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Frontal osteomyelitis is a rare complication of sinusitis. Common intracranial complications of the frontal osteomyelitis are meningitis, epidural empyema, subdural empyema and brain abscess. We described a case of frontal osteomyelitis with brain abscess caused by Staphylococcus aureus with improve after needle aspiration and antibiotics to brain abscess for eight weeks and for chronic osteomyelitis for four months.
We report here a 2-year-old boy with a Streptococcus intermedius brain abscess and bilateral ventriculitis successfully treated with a high dose penicillin G (200,000 U/kg/dose, 6 times a day, 1 hour continuous infusion). Although hydrocephalus residuced, the high dose penicillin G therapy cured his brain abscess and bilateral ventriculitis. The minimal inhibitory concentration of penicillin G to the isolate was 0.008 microgram/ml. The penicillin G concentration in the cerebrospinal fluid after 2 hours from the infusion was about 5 micrograms/ml. S. intermedius must be considered as one of the causative agents for brain abscess. High dose penicillin G therapy is one choice of treatment for brain abscess due to penicillin-susceptible streptococci.
A case is reported here of brain abscess due to Streptococcus sanguis in association with multiple pulmonary arteriovenous fistulas. A 19-year-old male who had been diagnosed in 1988 as pulmonary arteriovenous fistulas was admitted to our hospital for repeated epistaxis, headache, and vomiting. A brain abscess which was diagnosed using various roentogenologic examinations, worsened despite conservative therapy. Additional surgical drainage was performed; S. sanguis was isolated from the drainage fluid. After drainage, clinical symptoms gradually improved with no subsequent neurological deficits. We have formulated the following hypothesis regarding the mechanism of abscess formation in this case: S. sanguis invaded from a ruptured nasomucosal vein, forming a septic emboli in the blood flow, which passed through a pulmonary arteriovenous shunt and led to the formation of a brain abscess which established a metastatic presence in the cerebral tissue.
OBJECTIVE: To elucidate prodromal signs and clinical factors influencing the prognosis in patients with intraventricular rupture of brain abscess (IVROBA) to prevent and manage this catastrophic condition. METHODS: In this study, 33 consecutive patients with IVROBA diagnosed by computed tomography (CT) were treated. Basic and therapeutic parameters were evaluated as independent predictive factors of a poor prognosis by using univariate analysis. The factors were statistically analyzed based on the interval between initial symptoms and IVROBA. RESULTS: Patients with a good outcome were younger (<21 yr old) (P < 0.003) and had fewer complications after IVROBA (P < 0.03). For the most part, these patients had undergone aspiration for brain abscess with ventricular drainage combined with the immediate administration of appropriate intravenous and intrathecal antibiotics (P < 0.02). In just a short time, abscesses located in the parieto-occipital region ruptured into the ventricle (P < 0.004), and those with nonsterile cultures (P < 0.01) developed into IVROBA. Just before IVROBA, patients had severe headaches, signs of meningeal irritation, and a rapidly deteriorating clinical condition within 10 days after the signs of meningeal irritation developed. A CT scan obtained before IVROBA ascertained localized enhancement of the ventricular wall adjacent to the abscess. CONCLUSION: Our findings suggest that signs of meningeal irritation and localized enhancement of the ventricular wall adjacent to the abscess, as observed on CT scans, preceded IVROBA. To decrease the mortality rate associated with purulent brain abscesses, signs forewarning of IVROBA should be recognized, and aggressive management of IVROBA should be initiated. Aggressive CT-guided aspiration of deep-seated abscesses, particularly in the parieto-occipital region, at the time forewarning signs of IVROBA are observed lead to the prevention of IVROBA and an improvement in outcome.
BACKGROUND: Papilloedema and brain abscess associated with persistent left superior vena cava draining into the left atrium without sinus coronarius and atrium septum defect is rare and until now in only few cases have been reported. PATIENT: A 12 year-old girl was admitted because she had suffered from headache and blurred vision for 2 weeks. Fundus examination revealed papilloedema with peripapillary intraretinal haemorrhages. Pupillary reaction to light was normal. An afferent pupillary defect was negative. Neurological examination was without any focal neurological signs. Cerebral magnetic resonance imaging showed the characteristic features of a brain abscess in the left frontal lobe (3.5 x 3.0 x 2.8). Cardiological examination showed the presence of an isolated left superior vena cava draining into the left atrium in the absence of coronary sinus and atrial septum defect. CONCLUSION: Congenital heart disease such as LSVC is rare. The association of LSVC with papilloedema and brain abscess is very rarely seen. However, the complications of LSVC can be life-threatening. Therefore in children with papilloedema, intraocular and intraorbital reasons as well as congenital heart disease as the underlying reason should be included in the differential diagnosis.
We report the first case of brain abscess due to Enterococcus avium in a 19-year-old man with chronic otitis media since childhood. The patient presented to the emergency department in a comatose condition. Contrast-enhanced brain computed tomography scan showed a hypodense area with ring enhancement in the right temporal lobe and mass effect with subfalcine and transtentorial herniation. Emergency temporal burr hole operation was performed and pus drained out, but the patient succumbed to his illness. Culture of the aspirated pus yielded growth of gram-positive cocci identified as E avium, an infrequent pathogen of human infections. The association of E avium with brain abscess further extends the clinical spectrum of this rare pathogen.
There are significant variations among countries in the incidence of brain abscess. We report here 26 cases of brain abscess treated at the Neurosurgery Department of King Faisal University and Dammam Central Hospital Saudi Arabia over a six year period (1982-1988). This is 2.3% of total admissions to the two neurosurgery departments serving a population of approximately 1.2 million in the same period. Young males were most often affected (M/F ratio 3.3:1; 31% were less than 15 years old, 46% aged between 15-39 years, and 23% older than 40 years). Streptococcus was found to be the most common microorganism (38.4%). Mixed infection was seen in 15.3%, and sterile abscesses were found in 11.5% of the patients after aerobic and anaerobic cultures of the pus. Chronic otitis media and paranasal sinusitis predisposed the patients to abscess formation in 57.6% of the cases. The temporo-parietal area was the commonest site. Epilepsy was a complication in 30.7% of our patients, and the mortality rate was 15.3%.
We present three patients with brain abscesses who also had pulmonary arteriovenous malformations (AVMs). All patients had hereditary haemorrhagic telangiectasia (Osler's Disease). It is probable that the lung AVMs contributed to the development of the brain abscesses by allowing bacteria easier access to the systemic circulation through a right to left pulmonary vascular shunt, bypassing the filtering action of the pulmonary capillaries. In addition, one patient required a period of postoperative ventilation using PEEP, which may have exacerbated the shunt through the lung AVM and led to difficulty in weaning her from the ventilator.
Brain abscess due to Salmonella species are very rare. In this paper a case of brain abscess caused by Salmonella typhimurium is reported. The patient had no history of Salmonellosis. A review of the literature is also presented.
Between 1953 and 1989 eighty cases of non-traumatic brain abscess were treated in our department. We have re-examined the clinical and neuroradiological features of this pathological process and present our therapeutic approach and results. We believe that the optimal treatment for brain abscess consists of surgical removal. The prognosis for these lesions has undergone a marked improvement over the last two decades in response to neuroradiological, microbiological and surgical advances. The most influential prognostic factor seems to be preoperative clinical status.
The characteristics of brain abscess in the Central Province of Saudi Arabia are outlined in this report which is a review of 22 consecutive cases that were treated at King Khalid University Hospital between 1985-1991. The incidence of brain abscess in Saudi Arabia is calculated to be 3.6 cases/500,000 population/year which is twice as high as the incidence reported from the West. There were 17 males and 5 females with an age range of 8 months-80 years (mean 29.9 years). The parietal lobe was involved in 27%, while the abscess was in the posterior fossa in 14% and multiple in another 14% of cases. The primary source of sepsis was unknown in 50%, post-traumatic in 18% and from a dental and mastoid origin in 14% of cases only. Duration of symptoms ranged between 4-30 days (mean 12 days). Fever was present in 55% of cases and epilepsy in 23%. Sixteen (73%) cases had burr hole aspiration, while 3 (14%) had craniotomy and excision, and 3 (14%) cases were managed with antimicrobial treatment only. Staphylococci were the pathogens in 27%, while streptococci were cultured in 23% cases and the culture was negative in 23%. Three (14%) cases all of which died had fungal abscesses caused by Fonsecaea pedrosoi. The mortality was 18%, good recovery in 68% and fair recovery in 14%. Follow-up was from 3 months to 5.5 years (mean 1.8 years).
Ear infection is the most common cause of brain abscess. A suppurative process in the ear has access to the central nervous system by direct extension or through preformed pathways, either developmental, traumatic or pathologic, or by retrograde spread along the thromobophlebitic vein. Squamous cell carcinoma of middle ear or mastoid cavity is a rare disease and often associated with chronic otitis or chronic draining ear. Ear malignancy easily produces the destruction of temporal bone which may serve as a route for coexistent infection spreading into the brain. This paper reports a case of brain abscess occurring in a patient with temporal bone cancer. To the best of our knowledge, no more than three similar cases have been reported in the literature. The authors suggest that if an otogenic brain abscess is concomitant with infection and granulomatous mass in the ear, biopsy should be performed to rule out malignancy.
This report presents a case of brain abscess due to Haemophilus aphrophilus in a six-year old boy. He was admitted to our hospital suffering from left-sided weakness. The initial radiological diagnosis was an intracranial abscess. Purulent material was obtained by puncturing the subcortical lesion and the sample was cultured on conventional media. H. aphrophilus was isolated in pure culture, identified according to conventional methods and confirmed by Becton Dickinson Laboratory (BBL) crystal system. After surgical drainage and eight weeks of antibiotic therapy, the neurological findings improved. The presented case is an example of H. aphriphilus causing brain abscess in the first decade without cardiac predisposition and with good outcome.
Surgical aspiration and/or drainage of brain abscesses is considered to be the first-line treatment for abscesses larger than 25 mm. This is ususally performed with the aid of CT-guided stereotaxy. A method of ultrasound guidance is presented that allows a single burr hole approach with real-time imaging of the whole procedure. A bayonet-like shaped ultrasound probe with tip dimension of 8 x 8 mm only (EUP-NS 32, Hitachi/Ecoscan) with frequencies of 3.5 and 5 MHz is used. After placement of a burr hole the target is identified by transdural insonation, a guideline is adjusted and a mounted puncture-adapter guides the cannula towards the lesion under real-time imaging control. Up to now 12 abscesses in 10 patients were treated. Visualization was always excellent. A second aspiration had to be performed twice. One abscess did not contain enough pus to be cured by aspiration and was removed by open surgery, another could not be tapped by the blunt cannula and was aspirated under stereotactic control using a sharp trocar. Outcome was excellent in 6 patients and fair in 2 patients but this was due to the pre-existing disease. Two patients admitted in deep coma died despite an emergency operation. The presented method has proven to be a very powerful guiding tool in the surgical treatment of brain abscesses through a single burr hole approach.
The author review 10 years' experience in managing brain abscess in childhood: 19 cases were treated in children from 1 to 18 years old. The etiology was rhinogenic in 5 cases, congenital heart disease in 5, hematogenous in 3, traumatic in 3, postoperative in 1, and unknown in 3 cases. Brain abscesses that developed by direct spread were located nearby the source, whereas metastatic abscesses (such as cardiogenic or hematogenous) in most cases spread via the vertebral-basilar system, usually developing in the parieto-occipital regions. Four of the 5 cases with multiple abscesses were cardiogenic and one hematogenous. The most important neurological signs were paresis (10 cases) and cranial nerve involvement (10 cases). Six abscesses were sterile and 6 grew aerobic and 6 anaerobic bacteria. In one case, aerobic as well as anaerobic bacteria were found. Fifteen patients were treated preoperatively with antibiotics. The treatment was operative in 17 cases. In two cases, gravely ill on admission, no surgical treatment was given. The etiology, localization, bacteriology, surgical methods, and results in those cases are discussed.
Tuberculous brain abscesses in AIDS patients are considered rare with only eight cases reported in the literature. We describe the case of a 34-year-old woman with AIDS and previous toxoplasmic encephalitis who was admitted due to headache and seizures. A brain computed tomography scan disclosed a frontal hypodense lesion with a contrast ring enhancement. Brain abscess was suspected and she underwent a lesion puncture through a trepanation. The material extracted was purulent and the acid-fast smear was markedly positive. Timely medical and surgical approaches allowed a good outcome. Tuberculous abscesses should be considered in the differential diagnosis of focal brain lesions in AIDS patients. Surgical excision or stereotactic aspiration, and antituberculous treatment are the mainstay in the management of these uncommon lesions.
Advances in the diagnosis and treatment of brain abscess and subdural empyema with neuroimaging techniques such as computerized tomography, magnetic resonance imaging, magnetic resonance spectroscopy, the availability of new antimicrobials, and the development of novel surgical techniques have significantly contributed to the decreased morbidity and mortality associated these infections. Determination of point of entry and source of infection is paramount to adequate treatment. A high index of suspicion along with typical clinical presentation of headache, seizures, or focal neurologic signs can lead to early diagnosis so that effective therapy can be instituted as soon as possible. This review discusses etiology and pathology of brain abscess and subdural empyema, neuroimaging techniques useful in the diagnosis, and optimal treatment, including use of antimicrobials and surgical procedures.
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