Second Place EMage Winner: Increasing Head Size

Department of Pediatrics: Okpara, Susan Chigorom, MD; Barricella Robert, MD; Alvarez‐Ballway, Maria Theresa, MD; Sin Quee, Diane, MD
Department of Neurosurgery: Bassani, Luigi, MD
Rutgers New Jersey Medical School

Case Presentation

3 month old female born via normal spontaneous vaginal delivery at term with 1 week NICU stay for indirect hyperbilirubinemia presents to the emergency department for increasing head size for 2 weeks. Prior to this patient has been active and playful with no change in behavior, except for a 2 day fever 1 week prior to presentation which resolved. Patient had prior nasal congestion which mother attributed to common cold. Mother denied recurrent or chronic sinusitis or infections. Patient initially presented to her pediatrician who started monitoring head circumference and subsequently referred to the Emergency department for further evaluation. Prenatal history was negative for fever, infection or sexually transmitted diseases.

In the emergency department patient had a pulse of 144 beats /min, blood pressure of 104/41 mmHg, temperature of 98.2F, respiratory rate of 16 breaths/min and oxygen saturation of 98% on room air. Examination was positive for a head circumference of 43 cm (97%) and bulging fontanel. Neck was supple and other examination was unremarkable.

2nd-place-image

Discussion

The differential diagnosis included septicemia, chronic meningitis, tuberculous meningitis, and cranial arteritis and immunodeficiency states.

CT Head in emergency room showed patchy areas of hypodensity in the frontal lobe with no clear boundaries.

MRI brain showed large infiltrative lesion predominantly involving the right frontoparietal and right anterior temporal lobes with solid and cystic components with associated areas of predominantly peripheral enhancement and extensive surrounding vasogenic edema.

Patient was taken to the operating room emergently with intra-operative findings of numerous loculated intracerebral abscesses.  Copious amount of purulent material was evacuated from multiple cystic lesions using intraoperative ultrasound navigation, and cultured. Broad spectrum antibiotics were given immediately. Post-operatively patient remained afebrile and feeding well. Abdominal ultra sound, transthoracic echocardiogram and infectious and immunodeficiency workup were initiated and no source for the intracerebral abscesses were found. Blood culture grew no organisms. Tissue culture was positive for Methicillin-Susceptible Staphylococcus Aureus and antibiotics were changed to Cefazolin. Patient was also started on seizure prophylaxis.

Pathology report showed brain abscess with fibrotic capsule and acute and chronic inflammation, with Gram positive cocci, also cerebritis.

There was no evidence of intraocular infection or papilledema bilaterally on dilated fundoscopic examination and no ENT source identified on exam or imaging.

 

Conclusion

Intracerebral abscesses are relatively uncommon and mortality is around 10%. Factors associated with increased mortality rate include age younger than 1 yr, multiple abscesses and coma. However morbidity such as hydrocephalus, seizures, hemiparesis, cranial nerve abnormalities, and behavior and learning problems occur in a third of survivors.

Sources of intracerebral abscesses include contiguous source (25-50%), hematogenous dissemination/trauma (20-35%), cryptogenic (10-35%). Routes of contiguous spread includes direct extension through osteitis/osteomyelitis, retrograde thrombophlebitis via diploic or emissary vein and via lymphatics.

Prompt diagnosis and proper treatment can avert complications and achieve cure in many cases.

The clinical features are non-specific and relate mainly to an expanding intracranial mass rather than an infectious process. Most intracerebral abscesses can be managed with a combination of surgical aspiration followed by appropriate antimicrobial therapy.

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