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PubMedDate not supplied

[Pathogenesis and methods of treatment of otogenic brain abscess].

UNLABELLED: Otitis media, acute or chronic, is a potentially dangerous disease which may lead to fatal complications. Meningitis is the most common intracranial complication, followed by otogenic brain abscesses while lateral sinus thrombosis is fairly uncommon. Mortality from otogenic brain abscesses remains relatively high. The aim of the study was to investigate mechanisms of development, diagnostic methods and treatment of these complications of otogenic brain abscesses. MATERIAL AND METHODS: The retrospective study covered 42 patients with otogenic brain abscess (28 cerebral and 14 cerebellar) treated from 1973 to 1995 at the ENT and Neurosurgical Hospital in Belgrade. Medical records of the studied patients were analyzed for the occurrence of the disease, diagnosis and mode of therapy. Special care was dedicated to type of otitis, surgical findings, diagnostic methods, mode of therapy and therapy outcome. RESULTS: In the period of 23 (1973-1995) 114 patients with otogenic intracranial complications were treated at the Clinic of Otorhinolaryngology and Maxillofacial Surgery. Meningitis was the most common complication in this series, followed by cerebral abscess, lateral sinus thrombosis, cerebellar abscess, while extradural abscesses were rare, and subdural occurred only exceptionally (Table 1). In somewhat more than half of the patients (55%) one intracranial complication was present, While in 54% two or more intracranial complications were recorded (Table 2). Otogenic brain abscesses are usually associated with meningitis. Meningitis was present in 20 patients with cerebral abscess (71%), and in 5 (33%) patients with cerebellar abscess. Meningitis and lateral sinus thrombosis were more commonly associated with cerebellar abscess (41%), and less with cerebral abscess (10%). In our group of patients otogenic brain abscesses were most common in the third decade of life, than in the second, while the frequency of the complication fell significantly in older age groups (Figure 1). Headache (92%). fever (91%), vomiting (68%) were the most common symptoms, while photophobia and vertigo were less common (38% and 30%, respectively). Active chronic otitis with cholesteatoma was most commonly present in patients with otogenic brain abscess, only somewhat more common in patients with cerebral abscess (84%), than in those with cerebellar abscess (80%). Neurological examination of 28 patients with cerebral abscess evidenced the abscess in 11, while in 15 the examination suggested meningitis. (Table 3). The diagnosis of abscess was most commonly established by computerized tomography. It revealed cerebral abscess in 18 out of 28 patients, and cerebellar abscess in 10 out of 12 patients. (Table 3). Radical trepanation of the temporal bone was performed in all our patients, while in nine patients revision was required after the surgery, since the initial operation was not sufficiently radical. (Table 4). Out of 28 patients with cerebral abscess 5 (18%) died while 3 (29%) patients died out of 14 patients with cerebellar abscess (Table 4). DISCUSSION: Otogenic brain abscesses imply accumulation of pus in the cerebrum or cerebellum developing after encephalitis, caused by pyogenic microorganisms originating from inflammatory process in the middle ear cavity. This is a severe otogenic complication with high mortality. Even with modern therapeutic alternatives, mortality remained high, about 40% (7). According to the data reported by several authors introduction of antibiotic therapy resulted in drastic fall of associated mortality. The annual risk of otogenic abscess of the brain is 1 per 1000 adults with active chronic otitis. The incidence of abscess is significantly higher in a certain age groups, i.e. 1 per 200 between the ages of 20 and 40 (3). The diagnosis of brain abscess established clinically is not quite reliable. The disease is usually associated with severe meningitis, so that neurological examination usually detects only signs of meningi

Adult↗
PubMed1997

Single and multiple pyogenic liver abscesses: clinical course, etiology, and results of treatment.

A total of 483 patients with pyogenic liver abscess during the years 1986 to June 1995 were studied at Chang Gung Memorial Hospital in Kaohsiung: 343 were a single abscess and 140 were multiple abscesses. Males were predominantly affected by this disease. Abdominal pain was more frequent with the single abscess than with multiple abscesses, and jaundice was more frequent with multiple abscesses. Blood levels of alkaline phosphatase, bilirubin, and creatinine and the white blood cell count were significantly higher in patients with multiple abscesses than in those with a single abscess; and the hemoglobin level was higher with single abscesses. The single abscess was usually larger than 5 cm, and the multiple abscesses were usually smaller than 5 cm. The single abscess was always located on the right side (72%) and the multiple abscesses always on the right or both sides. Single abscesses mainly had a cryptogenic origin (58.9%) and multiple abscesses a biliary origin (45.0%). Liver aspirates revealed Klebsiella pneumoniae, Escherichia coli, Streptococcus, Bacteroides, Enterococcus, among others. K. pneumoniae was more often found in a single abscess and E. coli more often in multiple abscesses. Percutaneous catheter drainage and aspiration comprised the main treatment initially, and the failure rate with multiple abscesses was higher than that with single abscesses. Surgical intervention should be considered for multiple abscesses because of the underlying disease. The overall mortality with multiple abscesses (22.1%) was higher than that with a single abscess (12.8%). Partial hepatectomy produced a low mortality rate for both single and multiple abscesses and should be considered in the presence of severe hepatic destruction by an abscess or a stone.

Adult↗
PubMed1999

Pyogenic hepatic abscesses: MRI findings on T1- and T2-weighted and serial gadolinium-enhanced gradient-echo images.

The purpose of this study was to determine the magnetic resonance imaging (MRI) features of pyogenic hepatic abscesses on T1-weighted, T2-weighted, and serial gadolinium (Gd)-enhanced T1-weighted spoiled gradient-echo (SGE) images including images acquired in the immediate, intermediate, and late phases of enhancement. The MRI studies of 20 patients with pyogenic liver abscesses were retrospectively reviewed. All patients were examined on 1.5 (n = 19) and 1.0 (n = 1) T MR scanners. MR studies included T1-weighted, T2-weighted, and serial Gd-enhanced SGE images. The following determinations were made: signal intensity of the abscess cavity and perilesional liver tissue, and the presence of internal septations, layering material, or air in the abscess cavity. The pattern of enhancement of the abscess wall, internal septae and peri-abscess liver were evaluated on serial Gd-enhanced SGE images. A total of 53 abscesses were observed in the 20 patients. Fortyeight abscesses were hypointense on T1-weighted and hyperintense on T2-weighted images. Internal septations were present in four abscesses. Lower signal intensity material was observed in a dependent location on T2-weighted images in one abscess. Signal void foci of air located on the nondependent surface was observed in two abscesses. Two other abscesses contained signal void air that occupied the entire abscess cavity, observed on all imaging sequences. On serial gadolinium-enhanced images, all abscesses revealed early enhancement of the wall, which persisted with negligible change in degree of enhancement or thickness on delayed images. Abscess walls ranged in thickness from 2 to 5 mm. Internal septations ranged in thickness from 2 to 3 mm. Abscess walls and septations were relatively uniform in thickness with no evidence of focal nodularity. Periabscess liver tissue was mildly hypointense on T1-weighted and mildly hyperintense on T2-weighted images in 20 lesions, which were either circumferential (n = 12) or wedge-shaped (n = 8). All these regions enhanced more than the remainder of the liver on immediate post-gadolinium images and remained relatively hyperintense on late phase images. Periabscess liver parenchyma was isointense on both T1- and T2-weighted images in 18 lesions, and in these lesions wedge-shaped subsegmental (n = 6) or segmental (n = 12) enhancement was observed on immediate gadolinium-enhanced images, which faded to isointensity on intermediate phase images. No perilesional signal changes and enhancement difference was observed in 15 lesions. Characteristic features of abscesses include: intense mural enhancement on early gadolinium-enhanced images, which persists with negligible change in thickness and intensity on later post-gadolinium images, and the presence of periabscess increased enhancement on immediate post-gadolinium images. These MRI features may help to distinguish abscesses from other focal liver lesions during differential diagnosis.

Contrast Media↗
PubMed1998

Medical treatment of pediatric subperiosteal orbital abscess secondary to sinusitis.

BACKGROUND: Subperiosteal abscess may accompany orbital cellulitis secondary to sinusitis. Common surgical principles include incision and drainage of all abscesses. Previous evidence suggests that some orbital abscesses may be treatable with intravenous antibiotics, especially in young children. Children's hospital records were reviewed to determine which abscesses may be treated medically. PATIENTS AND METHODS: Records of patients admitted for orbital cellulitis from 1993 to 1996 were reviewed. Patients with subperiosteal abscess on CT scan were included. Clinical outcomes for initial surgical versus medical management of medial abscesses were compared. Differences in age, hospital stay, and intracranial involvement were analyzed for medial versus nonmedial abscesses. RESULTS: All patients had abscesses adjacent to infected sinuses. Eighteen young children had medial abscesses. Twelve of 13 were cured by initial medical treatment; 4 of 5 underwent successful initial drainage. Outcomes were not statistically different (P > .490). Seven children with nonmedial abscesses were older (P < .001) and had more complicated courses than those with medial abscess. Three of 6 children with superior orbital abscess also had intracranial abscess. Intracranial complication was more likely with superior versus medial orbital abscess (P < .01). CONCLUSIONS: Medial subperiosteal orbital abscesses secondary to sinusitis in children 6 years of age and younger are highly amenable to treatment with intravenous antibiotics. Older children and children with nonmedial abscesses may have more complicated infections. Children with superior orbital abscesses are at higher risk for intracranial abscess.

Abscess↗
PubMed2001

Comparison of tuberculous and pyogenic epididymal abscesses: clinical, gray-scale sonographic, and color Doppler sonographic features.

OBJECTIVE: The purpose of this study was to evaluate the capability of clinical, gray-scale sonographic, and color Doppler sonographic features for differentiating tuberculous and pyogenic epididymal abscesses. MATERIALS AND METHODS: Retrospective analysis was performed in 10 cases of tuberculous epididymal abscess and in 13 cases of pyogenic epididymal abscess. The following clinical, gray-scale sonographic, and color Doppler sonographic features were analyzed: patient's age; duration of symptoms; scrotal tenderness; presence of sinus tract; concurrent tuberculosis in other organs; location, size, and echogenicity of the abscess; hyperechoic rim; testicular involvement; hydrocele; and blood flow in the epididymal lesion. RESULTS: Tuberculous epididymal abscess had a longer duration of symptoms (p = 0.0001) and a lower frequency of scrotal tenderness (p = 0.0048) than pyogenic epididymal abscess. The size of the abscess was larger in tuberculous epididymal abscess than in pyogenic epididymal abscess (p = 0.0002). The degree of blood flow in the peripheral portion of the abscess was lower in tuberculous epididymal abscess (p = 0.001). The patient's age, location and echogeninicity of the abscess, presence of sinus tract, hyperechoic rim, testicular involvement, and hydrocele did not differ between the tuberculous and pyogenic epididymal abscesses. CONCLUSION: Some clinical findings, gray-scale sonography, and color Doppler sonography were useful in differentiating tuberculous epididymal abscess from pyogenic epididymal abscess. The presence of long-term scrotal swelling without tenderness and a lower degree of blood flow in the peripheral portion of a large abscess are suggestive of tuberculous epididymal abscess.

Abscess↗
PubMed2000

Usefulness of magnetic resonance imaging for diagnosing deep anorectal abscesses.

PURPOSE: We evaluated the usefulness of magnetic resonance imaging for the preoperative diagnosis of deep anorectal abscesses. METHODS: Subjects were 21 patients with deep anorectal abscesses. Deep anorectal abscesses were classified into two types, ischiorectal and pelvirectal, according to their location. Patients were also classified into a single abscess group, which showed either an ischiorectal or pelvirectal abscess, and a double abscess group, which showed both ischiorectal and pelvirectal abscesses. The final diagnosis was made from surgical findings, and the types of deep anorectal abscesses determined by digital examination and magnetic resonance imaging were compared. RESULTS: Sensitivity of ischiorectal abscesses (20 lesions) with digital examination and magnetic resonance imaging was 75 and 95 percent, respectively, and that of pelvirectal abscesses (10 lesions) with digital examination and magnetic resonance imaging was 60 and 70 percent, respectively. Sensitivity of the magnetic resonance imaging was significantly higher than that of digital examination in ischiorectal abscesses. Diagnostic accuracy of digital examination and magnetic resonance imaging were both 83 percent in the single abscess group (12 patients), whereas in the double abscess group (9 patients) it was 22 and 78 percent, respectively. The rate of accurate diagnosis of magnetic resonance imaging compared with digital examination in the double abscess group was significantly higher than that in the single abscess group. CONCLUSION: Magnetic resonance imaging was useful for diagnosing and differentiating ischiorectal and pelvirectal abscesses.

Abscess↗
PubMed1989

Liver abscesses.

Clinical suspicion of a liver abscess mandates an investigation of the liver for evidence of a liver abscess by radionuclide, ultrasound, or CT scan. Amebic abscesses have a lower mortality rate than pyogenic abscesses. Amebic and pyogenic abscesses can be distinguished on the basis of epidemiologic, clinical, and laboratory studies. The definitive studies for identifying amebic liver abscesses are hemagglutinin or gel diffusion studies. Amebic abscess of the liver may be complicated by extension to the lung, with pulmonary complications. Patients suspected to have amebic abscesses require metronidazole. Emetine or chloroquine may be added if there is no response or if the abscess recurs. Unless there is a failure of the amebic abscess to resolve or secondary infection occurs, there is seldom a need to aspirate or drain these abscesses. Pyogenic abscesses should be treated with broad-spectrum antibiotics to cover gram-negative aerobes and anaerobic organisms. All pyogenic abscesses larger than 1.5 cm in diameter should be aspirated, and the aspirate should be Gram stained and cultured. Percutaneous or surgical drainage should then be performed. Operative intervention is required in those patients with intra-abdominal pyogenic infections that are seeding the liver abscess. The marked reduction in the mortality rate of pyogenic liver abscess witnessed in this decade is multifaceted and attributable in part to earlier diagnosis, permitting definitive treatment in a timely fashion, as well as to improved intensive unit care, antibiotic management, and operative technique.

Adult↗
PubMed1991

Epizootic of external and internal abscesses in a large goat herd over a 16-year period.

From 1973 through 1988, 518 external and internal abscesses were diagnosed in a large commercial goat herd. Of the 518 abscesses, 238 were primary and 280 were secondary abscesses in the same or other anatomic locations. During this period, the herd varied in size from 94 goats in 1973 to 431 goats in 1988. Abscesses in the jaw area were detected in 141 goats, 4 of which developed osteomyelitis of the mandible. Sternal abscesses were detected in 72 goats, with 2 also having osteomyelitis of the sternum diagnosed at necropsy. Most of the abscesses were in the jaw, sternal, facial, and cervical areas. Lung abscesses were diagnosed at necropsy in 20 goats that most recently had 1 or more superficial abscesses. Abscess incidence was 27.6% (112 of 406) in wethers and 22.9% (154 of 687) in does. Actinomyces pyogenes was isolated most frequently by bacteriologic culture of abscess specimens and about 3 times as often as was Corynebacterium pseudotuberculosis or Staphylococcus sp, usually coagulase-positive S aureus. Bacteriologic culture of blood samples, taken during abscess episodes, yielded A pyogenes (n = 3) or C pseudotuberculosis (n = 1) in 3 goats. Results of antibiotic treatment of abscesses were disappointing, with little evidence of altering the course of the disease or sterilizing the abscess, despite the fact that the bacteria were susceptible in vitro to the antibiotics used. Excision of intact abscesses was the preferred treatment for abscesses of the jaw and facial areas.(ABSTRACT TRUNCATED AT 250 WORDS)

Abscess↗
PubMedDate not supplied

Hepatic abscess.

Hepatic abscess--amebic or pyogenic--can be diagnosed with great accuracy by either ultrasonography or computed tomographic (CT) scanning. Ultrasound is the modality of choice and will detect almost 100% of abscesses. Confirmation of a diagnosis of amebic liver abscess is made by the indirect hemagglutination test that should be positive in almost 100% of cases. Cultures of pus from the abscess and from the blood must be obtained in cases of pyogenic liver abscess. A positive culture of pus from the abscess has been achieved in 90% of cases. Ultrasound or CT guidance is utilized in aspiration of a hepatic abscess. In the treatment of an amebic liver abscess, metronidazole is the amebicide of choice. Open drainage is contraindicated. For cases that fail to respond to therapy with amebicides, closed drainage guided by CT or ultrasound is performed. Secondary bacterial infection of an amebic liver abscess is an extremely rare event. The identification and determination of the antibiotic sensitivity of organisms responsible for pyogenic liver abscess is a crucially important step. Unless a celiotomy is necessary to correct an intraabdominal process or the abscess is extremely large, the initial treatment of pyogenic liver abscess is a 2 week course of appropriate antibiotics followed by a 1 month course of oral antibiotics. The majority of pyogenic liver abscesses will respond to such treatment. If drainage of a pyogenic abscess is required, the preferable technique is with a percutaneous CT- or ultrasound-directed catheter.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1987

A comparison of amebic and pyogenic abscess of the liver.

We evaluated the clinical features of 96 cases of amebic liver abscess and 48 of pyogenic hepatic abscess. Most patients with amebic abscess were young Hispanic males. Those with pyogenic abscess were older, without any ethnic predominance. Symptoms tended to be acute and localized to the right upper quadrant in amebic infection. In pyogenic disease, symptoms were often nonspecific and chronic in nature. A marked shift to the left of the leukocyte count occurred more frequently in pyogenic abscess, as did markedly abnormal values of the serum albumin, direct bilirubin, lactic dehydrogenase and aspartate aminotransferase. Sonography detected all cases of amebic abscess and missed the lesions in 2 of 39 patients with pyogenic abscess. Abscess cultures yielded pathogens in 90% of cases of pyogenic disease, while blood cultures were positive in 50%. Five of 20 patients with positive blood cultures had additional organisms isolated from the abscess that would have required adjustment of antibiotics for optimal coverage. We believe that all pyogenic abscesses should be aspirated to guide antibiotic therapy. In amebic abscess, the diagnosis was usually based on clinical and sonographic findings, aspiration being performed in only 14% of cases. Ninety-eight percent of patients were treated with amebicidal agents alone, and all responded to therapy. Therapeutic needle aspiration is rarely necessary. In pyogenic abscess, prolonged fever was common during medical therapy. Even in those eventually cured without surgery, the median time to defervescence was 8 days. Though 19 patients underwent surgical drainage, only 2 clearly did not benefit from medical treatment, having high fevers after more than 2 weeks on a regimen of appropriate antibiotics. Surgery is often performed prematurely because physicians expect fever to resolve quickly, but persistent fever of less than 2 weeks' duration should not constitute an indication for surgical drainage. Seven patients with pyogenic abscess died, 5 as a result of hepatic abscess. In 3 of these cases, the diagnosis was unsuspected till autopsy. Improved awareness of this disease may decrease morbidity and mortality from this treatable condition.

Adult↗
PubMed1995

Improved management of multiple brain abscesses: a combined surgical and medical approach.

Bacterial brain abscesses occur in approximately 1500 to 2500 patients each year in the United States. Multiple abscesses have been noted in 10 to 50% of these patients. The goal of this study was to better define the roles of surgery and medical management in patients harboring multiple brain abscesses and to develop an algorithmic approach to the treatment of these complex patients. Between 1976 and 1992, 16 patients with multiple brain abscesses were treated by a single physician (M.L.R.). The ages of the patients ranged from 1.5 to 73 years (median, 47 yr). In all patients, a diagnosis of multiple abscesses was made by computed tomography (15 patients) or magnetic resonance imaging (1 patient) brain scans. The number of abscesses per patient ranged from 2 to 30, and the abscesses were located in all regions of the brain. Thirteen received a combination of antibiotics and surgical drainage, and three received antibiotics only. Surgery was performed on abscesses larger than 2.5 cm or on those situated in critical areas of the brain or causing significant mass effect. Excision and open aspiration via craniotomy and stereotactic aspiration were analyzed on the basis of the location of the lesion and infecting organism. Any abscess that enlarged after 2 weeks of antibiotics or that failed to shrink after 3 to 4 weeks of antibiotics was again aspirated or excised. Forty-three surgical procedures were performed in 13 patients, and 8 (62%) of the patients operated on required more than one surgical procedure. No significant morbidity was observed in any of the surgical procedures. Antibiotics were administered intravenously for an average of 6 to 8 weeks and were adjusted according to organism type and sensitivity to antibiotics. One patient (6%) died, and the remaining 15 patients had resolution of all abscesses and good neurological recovery within 6 months. On the basis of these results, we propose a combined surgical and medical approach to the treatment of patients with multiple brain abscesses. We recommend the aggressive surgical drainage of all abscesses larger than 2.5 cm in diameter, combined with 6 to 8 weeks of intravenous antibiotics. Biweekly computed tomography or magnetic resonance imaging is necessary to closely monitor patients for evidence of abscess growth or failure to resolve despite antibiotics, prompting another operation. The application of this combined approach should yield cure rates of more than 90% in patients with multiple brain abscesses, a result similar to that expected when treating patients with solitary lesions.

Adolescent↗
PubMed2000

[Suburban amebiasis: the diagnostic aspects via computed tomography and echography and the percutaneous treatment of amebic liver abscesses].

INTRODUCTION: Liver is the most common site of extraintestinal amebiasis and hepatic abscesses are the most frequent symptom, occurring in 3-9% of patients with amebic infection. Several studies have shown that drug treatment is more efficacious when combined with percutaneous drainage of the abscess, yielding quicker recovery and a positive body response. We report our US and CT findings in 16 patients with amebic abscesses, 12 of whom lived in a temperate peripheral area north-east of Naples. All patients had a clinical-diagnostic condition that we called "suburban amebiasis". Finally we report our personal experience with the US-guided therapeutic drainage of amebic abscesses with repeated cavity washings, which is important for positive parasitology. MATERIAL AND METHODS: We retrospectively reviewed the findings of 16 patients (11 men and 5 women; age range 36-78 years; mean 52) with amebic abscesses of liver examined with US and CT. US with a 3.5 MHz transducer was the technique of choice in all patients. 94% of liver abscesses and some extraintestinal complications were easily shown with this technique. CT angiography was then performed to detail and clarify US findings. Abscesses over 4 cm in diameter were submitted to US-guided percutaneous treatment which permitted abscess drainage, the collection of material for parasitology and repeated cavity washings. RESULTS: US showed multiple liver abscesses in 12 patients, which were multiseptate and formed by multiple hypo-/hyperechoic microabscesses in 4 of them. Four non-European patients had a single abscess, which is typical of tropical endemic forms. CT showed the amebic abscesses as hypodense roundish masses with clear-cut outline most often localized in the right lobe in the 12 multiple cases. After percutaneous drainage 13/16 patients (81%) reported less pain in the right hypochondrium and had a lower temperature; their hospitalization was also shorter. DISCUSSION AND CONCLUSIONS: Combined US and CT assessment facilitated the diagnosis of amebiasis and its differentiation from pyogenic abscess and hepatoma. The combination of US-guided drainage and drug treatment provides better results than either treatment alone and quicker improvement of patient conditions, with fewer extraintestinal complications. Percutaneous drainage should be used in abscesses bigger than 4-5 cm, those with questionable clinical-laboratory findings and finally those failing to respond to drug treatment alone. Positive parasitology of abscess content is related to repeated cavity washings after percutaneous drainage, likely because peripheral layers are much richer in amebae.

Adult↗