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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 5  |  Issue : 3  |  Page : 213-217

Neonatal brain abscess: Clinical report and review of Indian cases


Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Date of Web Publication28-Sep-2016

Correspondence Address:
Dr. Ankur Singh
Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221 005, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4847.191272

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  Abstract 

Septicemia, pneumonia, meningitis are common problems in neonatal age group in developing countries. Epidemiology of meningitis differs in developed and developing countries with Group B streptococci, being more common in developed countries and Klebsiella pneumoniae in developing countries. In some of the cases, meningitis can lead to complications such as abscess, ventriculitis, and communication with ventricles. Proteus is the most common organism reported for brain abscess in neonatal age group in western literature. We found more cases of K. pneumoniae from the Indian subcontinent. Hence, we collected data from all published cases of Indian origin to highlight the etiology, any risk factor, most common site, complication, and outcome. We concluded that: K. pneumoniae is the most common organisms for neonatal brain abscess with fatal outcome in cases with ventricular perforation. Frontal lobe was the most common site of abscess. Minimum 6 weeks of antibiotic therapy was mentioned in 7 of 15 cases. Survival and discharge were reported in 13 of 15 cases, suggesting good immediate outcome in such cases.

Keywords: Indian, Klebsiella, neonatal brain abscess, review, ventricular perforation


How to cite this article:
Singh A, Abhinay A, Prasad R, Mishra OP. Neonatal brain abscess: Clinical report and review of Indian cases. J Clin Neonatol 2016;5:213-7

How to cite this URL:
Singh A, Abhinay A, Prasad R, Mishra OP. Neonatal brain abscess: Clinical report and review of Indian cases. J Clin Neonatol [serial online] 2016 [cited 2019 Dec 6];5:213-7. Available from: http://www.jcnonweb.com/text.asp?2016/5/3/213/191272


  Introduction Top


Brain abscess is a focal, intracerebral infection that begins as a localized area of cerebritis and develops into a collection of pus surrounded by a well-vascularized capsule. It is rare in newborns and infants under 6 months of age but usually associated with high mortality and morbidity rates.[1] Brain abscess is a rare complication of neonatal meningitis that occurs in 1%-4% of all cases.[2],[3] Early diagnosis using radiological modalities such as ultrasonography (USG), computed tomography (CT), magnetic resonance imaging (MRI), and microbiological techniques together with more effective antibiotics have improved treatment.[4] There is a lack of Indian data in neonatal period to comment on the common organism, site of abscess, complications, and outcome. Hence, we undertook this study and reviewed all neonatal abscess cases of Indian origin to answer the questions. We collected data from 14 more cases and highlighted most common organism, site, complication, and outcome in neonatal brain abscess.


  Case Report Top


A 15-day-old male neonate presented to us with a complaint of fever for 9 days and multiple episode multifocal seizure for 6 days. He was born full term by caesarean section with a birth weight of 2.8 kg and cried immediately after birth. There was no history of maternal fever, rashes, per vaginal discharge, or bleeding during antenatal period.

At presentation: Examination revealed active neonate with vitals, temperature febrile (102.2°F), capillary refill time <3 s, heart rate 136/min, respiratory rate 38/min, and SPO2 is 98% at room air. Anterior fontanels were open and at the level, Moro's reflex was present. There was no pallor, icterus, cyanosis, clubbing, pedal edema. Rest of systemic examination was normal. Blood showed total count was raised (27,000) with 64% of polymorphs 36% lymphocytes. C-reactive protein was positive (54 mg/L). Renal function, chest radiograph, and electroencephalograph were within normal limit. HIV of mother and father was negative. Blood and cerebrospinal fluid (CSF) culture were sterile. CSF routine microscopy showed total count of 192 with 80% polymorphs and 20% lymphocytes, protein 255 g/dl, sugar 3.9 mg/dl (random blood sugar: 72 mg/dl), chloride 680. Cranium sonography shows large frontoparietal cerebral abscess of volume 60 ml approximately with interventricular communication with left frontal horn with ventriculitis of the right side lateral ventricle, mild ventriculomegaly present and midline shift toward right side by abscess. MRI showed large cystic lesion (5.4 × 4.5 × 4.4 cm) in the left frontal lobe communicating with left frontal horn with mild perilesional edema and mass effect leading to the effacement of adjacent cortical sulci and mild midline shift to right, suggestive of brain abscess, associated ventriculitis with mild communicating hydrocephalus [Figure 1]a-c.
Figure 1: (a) Magnetic resonance imaging showed large cystic lesion in left frontal lobe. (b) Communicating with left frontal horn with mild perilesional oedema and mass effect. (c) Abscess, associated ventriculitis with mild communicating hydrocephalus

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Initially empirical intravenous (IV) antibiotics (ceftriaxone + vancomycin + metronidazole) were started. 100 ml pus was aspirated by surgeons. Pus culture sensitivity report showed growth of Proteus mirabilis which was sensitive to ofloxacin, Imipenem, and meropenem. Antibiotics were changed on day 3 of admission according to pus culture sensitivity report, and neonate received 6 weeks of change antibiotics. At discharge neonate was active, vitals stable, afebrile, accepting feed well and no collection of pus on repeat sonography.


  Discussion Top


There have been few case reports of brain abscess, citing its rarity, organism, duration of treatment from the Indian subcontinent. No large case series have been reported in the neonatal age group to comment on etiology, site of abscess, antibiotic therapy, and outcome. Although Proteus and Citrobacter are common pathogens for brain abscess in western literature, there are no such reports from Indian continent.[5] Hence, we searched the literature to include all cases of neonatal brain abscess, reported from the Indian subcontinent. [Table 1] depicts the age, clinical features, etiology, neuroimaging, treatment (antibiotics and surgical) and outcome profile of all cases (14 reported and 1 present study).
Table 1: Clinical, microbiological, radiological, treatment, and outcome profile of neonatal brain abscess


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Most common clinical presentations in all cases were: Fever, focal seizures, not feeding well. We found Klebsiella pneumoniae in 8 of 15 cases. Rest seven cases were: Candida tropicalis, Citrobactor Koseri, Cladosporium bantianum,  Neisseria More Details menigitidis Group A, Staphylococcus aureus and Proteus mirabilis (2 cases).[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17] K. pneumoniae is one of the common organisms, causing neonatal sepsis in Indian set up.[18] Untreated meningitis can lead to a complication like brain abscess. Meningitis was associated with 5 of 8 cases in Klebsiella neonatal brain abscess. This is unlike report by Renier et al. where Proteus was found to be the commonest organism. Fungal brain abscess was found in 2 of 15 cases. Our is the second case of neonatal brain abscess having Proteus as etiology from the Indian subcontinent. The likely cause for this could be population differences in colonization, genetic differences in immune response, and possibly geographic differences in laboratory techniques for pathogen isolation and reporting.[19],[20]

Cranial CT and USG were the most important imaging modality depending on availability at centers. Frontal region was the most common site for brain abscess, found in 9/15 (60%) of cases with bilateral abscess present four of nine cases. This finding was reported by Renier et al. in the year 1988.[5] These cases were further complicated by the presence of communication with ventricles and associated ventriculitis.[6],[7],[12],[15] Our case, too, had features of abscess, ventriculitis, and communication with ventricles. The communication of abscess with ventricles was present in five cases including ours. The intraventricular communication of abscess is associated with fatal outcome in the form of death or left against medical advice. Our case survived with medical and surgical management. The severity of cases could be explained by following possible factors: delay in presentation, poor immunity, and pathogenic virulence. Immune dysfunction could lead to complications in cases of meningitis.[21] However, there was no work up for immune dysfunction except one case.[8] Reasons for this could be a lack of suspicion, affordability, lack adequate laboratory facilities. We could not test the child for immune defect due to nonaffordability of the test by parents. All cases were managed with IV antibiotics, aspiration, and surgical drainage. Minimum 6 weeks duration was mentioned in 7 of 15 cases, suggesting long duration of antibiotics are required for treating such cases. An indication of surgical drainage in most of the cases was: No improvement despite antibiotic course, enlarging head circumference, large abscess with midline shift, multiple abscess. Most common surgical therapy was aspiration alone or aspiration followed by VP shunt.

Maternal risk factors are known to be associated with meningitis in the neonate.[6] We found risk factors like urinary tract infection and premature rupture of membrane, present in 6 of 15 cases. No maternal risk factor was indentified in eight cases including ours. There was one case where underlying osteomyelitis of skull bone was identified as causative factor.[17] Immediate short term outcome was fairly good with survival in 12 out of 14 cases with conservative and surgical treatment. No case report mentions the long-term outcome in such patients. We need to develop national and international collaborative network to collect data on such cases.

In summary, we have collected data from 15 neonatal brain abscess (including ours), reported from India. This data suggest K. pneumoniae is the most common organisms for neonatal brain abscess. It was a direct complication of neonatal meningitis in 10 of 15 cases. Frontal lobe was the commonest site of abscess. Communication with ventricles was seen in five cases and is associated with poor outcome. Six weeks course of antibiotic therapy was given in 50% of cases. Survival and discharge were reported in most (13/15) of cases, suggesting good short-term outcome in such cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Banerjee TK, Patwari AK, Dutta R, Anand VK, Chabra A. Cladosporium bantianum meningitis in a neonate. Indian J Pediatr 2002;69:721-3.  Back to cited text no. 14
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