Streptococcus is the principle causative organism of brain abscess but widespread use of antibiotics, immunization and frequent neurosurgical intervention seems to have changed the epidemiology and clinical spectrum of this entity in recent years [1,2].

A 5½-month-old boy presented to neurosurgical emergency of our hospital with complaints of progressively increasing head size. He had severe anemia for which he was referred to pediatric emergency. There was no fever, seizures or focal neurological deficit. This child had jaundice within 24 hours of life, and received blood transfusion for severe anemia on day 8 of life. He later developed fever and abscess at the site of intravenous cannulation for which he received oral drugs from a local practitioner. At 4 months of age, child developed severe pallor and parents noticed an increased head size for which he was referred to our hospital.

Blood investigations of the child suggested hereditary spherocytosis. Computed tomography (CT) of head showed multiple brain abscesses. No primary or secondary immunodeficiencies were identified. Serum levels of immunoglobulins (IgA, IgG and IgM) were normal; mother’s HIV ELISA was negative.

Patient was started on empirical antibiotics (Ceftriaxone, vancomycin and metrogyl) and surgical drainage was performed. No organism was identifiable in pus culture and gram stain but CSF culture grew Klebsiella pneumoniae sensitive to Gentamicin, Ciprofloxacin, Cotrimoxazole, Amikacin, Ceftriaxone, Ceftazidime and Piperacillin–tazobactum. Drugs were changed according to the sensitivity pattern to Ciprofloxacin and Amikacin and continued for 6 weeks. Non-contrast CT after completion of treatment showed significant decrease in size of the abscess.

The spectra of clinical presentations of brain abscess range from insidious to fulminant. In a previous study, the classic triad of headache, fever, and focal neurologic deficit was present in fewer than half of patients with brain abscess [3]. Our patient presented as hydrocephalus without any other constitutional symptom or features of raised intracranial tension. Klebsiella is a rare cause of cerebral abscess in infants. In our patient, the cause of the abscess is likely to be hematological spread from skin abscess due to intravenous cannulation at day 8-9 of life.

Unlike other hemolytic anemias like sickle cell anemia and thalassemia, cerebrovascular events and their complications are rare with hereditary spherocytosis [4]. An increased propensity of thrombosis in these patients is due to increased aggregability and reduced deformability of red blood cells, and increased viscosity of blood. An area of infarct thus formed could later on become a site for abscess formation. Apart from that, brain abscess is a known complication in meningitis and septicemia, and association of hereditary spherocytosis could be coincidental.

1. Su TM, Lin YC, Lu CH, Chang WN, Liliang PP, Rau CS, et al. Streptococcal brain abscess: Analysis of clinical features in 20 patients. Surg Neurol. 2001;56:189-94.

2. De Louvois J, Gortavai P, Hurley R. Bacteriology of abscesses of the central nervous system: A multicentre prospective study. BMJ. 1977; 2:981-4.

3. Tunkel AR, Wispelwey B, Scheld WM. Brain abscess. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Gouglas, and Bennett’s Principle and Practice of Infectious diseases. 5th ed. Vol 1. Philadelphia: Churchill Livingstone; 2000. p. 1016-28.