Rare Dual Complication of Infantile Meningitis: Subdural Empyema and Cerebral Venous Sinus Thrombosis in a 9-Month-Old Infant.

Subdural empyema (SDE) and cerebral venous sinus thrombosis (CVST) are rare but life-threatening complications of infantile meningitis. Their coexistence is exceptionally uncommon and poses significant diagnostic and therapeutic challenges. We report the case of a previously healthy 9-month-old girl who presented with a 10-day history of high-grade fever, respiratory distress, seizures, and irritability. On admission, she was critically ill with altered sensorium, generalized spasticity, papilledema, and severe anemia. Magnetic resonance imaging (MRI) with venography revealed bilateral SDE, leptomeningitis with pachymeningeal enhancement, acute venous infarcts, and thrombosis of the superior sagittal and right transverse sinuses. She was treated with prolonged broad-spectrum intravenous antibiotics (meropenem, vancomycin, metronidazole, and acyclovir), anticoagulation with enoxaparin, red blood cell transfusion, iron supplementation, and anticonvulsants. Neurosurgical drainage was deferred given the small, non-loculated nature of the empyema and favorable response to medical therapy. After 18 days of mechanical ventilation and one month of intensive multidisciplinary management, the patient achieved marked neurological recovery and was discharged in stable condition. At 1-month follow-up, she showed only mild residual spasticity without focal deficits or developmental regression. This case underscores the importance of early neuroimaging with MR venography in infants with severe meningitis, highlights the role of anticoagulation in pediatric CVST, and demonstrates that carefully selected cases of SDE may be successfully managed medically.