ABSTRACT
A 66-year-old man with hypertension presented with fever which has started three days prior. Computed tomography (CT) revealed the presence of multiple low-density areas in the liver, the largest of which was over 10 cm in diameter, with clear demarcation. Streptococcus intermedius was detected in the blood culture, thus we diagnosed suspected liver abscess with bacteremia. Because the patient refused invasive drainage and was not poor general appearance, we had initiated intravenous meropenem followed by ceftriaxone plus metronidazole without any abscess drainage. After 6 weeks antibiotics treatment, liver abscess was almost completely diminished on the CT scan. To the best of our knowledge, this is the first report of a giant liver abscess caused by Streptococcus intermedius treated successfully without drainage.
ABSTRACT
Purpose of Study Streptococcus intermedius is a Gram-positive bacterium that is part of normal oropharyngeal flora but can cause serious infections such as brain and liver abscesses. An increase of brain abscess cases related to sinusitis were recognized during the coronavirus disease 2019(COVID-19) pandemic. We present three cases of brain abscess related to sinusitis in pediatric patients. S. intermedius was isolated in all cases. Methods Used A retrospective chart review was performed in patients with brain abscess whose cultures grew S. intermedius during the COVID-19 pandemic. Summary of Results Case 1: A 6-year-old male with 4-day history of headaches, diagnosed with viral infection by his pediatrician. He was also seen at an Urgent Care facility for fevers and managed supportively. He then developed a seizure- like episode which prompted an emergency room (ED) visit. Head computerized tomography (CT) revealed bifrontal epidural abscess and pansinusitis. He underwent bifrontal craniotomy with evacuation of epidural abscess and maxillary antrostomy. He was treated with a prolonged course of IV antibiotics with good response to treatment and resolution of seizures. Case 2: A 9-year-old female with left eye pain and swelling for six days associated with headaches and emesis. She was diagnosed with a hordeolum at an ED. Worsening of symptoms prompted a second ED visit where a CT revealed preseptal cellulitis and abscess. Further imaging showed left orbital abscess with epidural abscess. She underwent bicoronal craniotomy with evacuation of abscess and maxillary antrostomy. Treatment also included a prolonged course of IV antibiotics. She was discharged at neurologic baseline. Case 3: A 14-year-old male with fever, left eye and forehead swelling for two weeks. At the initial ED visit, he was diagnosed with a 'boil' and prescribed antibiotics and steroids. He had interval improvement of swelling but continued with daily fevers and developed vomiting prompting another ED visit. He was admitted to the pediatric intensive care unit (PICU) due to hypertension and vision changes. Upon arrival to the PICU, he required immediate cardiopulmonary resuscitation due to pulseless ventricular tachycardia. Further workup demonstrated extensive subdural empyema and partial venous sinus thrombosis. Left decompressive hemicraniectomy and maxillary antrostomy was done emergently. He received a prolonged course of IV antibiotics. He developed right sided weakness, required nutritional and ventilatory support despite appropriate treatment. Conclusions S. intermedius can cause life threatening intracranial infections which may have increased during the COVID- 19 pandemic for reasons unknown. The diagnosis is often delayed as patients present with nonspecific symptoms. Prompt neurosurgical intervention and administration of prolonged antibiotics improve outcomes.