A 78-year-old woman with bilateral fungal
sinusitis, which resulted in right orbital apex syndrome, underwent endoscopic sinus surgery and optic nerve
decompression. Two months after the operation, she complained of anxiety and
insomnia. Head CT showed
subdural hematoma-like effusion and burr hole drainage was conducted. The collected fluid was not
hematoma, but bloody, xanthochromic effusion with no pathogenic bacteria. Ten days later, she underwent drainage and dural biopsy after
craniotomy because of relapse of
subdural hygroma and progression of hypertrophic
pachymeningitis associated with aggravation of psychiatric symptoms. A sample of the dura mater showed dense
fibrosis with thickening, and Pseudomonas aeruginosa (P. aeruginosa) was detected by culture. Although
otitis or
sinusitis secondary to P. aeruginosa
infection has been reported as a leading cause of infectious
pachymeningitis, psychiatric symptoms alone and concomitant refractory
subdural hygroma are atypical and unreported manifestations. In patients with
pachymeningitis and a history of transnasal endoscopic surgery, P. aeruginosa
infection should be considered, irrespective of an atypical
clinical course and negative blood or fluid culture. Additionally, dural biopsy might help in detection of pathogenic bacteria.