A 3-month-old male infant who presented with a group A streptococcal subdural empyema on day 5 of a varicella skin rash is reported from the University of British Columbia, Vancouver, BC, Canada. On day 1 of the rash, he had decreased appetite and vomited twice, on day 2, fever, and on day 4, otitis media. On day 5, he developed right-sided focal seizures with ocular deviation and generalized status epilepticus. CT showed bilateral subdural fluid collections, maximal left. A 5-year-old sibling had developed uncomplicated varicella 2 weeks earlier. On admission to BC Children’s Hospital, the varicella rash was diffuse, without secondary bacterial infection. He was irritable, his fontanelle was bulging, and his fundi showed papilledema. Lumbar puncture was not done because of skin lesions and intracranial hypertension. MRI findings were consistent with subdural empyema. A subdural tap yielded 55 ml of purulent fluid with Streptococcus pyogenes, susceptible to penicillin. After 2 weeks treatment with iv. penicillin, focal seizures recurred and he had developed a right-sided hemiparesis with increased size of the left subdural effusion. A subdural empyema was drained at craniotomy. The CSF smears and cultures were negative. Treatment with cefotaxime, vancomycin, and penicillin G was followed by resolution of the subdural empyema, sterile cultures, and slow improvement of the hemiparesis. Seizures were controlled with clobazam. The association of GAS subdural empyema and varicella had not previously been described. 
COMMENT. Varicella is the most commonly identified risk factor in children with severe invasive group A streptococcal (GAS) infections. The portal of entry is unknown in 50% of cases, but the skin is the prime suspect. (AAP Red Book, 25th ed;528). GAS bacterial meningitis was presumed to be the source of the subdural empyema in the above case, although the diagnosis was not confirmed by lumbar puncture and CSF examination. Bacteremia and a hematogenous source were other possibilities considered, despite sterile blood cultures. Invasive GAS infections associated with varicella have decreased with vaccination.