[ON A CASE OF A BRAIN ABSCESS IN A CHILD (ABSCESS OF THE RIGHT FRONTAL LOBE AS A COMPLICATION OF LEFT FRONTAL SINUSITIS)].
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Abscess↗
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Fungal brain abscess in transplant recipients: epidemiologic, microbiologic, and clinical features.
Fungal brain abscess is an unusual but serious complication associated with solid organ and hematopoietic stem cell transplantation. To examine the epidemiology and clinical features of fungal brain abscess in transplant recipients, we reviewed retrospectively all cases of fungal brain abscess diagnosed during a 3-yr period among 1,620 adult patients who underwent allogeneic or autologous stem cell, liver, heart, lung, or renal transplantation at one institution. Seventeen cases of fungal brain abscess were identified and occurred a median of 140 d post-transplantation. Fungal brain abscess was more common among allogeneic stem cell transplant recipients (p < 0.01). Aspergillus species were most commonly isolated, but unusual, opportunistic molds were also identified. Altered mental status was present in 65% of patients, and multiple brain lesions were commonly seen on imaging studies. Although fungal brain abscess is an uncommon disease in this population, outcome was poor, suggesting that early recognition of this disease might be helpful.
Adolescent↗
Otogenic brain abscess: management by otologist.
INTRODUCTION: Fifty per cent of brain abscesses in adults and 25 per cent of those in children are otogenic in origin. The current neurosurgical options are to drain the abscess repeatedly through burr holes or to excise it completely with the capsule. We successfully managed 10 cases of brain abscess by draining through the transmastoid route. The technique and its advantages are discussed. MATERIAL AND METHODS: The patients underwent surgery at two different institutions. Computed tomography scanning and magnetic resonance imaging were performed, along with diffusion-weighted imaging and in vivo proton magnetic resonance spectroscopy. The abscesses were drained via a transmastoid route. RESULTS: In eight cases, ear disease and brain abscess were treated in a single-stage procedure. In the remaining two cases, residual brain abscess was excised subsequently by our neurosurgical colleagues. CONCLUSIONS: Transmastoid drainage of pus can successfully treat mastoid disease and brain abscess in a single surgical intervention. Residual abscess can be subsequently excised, with relatively reduced morbidity. Repeated needling is also avoided with this approach. Diffusion-weighted imaging and proton magnetic resonance spectroscopy are helpful.
Brain Abscess↗
[On the diagnosis of brain abscesses].
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Abscess↗
[Computed tomographic diagnosis of epidural abscess, subdural empyema, meningitis and brain abscess].
Computerised tomography cannot be of great help in diagnosing meningitis. Examination of the cerebrospinal fluid remains essential. After the inflammation of the meninges has progressed to some stage of encephalitis, the formation of an abscess can be located via computed tomography. It is characterised by the ring-type abscess capsule. Computed tomography for diagnostic purposes is superior to cerebral scanning, which demonstrates enhanced activity, but does not show the formation of a membrane, so essential for differential diagnosis. Furthermore, computed tomography shows the adjacent anatomical structures and answers the questions of displacements and threatening invasion of the ventricle system. Epidural and subdural abscesses can also be located by computed tomography. Therapy can begin directly after computerised tomography, whereas in scintigraphy only a non-specific enhanced activity is present, which often does not allow differentiation between epidural and subdural location.
Brain Abscess↗
Nocardial brain abscess in a renal transplant recipient.
Nocardial brain abscess is rare and accounts for about 1-2% of all cerebral abscesses. However, the early detection and treatment of it is very important because the mortality of it is three times higher than that of other bacterial brain abscesses. We report a case of nocardial brain abscess in a renal transplant recipient. Enhanced brain CT and MR scans showed multiple conglomerated ring-enhancing lesions with budding appearance and distinct surrounding edema.
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Diffusion MRI findings in neonatal brain abscess.
In neonates and infants, bacterial brain abscess is rare, and the diffusion weighted MR imaging appearance of such abscesses has not been reported. We report the diffusion weighted MR findings of a brain abscess in a 25-day-old boy. The lesion initially had a large cystic component with some high-signal pyogenic material inside on diffusion-weighted (b=1000 sec/mm(2))images. The ADC value of this material was low (0.59 x 10(-3) mm(2)/sec), compared to the value from normal cerebellar parenchyma (0.78 x 10(-3) mm(2)/sec). The unusual initial appearance mimicked a cystic tumor. The lesion markedly decreased in size over 20 days after antibiotic therapy with persistent high-signal pyogenic material. In addition, at the initial presentation b=1000 sec/mm(2) images revealed high-signal changes in the brain parenchyma compressed by markedly dilated ventricles, consistent with ischemia. Also, ADC values of perilesional vasogenic edema (1.74 x 10(-3) mm(2)/sec), and that of transependymal resorption of CSF (1.56 x 10(-3) mm(2)/sec) were noted at the initial stage.
Anti-Bacterial Agents↗
[Otogenic brain abscess].
The authors report the 20-year experience in the diagnosis and treatment of patients with otogenic brain abscess. In the studies were included 36 patients of whom 24 had a cerebral abscess and 12 a cerebell abscess. The otogenic brain abscess was usually associated with meningitis (45%). Headache and temperature were common with otogenic intracranial complications. The active chronic otitis with cholesteatoma was usually found in the middle ear. The inflammatory process was usually spread in the endocranial space through destroyed walls of the midle ear. Computerized tomography (CT) is the most safe method in the diagnosis of brain abscess, by which it is possible to localyze the abscess, to plan the operation and follow-up the success of treatment. Neurological and ophthalmological examinations cannot always detect brain abscess. The authors suggest that in cases of brain abscess, it is important to neurosurgically remove the abscess. After improvement of the general condition of the patient, otosurgical procedure must be done. In this group of patients mortality is relatively high, both in abscessus cerebri (20%) and abscessus cerebelli (25%).
Brain Abscess↗
Stereotactic drainage of brain abscesses.
Between 1981 and 1986, 16 patients with brain abscesses underwent computed tomography (CT) guided stereotactic aspiration with (n = 5) or without (n = 11), catheter drainage. Infectious sources were found in 11 patients; 6 patients had concomitant immune suppression. Bacterial or mixed toxoplasmic-fungal or toxoplasmic-viral abscesses were diagnosed in 14 patients. After prolonged antimicrobial treatment, follow-up clinical and radiological evaluations confirmed abscess resolution in 12 patients. The abscess size was smaller in four patients, three of whom died 30-60 days after surgery due to overwhelming systemic opportunistic infections. One patient with a tuberculous brain abscess continued to exhibit gradual abscess regression one year after beginning three-drug antituberculous therapy. No surgical mortality occurred but two patients required evacuation of post-operative intracerebral haematomas that resulted from over-vigorous abscess aspiration. CT stereotactic drainage is a safe and effective technique to diagnose and treat brain abscesses and is mandatory for small or deep-seated lesions. Empirical therapy of suspected brain abscesses is rarely warranted in the era of CT stereotactic surgery.
Adult↗
Risk factors for brain abscess in patients with congenital cyanotic heart disease.
Brain abscess is a serious complication of congenital cyanotic heart disease. We retrospectively evaluated the risk factors for brain abscess in 21 such patients treated between 1975 and 1990 in comparison with a control group. The mean arterial oxygen saturation, arterial partial pressure of O2, arterial blood oxygen content, and base excess in patients with brain abscess were significantly lower than in the control patients. The mean arterial partial pressure of CO2, pH, hematocrit, hemoglobin, and red blood cell content in patients with brain abscess were not significantly different. Patients with congenital cyanotic heart disease may develop minute encephalomalacia due to severe hypoxemia and increased blood viscosity resulting from compensatory polycythemia. The increased blood viscosity and reduced blood flow in the microcirculation may induce cerebral thrombosis or exaggerate minute encephalomalacia during dehydration or cardiac dysfunction, and shunted blood containing infectious organisms at such sites may be followed by focal cerebritis.
Brain Abscess↗
Further refinement of the Escherichia coli brain abscess model in rat.
The rat brain abscess model provides a substrate for the modeling of delivery of therapeutic agents to intracerebral mass lesions. We now report refinement of the Escherichia coli brain abscess model in rat. A K1 surface antigen-negative E. coli isolated from human blood culture was stereotaxically inoculated into deep brain sites. Histopathologic analyses and quantitative cultures demonstrated the consistent production of lesions. No animal in this consecutive series developed meningitis, ventriculitis or sepsis. By contrast, prior experience with E. coli abscess production resulted in 25% failure rate of abscess production or death from sepsis. This improvement in the model may be attributable to specific characteristics of the bacteria used, modification of the inoculation method or the intracerebral placement technique. The present work suggests a reliable and consistent brain abscess model, which may be further used to study brain suppuration.
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[Isocount scanning in the diagnosis of the brain abscess (author's transl)].
The purpose of this study is to investigate salient diagnostic features of the brain abscess in RI brain scanning. In 27 patients with brain abscess, 37 scannings were performed in the various stages of their clinical courses. The results were positive in all cases. Among 27 cases, ten cases were investigated by means of the ISOCOUNT SCANNING SYSTEM, the technical detail of which was reported previously. It was proved that the isocount scanning method combined with the multilevel analysis was more sensitive diagnostic aid than the conventional RI scintigraphy. Using the newly developed method, it was not difficult to diagnose the brain abscess in its early stage, even in the stage of presuppurative cerebritis. Doughnut sign was seemed to be more frequently visualized by this method. Surgical indication of the brain abscess was discussed from nucleomedical view point, and it was emphasized that so-called doughnut sign in brain scanning would indicate the appropriate stage of the brain abscess to be operated on.
Adolescent↗
[Brain abscess following thalamic hemorrhage: a case report].
Brain abscess following stroke is rare. We present a case of brain abscess which developed after hypertensive thalamic hemorrhage. A 51-year-old man had a left thalamic hemorrhage. Three months later, the patient was admitted to our hospital due to deterioration of right hemiparesis and motor aphasia. On admission, CT scan showed a ring-like high density area with peripheral edema in the left thalamus. T1-weighted magnetic resonance (MR) images revealed a large ring-enhanced lesion with surrounding edema in the same region. Laboratory examination demonstrated no signs of infectious disease. The patient's neurological state rapidly deteriorated 10 days after admission. Yellowish pus was aspirated during the emergent surgery. Bacteriological study of the pus revealed Staphylococcus Aureus. His symptoms improved after surgery followed by antibiotics therapy. The correct diagnosis prior to surgery was difficult in the present case because of lack of any signs of infection. Our case indicates that possibility of brain abscess should be taken into consideration as a rare differential diagnosis following intracerebral hemorrhage.
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Discrimination of brain abscess and cystic tumor by in vivo proton magnetic resonance spectroscopy.
Proton magnetic resonance (MR) spectroscopy was evaluated for the differentiation of brain abscesses and cystic brain tumors. Proton MR spectroscopy was performed in vivo in two patients with brain abscess and eight patients with various cystic brain tumors (anaplastic astrocytoma, glioblastoma, and metastatic brain tumor). MR imaging with contrast medium demonstrated ring-like enhanced mass lesions in all patients. The various resonance peaks in proton MR spectra were assigned to metabolites according to chemical shifts. Treatment of the cystic brain lesions was based on the information from proton MR spectroscopy. Aspirated pus from one patient with brain abscess was examined using ex vivo proton MR spectroscopy. The in vivo spectra of brain abscess contained resonance peaks attributed to acetate, lactate, alanine, amino acids, and lipids in both cases, and an additional peak of succinate in one case. In vivo spectra of the neoplasms contained resonance peaks corresponding to lactate, lipids, choline, creatine, and N-acetyl aspartate. Proton MR spectroscopy is useful for discriminating brain abscess from cystic tumors with similar neuroimaging appearance, which is very important for determining the treatment strategy.
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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.
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Diminished virulence of an alpha-toxin mutant of Staphylococcus aureus in experimental brain abscesses.
Staphylococcus aureus is one of the major etiologic agents of brain abscesses in humans, occasionally leading to focal neurological deficits and even death. The objective of the present study was to identify key virulence determinants contributing to the pathogenesis of S. aureus in the brain using a murine brain abscess model. The importance of virulence factor production in disease development was demonstrated by the inability of heat-inactivated S. aureus to induce proinflammatory cytokine or chemokine expression or brain abscess formation in vivo. To directly address the contribution of virulence determinants in brain abscess development, the abilities of S. aureus strains with mutations in the global regulatory loci sarA and agr were examined. An S. aureus sarA agr double mutant exhibited reduced virulence in vivo, as demonstrated by attenuated proinflammatory cytokine and chemokine expression and bacterial replication. Subsequent studies focused on the expression of factors that are altered in the sarA agr double mutant. Evaluation of an alpha-toxin mutant revealed a phenotype similar to that of the sarA agr mutant in vivo, as evidenced by lower bacterial burdens and attenuation of cytokine and chemokine expression in the brain. This suggested that alpha-toxin is a central virulence determinant in brain abscess development. Another virulence mechanism utilized by staphylococci is intracellular survival. Cells recovered from brain abscesses were shown to harbor S. aureus intracellularly, providing a means by which the organism may establish chronic infections in the brain. Together, these data identify alpha-toxin as a key virulence determinant for the survival of S. aureus in the brain.
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Multiple fungal brain abscess in a child with acute myeloblastic leukemia.
Fungal brain abscess is rarely cured in childhood. The mortality rate is higher than 95% in immunocompromised patients, even if antifungal agent and surgery are used. A 5-year-old boy with acute myeloblastic leukemia (AML) (M2 according to FAB classification) and multiple candidal brain abscesses is discussed. The candidal brain abscesses of this patient were thought to be iatrogenic, due to the difficult lumbar puncture of intratechal therapy. He was successfully treated with combination conventional amphotericin B (ABC), surgical drainage, and granulocyte colony-stimulating factor. Toxicity was not determined due to ABC. This is thought to be the first child to survive AML and multiple candidal brain abscesses.
Amphotericin B↗
Electroencephalographic cranial computerized tomographic correlations in brain abscess.
The authors studied 19 cases of brain abscess. The investigation included one or more EEG records from 13 patients and one or more cranial computerized tomograms in all cases. In this work the two techniques were associated to establish the diagnosis of cerebral abscess. The EEG is almost always abnormal and pronounced EEG disturbances are, in most cases, sufficient for indicating a diagnosis of a space-occupying process. On the other hand, EEG patterns suggestive of brain abscess were detected in only 38% of the patients. In brain abscess, CCT is of considerable value since the existence of 'suppurative' images was demonstrated in all cases and of these, 70% were characteristic. The association of these two techniques is thus extremely useful in the diagnosis of cerebral abscess, to follow its evolution and to detect postoperative relapse or to evaluate the efficiency of medical management alone.
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