Non-contrast Enhancing Group A Streptococcus Subdural Empyema: An Illustrative Case Report of a Potential Radiographic Pitfall

Subdural empyemas (SDEs) are an uncommon complication of intracranial infection, typically presenting as a hypodense collection with peripheral contrast enhancement. Herein, we report two rare cases of SDE without contrast enhancement, both secondary to group A streptococcus. The first is a 27-year-old previously healthy female, at 27 weeks of gestational age who presented with fever, headache, neurological decline, and blood cultures positive for gram-positive cocci. The second case is a previously healthy 48-year-old male who presented with left-sided otalgia, fever, headache, and precipitous decline in altered mental status and hemiplegia. Computed tomography (CT) and magnetic resonance imaging (MRI) in both cases showed a subdural collection without contrast enhancement and without diffusion restriction. Despite appearances similar to subdural effusion, because of a heightened suspicion due to clinical decline, both were taken to surgery for irrigation and debridement which confirmed SDE. Both patients were treated with six weeks of intravenous antibiotics and eventually recovered without neurological deficits. SDEs are uncommon but clinically significant phenomena. These two cases demonstrate that SDEs in rare circumstances may present as non-enhancing subdural collections. Missing the diagnosis of SDE can have significant consequences to patient morbidity and mortality and as such, it not be excluded based on radiographic findings alone.