Unusual cause of a raised right hemidiaphragm.

collection, the patient was started on intravenous cefotaxime and transferred back to Torbay for further care. He received a total of three weeks of intravenous antibiotics and, at follow up five weeks following surgery, his computed tomogram had returned to normal and he was symptom free. During his recovery, he recalled an incident two years previously when he had been struck on the head while playing football and had lost consciousness. He did not obtain medical help after this and had no postconcussion symptoms. Extradural haematomas are normally the result of trauma to the head and typically present with signs and symptoms of rapidly increasing intracranial pressure. The term chronic extradural haematomas is usually reserved for those haematomas that exist for more than 13 days after trauma' but there is no precise definition. They represent 7% to 14%23 of extradural haematomas and, in almost a quarter of patients, the cause is not determined.3 Infection of the extradural space is extremely uncommon but there is a recognised association of extradural abscess formation with chronic sinusitis and with otitis media. Secondary infection of a chronic extradural haematoma is, however, unreported. S anginosus, one of the Streptococcus milleri group of organisms, is considered to be commensal and is associated with abscesses and purulent infections particularly affecting the cardiac, abdominal, skin, and central nervous systems.4 The organisms are usually sensitive to common antibiotics but surgical evacuation is usually necessary when there is abscess formation. Our patient had a chronic extradural haematoma, which we assumed to be a result of his head injury two years previously. The source of his infection is not entirely clear but it is conceivable that he had a transient bacteraemia that resulted in colonisation of his haematoma. We recommend that when assessing patients with a suspected space occupying lesion, an extended history should be taken looking for evidence of a traumatic origin.