Brain Abscess

While playing outside, a 23-month-old girl became sleepy and difficult to arouse. The mother brought her daughter to the emergency department (ED); posturing and a dilated and fixed right pupil were noted. The child was hospitalized.

The family had recently moved to the United States from Mexico. The child had no significant medical history before the onset of fever, headache, and intermittent nonbilious vomiting 2 weeks earlier. Five days before admission to the hospital, a viral syndrome had been diagnosed; 2 days later, the patient was seen in another ED where a lumbar puncture was performed; white blood cell (WBC) count was 120/mL, with 66% lymphocytes and 34% polymorphonuclear leukocytes. Complete blood cell count and chest film findings were normal. Viral meningitis was diagnosed; no treatment was prescribed.

Dr D. Brady Pregerson of Los Angeles writes that on the day of admission, the ED staff performed rapid sequence intubation and gave the child cefuroxime axetil, vancomycin, acyclovir, lorazepam, and phenytoin. A CT scan of the head showed 2 ring enhancing lesions in the right parietal lobe, with surrounding vasogenic edema and mass effect.

An emergent craniotomy and drainage of the intracranial abscesses were performed. Initial presurgical blood tests showed a WBC count of 11.3/mL, with 72% polymorphonuclear leukocytes, 16% lymphocytes, 6% band neutrophils, and 5% monocytes. The hemoglobin level was 9.3 g/dL; hematocrit, 27.7%; and platelet count, 226,000/µL. Gram stains of culture material from the abscess showed 31 gram-positive cocci and 21 polymorphonuclear WBCs. Initially, a number of organisms had been suspected, including staphylococci, streptococci, Mycobacterium tuberculosis, Citrobacter species, and the larval form of the tapeworm Taenia solium that causes neurocysticercosis. The cultures of the abscess grew out 31 microaerophilic streptococci.

During her 6-week hospital stay, the patient was given vancomycin, piperacillin, and tazobactam. She has recovered completely and currently appears to be functioning at her baseline.

Although brain abscesses are uncommon in developed countries, they need to be considered in patients who have fever or headache accompanied by persistent vomiting or focal neurologic signs. It is not standard care to obtain a CT scan before a lumbar puncture is performed in a child; however, a scan may be warranted in certain settings:

• Focal neurologic findings are present, or an adequate neurologic examination cannot be performed.
• The patient is an immigrant or is unvaccinated.
• Potentially worrisome symptoms attributed to a viral syndrome-such as headache, fever, and vomiting-persist longer than 5 to 7 days.