Cerebral Abscess in a 16 year old boy

Editor,

We present an unusual case of Cerebral Abscess in a 16 year old boy

Clinical Presentation

A 16 year old boy was admitted with a one week history of an upper respiratory tract infection (URTI). On the day of admission he complained of severe frontal headache, 10/10 in severity, and had vomited three times. He complained of neck stiffness and photophobia. On questioning his parents, they found him mildly confused and had noticed his difficulty in retaining new information. He had no psychiatric or behavioural symptoms other then lethargy. Before admission he had a complex generalised seizure lasting less than a minute. He had no history of alcohol or drug abuse, no travel history and no rash. His General Practitioner had commenced ciprofloxacin 250 mg twice daily one day prior to his admission. On examination he had pyrexia of 39.5°C. There was no focal neurology; Glasgow coma scale was 15/15. His cranial nerves were intact, tone, power, and reflexes were normal with flexor planter responses. He had no objective signs of neck stiffness with a negative Kernig's sign. On fundoscopy there was no papilloedema. Other systemic examination was unremarkable with normal ECG and chest X-ray.

Differential diagnosis & management

A probable diagnosis of meningitis was made and differentials of encephalitis, space occupying legion or viral illness were considered. He was treated with cefotaxime & acyclovir. Computed Tomogram (CT) of brain showed an epidural abscess measuring 2.2 × 1.4 cm in left frontal region. He was immediately transferred to the regional neurosurgery department and underwent drainage of the abscess through a left frontal burr hole. The patient remained stable but after five days required further burr hole decompression. Streptococcus constellates and milleri were isolated from the pus. He was discharged on Ertapenam 1g intravenously daily.

Discussion

Once a fatal condition and a complication of URTI and sinusitis, cerebral abscess is rare in Western society. This is due to extensive use of broad spectrum antibiotic therapy. The incidence of cerebral abscess is about 4 cases/million/year and it is ten times less common then a brain tumour. Once recognised it is a neuro-surgical emergency. This case illustrates that although rare, the condition can complicate an apparent benign URTI in a young and fit patient with no previous morbidity. Symptoms can be non specific and neurological signs subtle.

CT and magnetic resonance imaging (MRI) are essential tools that enable the diagnosis of intracranial purulent collections. Delay in surgical drainage can be associated with high morbidity and case-fatality rates.¹ The infection can originate from contiguous sites of existing infections, such as chronic otitis media, dental infection, mastoiditis, or sinusitis, where anaerobic bacteria predominate.²

Close coordination of care between neurosurgeons and infectious diseases specialists is important in the management. The relative rarity of brain abscess and the frequent delays in making the diagnosis render this condition a significant challenge for the clinician.³

Conclusion

Cerebral Abscess should be considered in ill patients presenting with pyrexia and neurological symptoms.

The authors have no conflict of interest.