative for a causative organism, and cultures from the sphenoid sinus demonstrated methicillin-resistant S aureus. The patient was treated with 4 weeks of IV vancomycin and piperacillin/tazobactam. The patient improved, and a gallium scan performed during follow-up showed significant improvement and only mild residual uptake in the skull base. Antibiotics were discontinued. The patient returned 4 weeks later with sepsis, and blood cultures were positive for Klebsiella species. In the next 3 months, the patient had a return of headaches and new right-sided symptoms. Imaging evaluation demonstrated progressive infection of the right skull base. Re-institution of IV antibiotics led to gradual resolution of clinical and imaging findings. A, Axial T1-weighted MRI through the skull base shows an infiltrative soft-tissue abnormality (arrows) involving the central skull base with abnormal marrow signal on the left side of the occipital bone (arrowhead). B, Axial enhanced T1-weighted MR image shows heterogeneous enhancement in the corresponding areas of the left petro-occipital fissure (arrow). C, Axial bone scan fused with CT shows radiotracer accumulation in the left central skull base, including the sphenoid bone and left petrous apex. D, Following initiation of empiric IV antibiotic treatment, the patient had improvement of symptoms on the left, but 4 months later, he developed severe headache, fever, and right-sided facial pain. Axial T1-weighted image shows an infiltrative process (arrows) of the central skull base that now extends to the right. E, Axial enhanced fat-saturated T1-weighted image demonstrates improved enhancement of the left central skull base and the adjacent soft tissues but interval worsening of enhancement of the right skull base (arrowhead) and soft tissues of the nasopharynx (arrow). F, Follow-up axial fused bone scan SPECT image demonstrates radiologic worsening with marked radiotracer uptake in the central skull base in the right petro-occipital region.