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.
4. van Hilten JJ, Haan J, Wintzen AR, van de Nes JC,
Heuvelmans JH, Aarts PA, et al. Cerebral infarction in hereditary
spherocytosis. Stroke. 1989;20:1755-6.