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Norlin et al 201.0 mg/dL, the WBC was elevated at 495/µL. The patient became febrile with increasing irritability the evening of hospital day 12. A head CT was obtained on hospital day 13 (Fig. 1) and the Impression was as follows, "bony defect in the left anterior inferior parietal skull with perisylvian epidural abscess and scalp cellulitis. "This bony defect noted below soft tissue thickening was concluded to be beneath the previously noted abrasion. The skull fracture may have occurred during the initial injury from the family dog and resulted in direct inoculation with Pasteurella. However, it is unable to be certain whether direct inoculation or hematogenous spread led to this meningitis and empyema, as head imaging was not performed initially on admission. After the CT, the patient was transferred back to the PICU for increased monitoring, and the following day an MRI was obtained, and Neurosurgery performed a craniotomy. The MRI impression stated, "status post puncture wound to the left parietal bone with associated multiloculated epidural abscesses and meningeal enhancement." Per both the CT and MRI, the abscess was seen to be epidural. However, the surgery note reported visualization of the fracture of the bone, an upon opening the dura, a thickened rind on both the dura and on the brain itself. Thus, surgery's subsequent notes describe the infection as a subdural empyema. The rind was scraped to send a portion for specimen but was not resected as it was very adherent to the brain. The brain was irrigated with vancomycin, the dura was repaired with a Medtronic Dural repair, and the bone was reaffixed using suture. The patient tolerated the procedure well and was extubated in the operating room. He returned to the PICU where did well postoperative and was stepped down to the hospital floor the next day, hospital day 15.Given the subdural empyema, the antibiotic course was extended to 21 days, and levetiracetam was started for seizure prophylaxis, and the patient subsequently remained afebrile. He was discharged on hospital day 22. Following discharge, he has been seen twice by neurosurgery for follow up, and by audiology. His incision has healed well, his repeat imaging shows near complete resolution of the injury, and he appears to have normal cochlear sensitivity bilaterally.

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