The patient was started on ampicillin and genta- micin for what was initially thought to be a urinary infection. Some confusion followed as to the nature of.
Sleep, 16(1):31-32 © 1993 American Sleep Disorders Association and Sleep Research Society
Clinical Corner Bacterial Meningitis-A Possible Complication of Nasal Continuous Positive Airway Pressure Therapy in a Patient with Obstructive Sleep Apnea Syndrome and a Mucocele *Colin R. Bamford and tStuart F. Quan Departments of*Neurology and tlnternal Medicine (Quan), The Sleep Disorders Center, College of Medicine, The University of Arizona, Tucson, Arizona, U.S.A.
Continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea syndrome, after initially being considered optimal treatment (1,2), is now being recognized to be accompanied by problems of compliance (3,4), side effects (4,5) (rhinitis, dry mouth, dry eyes, claustrophobia) and the rare complication of pneumocephalus (5). We present another possible rare complication of CPAP therapy.
Following institution ofCPAP therapy, the patient developed recurring bouts of sinusitis with increasing frequency and severity accompanied by purulent drainage, for which he was treated with courses of antibiotics. He was recently admitted in a confused state and specifically denied headache and fever. On examination at the time of admission, he was afebrile, mildly somnolent and moderately confused. He had normal cranial nerves, slight weakness of the legs, a right BaCASE REPORT binski reflex, normal coordination, decreased sensaA 78-year-old male presented initially at the age of tion to vibration at the ankles and a supple neck. There 70 with excessive daytime sleepiness, hypertension, was tenderness of the left maxillary region and a puffobesity and loud snoring. He had a past history of iness of the left external nose and medial orbit. The chronic sinusitis and a mucocele, which he refused to left eye was mildly proptotic. have surgically treated. A polysomnograph was perOn admission, he had a peripheral white blood cell formed, which confirmed a diagnosis of obstructive (WBC) count of 18,900, with 88% segmented neutrosleep apnea syndrome of moderate severity. The re- phils and 4% bands. A urinalysis showed a slight elespiratory disturbance index (RDI) was 67 events/hour vation of the WBC count without bacteriuria. The patient was started on ampicillin and gentaof total sleep time, and the patient de saturated from a baseline of94% to a low of 66% during rapid eye move- micin for what was initially thought to be a urinary ment (REM) sleep. During a night of CPAP titration, infection. Some confusion followed as to the nature of it was determined that a CPAP level of 7.5 cm H 2 0 the patient's problem until 3 days later, when a spinal resulted in a RDI of 2.1. He was maintained at this tap was performed, which showed a 720 WBC (93% level subsequently with good control of his symptoms. segs), a protein of 200 mg % and a glucose of 64 mg % (blood glucose 151 mg %). A head magnetic resonance imaging (MRI) scan showed a left maxillary and frontal mucocele and sinusitis (see Fig. 1). A diagnosis Accepted for publication September 1992. Address correspondence and reprint requests to Colin R. Bamford, of partially treated bacterial meningitis secondary to M.D., Department of Neurology, College of Medicine, The University of Arizona, 1501 N. Campbell Avenue, Tucson, AZ 85724, sinusitis was made and the patient was treated with ceftriaxone and metronidazole. The sinus was drained, U.S.A. 31
C. R. BAMFORD AND S. F. QUAN
FIG. 1. T, weighted MR! scan (sagittal cut) showing a large mucocele involving the left maxillary, ethmoid and frontal sinuses.
and the patient made a gradual, but incomplete, re- particularly in association with erosive sinus patholcovery over the next 3 months. The patient refuses to ogy, are a relative contraindication to the use of nasal use CPAP therapy or to accept surgical intervention. CPAP therapy. Such individuals would probably be He is currently being maintained on nocturnal oxygen best treated by one or more of the available surgical at 1.5 liters/minute, which blunts the degree of his procedures (nasal reconstruction, uvulopalatopharyngoplasty, and/or horizontal mandibular osteotomy), desaturations. which is most appropriate for the patient's level of airway obstruction. DISCUSSION Based on the patient's history as given by his wife, we presume that CPAP therapy increased the frequency and severity of the patient's bouts of acute sinusitis. It is well recognized that bacterial meningitis is a complication of sinusitis (6,7). It is probable that the mucocele's erosion of the adjacent bony structures facilitated the passage of organisms from one of the involved sinuses into the subarachnoid space. We suspect that CPAP therapy contributed to the passage of these organisms by subjecting the contents of the sinuses to increased pressure. This suspicion, of course, cannot be definitely proven without the simultaneous demonstration ofpneumocephalus, a condition that we did not observe. The absence ofpneumocephalus does not exclude our contention, however. We suggest that recurring bouts of acute sinusitis, Sleep. Vol. 16. No.1. 1993
REFERENCES I. Berry RB, Block JA. Positive nasal airway pressure eliminates snoring as well as obstructive sleep apnea. Chest 1984;85: 15-20. 2. Sanders MH. Nasal CPAP effect on patterns of sleep apnea. Chest 1984;86:839-44. 3. Rauscher H, Formanek D, Popp W, Zwick H. Subjective versus objective compliance with nasal CPAP therapy for obstructive sleep apnea. Presented at the Association of Professional Sleep Societies, 6th Annual Meeting, 1992, abstract 103. 4. Waldhorn RE, Herrick TW, Nguyen MC, O'Donnel AE, Sodero J, Potolicchio SJ. Long term compliance with nasal CPAP therapy of obstructive sleep apnea. Chest 1990;97:33-8. 5. JaIjour NN, Wilson P. Pneumocephalus associated with nasal continuous positive airway pressure in a patient with sleep apnea syndrome. Chest 1989;96:1425-6. 6. Nankervis BA. Bacterial meningitis. Medical Clinics oj North America 1974;58:581-92. 7. Underman AE, OverturfGD, Leedom JM. Bacterial meningitis. Disease-a-month 1978;24:8-63.
