Multiple Brain Abscesses by an Air Gun Shot: A Case Report

Introduction Low-velocity penetrating brain injury is not prevalent. In some conditions such as childhood, and with the penetration of a pellet in weak spots of skull, low-velocity penetrating brain injury is expected; however, high-velocity projectiles have also been reported as the cause of severe brain injuries. One of the complications of penetrating brain injury is infection, in which different types ofmicroorganisms play a role. The Streptococcus genus is the leading cause of abscess formation in nontraumatic patients. Multiple brain abscesses are not common. Case Presentation A 10-year-old boy with penetrating brain injury caused by an air gun pellet, who developed signs and symptoms of high intracranial pressure 18 days after the trauma. After the imaging scans and the detection of multiple brain abscesses and severe brain edema, prompt surgical intervention was performed for all three lesions in a single operation. The culture of a pus specimen was positive for Streptococcus species, and, with adequate antibiotic therapy, the patient was discharged from the hospital in good condition. Conclusion Brain injurywith air gun shot is not prevalent. The penetration of a low-velocity air gun pellet in weak points of the skull (such as the orbit, the squamous portion of the temporal bone, and the cranial suture), specially in children, can cause significant brain injuries.

Brain Abscess Caused by Nocardia: Case Report and Literature Review

Nocardia brain abscess is a rare clinical entity, accounting for 2% of all brain abscesses, associated with high morbidity and amortality rate 3 times higher than brain abscesses caused by other bacteria. Proper investigation and treatment, characterized by a longterm antibiotic therapy, play an important role on the outcome of the patient. The authors describe a case of a patient without neurological comorbidities who developed clinical signs of right occipital lobe impairment and seizures, whose investigation demonstrated brain abscess caused by Nocardia spp. The patient was treated surgically followed by antibiotic therapy with a great outcome after 1 year of follow-up.

Multiple Brain Abscesses Secondary to Odontogenic Infection: A Clinical Case Report

Introduction Cerebral abscess is a suppurative infection of the cerebral parenchyma, which may occur due to contiguity, hematogenous dissemination of distant foci, secondary to open traumatic brain injuries, or be idiopathic. Clinical Case A 63-year-old male patient sought assistance due to a severe headache in the frontal region associated with chills and lack of appetite that started four days before. Clinical examination of the patient showed no significant changes. Imaging and laboratory tests on admission showed only nonspecific changes, such as leukocytes 18,540, platelets 517,000, and c-reactive protein 2,0. In such case,magnetic resonance imaging (MRI) of the skull was performed with contrast, showing the presence of expansive lesions compatible with multiple brain abscesses in the right parietooccipital region. Discussion After excluding the main focus of hematogenous dissemination and in view of the identification of the agent Streptococcus intermedius by means of secretion culture collected through a surgical method, the hypothesis of abscess due to contiguous dental pyogenic foci was pointed out. Conclusion Dental evaluation showed multiple foci of infection with periodontitis and dental abscess, which were treated along with the use of antibiotics directed to the etiologic agent.

Absceso cerebral múltiple del lóbulo temporal derecho, reporte de un caso / Multiple brain abscess of the right temporary lobe, report of a case

RESUMEN El absceso cerebral es un proceso infeccioso focal del parénquima cerebral. Se inicia con un área localizada de cerebritis y progresa a una colección de pus rodeada por una cápsula bien vascularizada. La mortalidad oscila entre 5 a 15 % de los casos, excepto en la ruptura intraventricular del absceso cerebral, situación en que la mortalidad oscila entre 38 a 84 %, con tasas altas de discapacidad en los sobrevivientes. Se presentó un caso de 47 años, con sintomatología neurológica infecciosa, además de signos neurológicos que demuestran el trastorno funcional del lóbulo temporal no dominante. Se realizaron varios exámenes complementarios y se diagnosticó dos abscesos cerebrales temporales derechos. Fue intervenido neuroquirúrgicamente, su evolución fue satisfactoria con regresión de casi la totalidad de los síntomas prequirúrgicos presentados (AU).

ABSTRACT Brain abscess is a focal infectious process of the brain parenchyma. It begins with a located area of cerebritis and progresses to a pus collection surrounded by a well-vasculirized capsule. Mortality oscillates from 5 % to 15% of the cases, except in the intraventricular rupture of the brain abscess, situation in which mortality oscillates from 38 % to 84 %, with high rates of disability in survivors. The case presented is the case of a patient aged 47 years, with infectious neurologic symptoms besides neurologic signs showing the functional disorder of the non-dominant temporal lobe. Several complementary tests were carried out and two right temporal brain abscesses were diagnosed. The patient underwent a neurosurgery; his evolution was satisfactory with the almost total regression of the symptoms before surgery (AU).

Absceso cerebral por Cladophialophora bantiana en un paciente con trasplante renal: reporte de un caso / Brain abscess caused by Cladophialophora bantiana after renal allograft loss: A case report

Resumen Las feohifomicosis cerebrales son infecciones graves causadas por mohos dematiáceos, entre los cuales Cladophialophora bantiana es una de las especies más comúnmente aislada. Esta tiene tropismo por el sistema nervioso central y frecuentemente produce abscesos cerebrales en pacientes inmunocompetentes; además, en los inmunocomprometidos también puede ocasionar infección diseminada. Pese a la disponibilidad de medicamentos antifúngicos de amplio espectro, a menudo se requiere también la intervención quirúrgica; de todas maneras, la mortalidad es elevada. El diagnóstico debe hacerse interviniendo para tomar la muestra y hacer el cultivo y las pruebas de sensibilidad. Se presenta aquí el caso de un paciente con trasplante renal que presentó un absceso cerebral por C. bantiana, el cual se extrajo mediante resección quirúrgica. El paciente recibió tratamiento con voriconazol, con adecuada respuesta, mejoría y sin secuelas neurológicas.

Abstract Cerebral feohifomycosis are severe infections caused by dematiaceous fungi. Cladophialophora bantiana is one of the most commonly isolated species; it has central nervous system tropism and it often manifests as a brain abscess in immunocompetent patients. In immunocompromised patients, it can lead to brain abscesses and disseminated infections. Despite the availability of broad-spectrum antifungal drugs, it is a must to perform surgical management, in addition to drug therapy. However, mortality is high. The diagnostic approach must be invasive to establish a timely diagnosis and direct treatment based on culture and susceptibility tests. We report a case of brain abscess caused by C. bantiana in an immunosuppressed patient who was treated with surgical resection and voriconazole with an adequate response to therapy and without neurological sequels.

Management of brain abscess: Changing trend and experience in Enugu, Nigeria

Background: Intracranial abscess remains a significant health-care problem. Its causes, diagnosis, treatment, and outcome are changing. Aim: This paper reviewed the demography, examined new trends, and compared outcomes with different treatment options. Methodology: Retrospective analysis of intracranial abscesses managed at Memfys Hospital, Enugu (2004­2014) and University of Nigeria Teaching Hospital (2009­2014). Patients were followed up for at least 6 months. All patients had neuroimaging before intervention. Microscopy and culture were performed for the specimens. Intravenous antibiotics were given for 2 weeks before conversion to oral. Results: Seventy-nine parenchymal abscesses (eight cases per year) were managed. Peak age was the second decade of life. Previous head injury (21.5%) and meningitis (16.5%) were the most common predisposing factors. The frontal lobe was most common anatomical location (32%). Only 24% had positive culture result. Three cases were fungal infections. Seventy percent of patients managed with burr hole drainage and 37.5% of craniotomy made complete recovery. Overall, 58% of patients made complete recovery, whereas 19.0% died. Nine percent of cases died before definitive intervention. Among the 24% of patients that presented in coma, 47% died within 6 months. Most important factor influencing mortality was admission level of consciousness. Abscess recurred in 6% of cases. Conclusion: Intraparenchymal abscesses in Enugu were mostly solitary lesions resulting from poorly managed head injury and meningitis. Predisposition from otitis media and systemic diseases has reduced. The proportion of fungal organisms is increasing. A significant proportion of the patients present in coma. Burr hole and aspiration of abscess is less invasive and has very good outcome

Absceso cerebral en pacientes pediatricos / Brain abscess in pediatric patients

El absceso cerebral se constituye como un área central supurativa dentro del parénquima cerebral, dentro de una envoltura ampliamente vascularizada. Los patógenos ampliamente aislados en la patogénesis de esta entidad en niños son los Streptococos spp. A pesar del avance en la terapia antimicrobiana, las técnicas neuroquirúrgicas e imagenológicas, que permiten su diagnóstico y ubicación oportuna, el absceso cerebral aún se considera un problema de salud pública, con una importante incidencia, morbilidad y mortalidad en países en vía de desarrollo. Para el manejo de este tipo de infección del SNC, se requerirá de un abordaje multidisciplinario que involucre terapia médico quirúrgica. El objetivo de esta revisión es hacer un abordaje amplio sobre la patobiología del absceso cerebral relacionada con la labor concerniente al neurocirujano.

Brain abscess is formed as a central suppurativa area within the brain parenchyma, within an envelope extensively vascularized. Microorganisms largely isolated in the pathogenesis of this condition in children are Streptococos spp. Despite the progress in antimicrobial therapy, neurosurgical techniques and imagenologic support, which enabling timely diagnosis and location, brain abscess is still considered a public health problem and has an important incidence, morbidity and mortality in developing countries. To handle this type of CNS infection, will require a multidisciplinary approach involving surgical medical therapy. The aim of this review is to make a comprehensive approach on the pathobiology of brain abscess related to the work concerning the neurosurgeon.

Abcesso cerebral num doente com Rendu-Osler-Weber / Cerebral abscess in a patient with Rendu-Osler-Weber

A telangiectasia hemorrágica hereditária é uma doença familiar rara, descrita pela primeira vez no final do século 19, caracterizada por telangiectasias mucocutâneas e viscerais, e por malformações arteriovenosas. Manifestações neurológicas ocorrem em 8 a 12% dos doentes e resultam em mais de metade dos casos de malformações arteriovenosas pulmonares. A telangiectasia hemorrágica hereditária é uma das causas mais frequentes de abcessos cerebrais recorrentes, múltiplos e bilaterais, tendendo estes a ocorrerem na 3a para a 5a década. Apresentamos o caso de uma mulher de 88 anos admitida por prostração, febre e insuficiência respiratória, com a suspeita de metastização pulmonar de neoplasia oculta, cuja investigação revelou, entretanto, um abcesso cerebral secundário a malformações arteriovenosas pulmonares. Apesar da antibioterapia e da drenagem cirúrgica do abcesso, a paciente veio a falecer. O prognóstico após drenagem dos abcessos sem ressecção das lesões pulmonares é desfavorável, podendo sua elevada mortalidade refletir um atraso diagnóstico pela falta de reconhecimento dessa associação.

Hereditary hemorrhagic telangiectasia is a rare familial disorder, first described in the late 19th century characterized by multiple mucocutaneous and visceral telangiectases and arteriovenous malformations. Neurologic manifestations occur in 8 to 12% of patients and result from pulmonary arteriovenous malformations in 50% of cases. Hereditary hemorrhagic telangiectasia is one of the most frequent causes of recurrent, multiple and bilateral cerebral abscess and these tend to occur in the 3rd to 5th decade. We present the case of an 88-year-old woman admitted for prostration, fever and respiratory failure who was thought to have pulmonary metastasis of an unknown tumor but investigation revealed a brain abscess secondary to pulmonary arteriovenous malformations. Despite antibiotics and surgical drainage the patient died. The prognosis of brain abscess drainage without resection of the pulmonary lesions is not favorable. The high mortality of brain abscess in these patients may reflect a delay in diagnosis due to lack of recognition of this association.

Absceso cerebral por Haemophilus influenzae serotipo e en un paciente pediátrico con Síndrome de Apert / Brain abscess caused by Haemophilus influenzae type e in a pediatric patient suffering from Apert syndrome

Se presenta el caso de un absceso cerebral causado por Haemophilus infl uenzae tipo e, en un paciente de 12 años con síndrome de Apert. El síndrome de Apert se caracteriza por el cierre prematuro de las suturas craneales. En 2010, el paciente presentó traumatismo craneano en región frontal, fractura y fístula de líquido cefalorraquídeo. En febrero de 2013 consultó por fi ebre, vómitos y convulsión tónica clónica generalizada, con deterioro progresivo del sensorio. La tomografía axial computarizada mostró una lesión frontal derecha, edema perilesional, leve dilatación ventricular y pansinusitis. Se diagnosticó absceso cerebral con pioventriculitis y se realizó drenaje. Se obtuvo desarrollo de un cocobacilo gram negativo, que fue identifi cado como H. infl uenzae serotipo e. Se realizó tratamiento empírico con meropenem (120 mg/kg/día) y vancomicina (60 mg/kg/día). Luego del resultado del cultivo, se rotó a ceftriaxona (100 mg/kg/día) y metronidazol (500 mg/8 h). El paciente cumplió 8 semanas de tratamiento y se observó evolución favorable

We report a case of a brain abscess caused by Haemophilus infl uenzae type e in a 12 year-old patient suffering from Apert syndrome. Apert syndrome is characterized by the premature closure of cranial sutures. In 2010 the patient suffered head trauma in the frontal area with cranial fracture and a cerebrospinal fl uid fi stula. In February 2013 he was admitted to hospital with fever, vomiting and generalized tonic-clonic seizure with deteriorating mental status/progressive sensory impairment. The computerized axial tomographic scan showed a right frontal lesion, perilesional edema, mild ventricular dilatation and pansinusitis. A brain abscess was diagnosed and drained. The clinical sample was then cultured. A gram negative coccobacillus was isolated and identifi ed as Haemophilus infl uenzae serotype e. Empirical treatment was started with meropenem (120 mg/kg/day) and vancomycin (60 mg/kg/day), which was later switched to ceftriaxone (100 mg/kg/day) and metronidazole (500 mg/8 h) after culture results arrived. The patient was discharged in good clinical condition

Absceso cerebral odontogénico posraspaje radicular: informe de un caso / Odontogenic brain abscess after periodontal therapy: a case report

Objetivo: informar un caso de absceso cerebral odontogénico secundario a bacteriemia posraspaje radicular y revisar el tratamiento de esta patología poco frecuente. Caso clínico: un paciente de sexo masculino, de 57 años de edad, con antecedentes de diabetes tipo II mal controlada, fue intervenido mediante una limpieza gingival con cavitador ultrasónico, sin profilaxis antibiótica. A las 2 semanas, evolucionó con cefalea, fiebre y deterioro del sensorio. Al ingresar al hospital, se le realizó una resonancia cerebral que evidenció imagen compatible con absceso temporomesial izquierdo. Se efectuó la evacuación quirúrgica bajo guía estereotáxica y se rescató material purulento con cultivos positivos para Streptococcus milleri. Se indicó un tratamiento antibiótico con ceftriaxona y metronidazol. El paciente evolucionó con mejoría sintomática, sin déficit neurológico y sin lesión, según la imagen por resonancia magnética de control. Conclusión: los abscesos cerebrales constituyen una patología con alta morbimortalidad. Aunque el origen odontogénico es raro, es necesario evaluar a los pacientes con comorbilidades -como la inmunosupresión- y someterlos a prácticas habituales de bajo riesgo, a fin de minimizar probables complicaciones asociadas.

Absceso cerebral en lactante: caso clínico y revisión de la literatura / Infant brain abscess: case report and literature review

El absceso cerebral concierne a una colección de pus localizada en el parénquima cerebral. Es muy poco frecuente en los niños lactantes, predominando en los jóvenes y personas de edad avanzada. Esta entidad se presenta con manifestaciones clínicas muy variable. Los agentes etiológicos son muy diversos pero predominan los Streptococos, Staphylococcus y la klebsiella. El diagnóstico se basa en el cuadro clínico, el examen físico y los complementarios. El tratamiento se adecua al estadio en el que se encuentre la lesión inflamatoria, el germen que la produzca, el tamaño de la lesión y la condición neurológica del paciente. En el presente trabajo se presenta un lactante de 4 meses de edad con antecedentes de haber tenido una infección respiratoria alta tres meses previos a su ingreso que un mes después comenzó con fiebre de 38-39° C asociado a irritabilidad y fontanela anterior ocupada, en la tomografía contrastada se evidenció imagen hipodensa en región frontal izquierda con gran efecto de masa y desplazamiento de las estructuras de la línea media. Fue puncionado dos días consecutivos donde se evacuaron 80 ml de pus amarillento, en cada proceder al 4to día se interviene quirúrgicamente con craneotomía frontotemporal izquierda y lobectomía frontal ipsilateral con resección de toda la cápsula. Se le mantuvo con tratamiento antibiótico por 3 semanas. En la resonancia magnética postoperatoria hubo una desaparición de los signos inflamatorios del encéfalo, su evolución posterior fue satisfactoria.

A cerebral abscess is defined as a collection of pus within the cerebral parenchyma. Though rare in infants, it is common among young patients and the elderly. The clinical manifestations are varied. The predominant etiological agents include Streptococci, staphylococci and klebsiella. A patient is diagnosed based on the clinical picture, the physical exam and complementary tests. Treatment options depend on the stage of the disease, its size, the causative agent, and the neurological condition of the patient. A case is presented of a four month old infant with a history of an upper respiratory tract infection three months prior to his admission. One month later, he exhibited a high fever of 38-39 °C with irritability and a tense anterior fontanel. The CT scan revealed a hypo dense lesion in the left frontal lobe with significant mass effect and midline shift. The lesion was punctured on two consecutive days and 80 ml of yellowish pus was removed on both occasions. Four days later, a left fronto-temporal craniotomy and an ipsilateral frontal lobectomy was performed, with complete excision of the capsule. Antibiotic therapy was continued for three weeks. The post op MRI confirmed the complete excision of the lesion and disappearance of the surrounding edema. Recovery was satisfactory

Isolated homonymous hemianopsia due to presumptive cerebral tubercular abscess as the initial manifestation of human immunodeficiency virus infection.

We report a case of isolated homonymous hemianopsia due to presumptive cerebral tubercular abscess as the initial manifestation of human immunodeficiency virus (HIV) infection. A 30-year-old man presented to our outpatient department with sudden loss of visibility in his left visual field. He had no other systemic symptoms. Perimetry showed left-sided incongruous homonymous hemianopsia denser above the horizontal meridian. Magnetic resonance imaging revealed irregular well-marginated lobulated lesions right temporo-occipital cerebral hemisphere and left high fronto-parietal cerebral hemisphere suggestive of brain tubercular abscess. Serological tests for HIV were reactive, and the patient was started only on anti-tubercular drugs with the presumptive diagnosis of cerebral tubercular abscess. Therapeutic response confirmed the diagnosis. Atypical ophthalmic manifestations may be the initial presenting feature in patients with HIV infection. This highlights the need for increased index of suspicion for HIV infection in young patients with atypical ophthalmic manifestations.

Manifestaciones neurológicas de endocarditis infecciosa en niños / Neurologic manifestations of infective endocarditis in children

Introducción. La endocarditis infecciosa (EI), es una patología poco frecuente en pediatría. Según diferentes series pediátricas reportadas, 15 a 25% de los casos, presentan una complicación neurológica como forma de presentación inicial. Las manifestaciones neurológicas más frecuentes son: accidente cerebro vascular (ACV), abscesos cerebrales, meningitis, encefalopatía, convulsiones. Estas manifestaciones son atribuidas a diferentes etiologías, sin tener en cuenta a la EI como causa probable de las mismas. Material y métodos. Se revisaron las EI del 2008 al 2011, estudio retrospectivo observacional, analizándose los datos en Epi-info versión 2008. Resultados. Se registraron 7 casos; 5 reunían los criterios de Duke, 2 asumidos como endocarditis posible. Media de edad: 73 meses (R 11-162 meses); media de fiebre: 10 días (R 2-19). Dentro de las características clínicas: 3 pacientes tenían cardiopatía congénita, 2 desarrollaron insuficiencia cardiaca, 4 eran desnutridos, 2 presentaron síndrome nefrítico y 3 insuficiencia renal. Tres pacientes desarrollaron fenómenos embólicos en SNC, uno debutó con ACV, otro con aneurismas micóticos en SNC y el 3º con absceso cerebral. Estos 3 últimos pacientes tenían síndrome parameníngeo con LCR alterado y cultivo negativo. En 5 casos la vegetación se localizó en cavidades cardiacas derechas; 3 requirieron cirugía (verrugectomía y recambio valvular). Se aisló germen de hemocultivos en 6 pacientes, siendo el Staphylococcus aureus el más frecuente. Dos pacientes fallecieron. Conclusiones. Tres de los pacientes debutaron con síntomas de SNC como forma de presentación de EI. Consideramos que ante un niño con síntomas neurológicos, como hemiplejia, debemos pensar en endocarditis como probable etiología.

Chronic brain abscess secondary to a retained wooden foreign body: Diagnostic and management dilemmas.

A four-year-old child presented with recent onset generalized tonic clonic seizures. She was operated for a suspected intracranial tuberculoma and was found to harbor an intra-parenchymal retained wooden foreign body with a chronic abscess. The foreign body had entered the brain parenchyma after a minor head injury, sustained three years earlier. She was asymptomatic for the intervening three years. The initial diagnosis was missed by several physicians. A retained wooden fragment via a transtemporal apparently closed head injury is an extremely rare event. The present study reveals the diagnostic and therapeutic challenges and stresses the importance of high degree of suspicion to diagnose retained intracranial foreign bodies and the need for early surgical exploration, to avoid chronic and potentially life threatening neurological complications.

Absceso cerebral por Citrobacter koseri en lactantes. Presentación de un caso y revisión de la bibliografía / Citrobacter koseri brain abscess in an infant. Case report and literature review

Se presenta el caso de una niña de 2 meses admitida con absceso cerebral, cuya manifestación principal fue la macrocefalia evolutiva. Presentaba irritabilidad y vómitos aislados comosíntomas asociados. Se realizó tomografía axial computada cerebral que reveló una lesión quística de localización frontal con desplazamiento hemisférico contralateral. La intervención quirúrgica permitió obtener material purulento, con cultivo positivo para Citrobacter koseri (diversus). El cultivo de líquido cefalorraquídeo fue negativo. Cumplió tratamiento antibióticodurante 6 semanas con buena evolución. Como complicación presentó hidrocefalia posquirúrgica que requirió colocación de válvula ventriculoperitoneal.

Disseminated tuberculosis presenting as mesenteric and cerebral abscess in HIV infection: case report

Disseminated tuberculosis in HIV infection involves multiple organs. Pulmonary and lymph node involvement are the commonest form of tuberculosis in HIV infection [1, 2]. Other forms of tuberculosis in the absence of lung and lymph node involvement are rare. Various forms of abdominal [3, 4] and neurological [5, 6] tubercular involvement in HIV infection have been reported. But tuberculosis presenting simultaneously with mesenteric and brain abscess has not been reported yet. We report a case of disseminated tuberculosis presenting as mesenteric and cerebral abscess in a HIV case without involving lung and lymph nodes. Bone marrow smears and fine needle aspiration cytology (FNAC) from mesenteric lesion were positive for acid fast bacilli (AFB) and the diagnosis of tuberculosis was confirmed by positive polymerase chain reaction (PCR). He responded well to treatment with anti tubercular drugs.