COTTON SWAB TODAY, BRAIN ABSCESS TOMORROW

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Brain abscess usually occurs as a result of predisposing factors such as HIV or other immunosuppressive state, systemic infection, or disruption in the protective barrier surrounding the brain, including trauma, operative procedures, mastoiditis, sinusitis or dental procedure. We report a very unique case of subdural empyema and abscess with associated mastoiditis and sinus thrombosis in the setting of a retained cotton swab. CASE PRESENTATION: Patient is a 47-year-old male with a past medical history of hypertension who presented with left arm weakness and numbness and left-sided facial droop. Computed Tomography (CT) of the brain showed an ill-defined hypodense 3.4 cm posterior right parietal lobe mass. Magnetic Resonance Imaging (MRI) was significant for an acute/subacute 2.8 x 3.1x 2 cm subdural empyema with extra-axial mass with smooth ring enhancement with associated thrombosis of the right transverse and sigmoid sinuses with right mastoiditis and medial erosion of air cells. A chronic left occipital abscess was also visualized on MRI with contrast. The patient was started on ceftriaxone, flagyl and vancomycin for empiric coverage and was managed in the ICU for septic shock. A decision was made not to anticoagulate due to the high risk of bleeding with an infectious etiology. HIV testing was negative. The patient was taken for right craniectomy with empyema evacuation and tympanomastoidectomy. During the surgical procedure, a posterior canal incision was made to the mastoid cortex and a cotton swab was found and retracted; it was attached to granulation tissue coming through the ear drum. Pathology confirmed cotton material representing a cotton swab. Gram stain showed gram positive cocci in pairs and surgical culture grew Anaerococcus species. DISCUSSION: The most common organism occurring in cases of contiguous spread of middle ear, mastoid, or sinus infection are streptococcus species, however, staphlococcal and polymicrobial abscesses caused by anaerobes, gram negative bacilli, and uncultured bacteria have been reported. Anaerococcus are gram positive strictly anaerobic bacteria that can occur in pairs, tetrads, or short chains. While many species are found as part of the normal flora of skin, oral cavity or gut, specimens isolated from abscesses have been reported. This is the first case to our knowledge of subdural empyema and abscess associated sinus thrombosis in the setting of retained cotton swab and isolation of Anaerococcus species. CONCLUSIONS: Warnings against the using cottons swabs in the ear canal exist due to the risk of foreign body, worsening cerumen impaction, and tympanic membrane rupture. Our case highlights the risk of cotton swab use in the ear. Physicians should be aware that resulting complications can include subdural empyema and abscess associated with transverse and sigmoid sinus thrombosis. REFERENCE #1: Brouwer MC, Tunkel AR, McKhann GM 2nd, van de Beek D. Brain abscess. N Engl J Med. 2014 Jul 31;371(5):447-56. doi: 10.1056/NEJMra1301635. PMID: 25075836. REFERENCE #2: Masalma MA, Lonjon M, Richet H, Dufour H, Roche P-H, Drancourt M, et al. Metagenomic Analysis of Brain Abscesses Identifies Specific Bacterial Associations. Clinical Infectious Diseases. 2011;54(2):202–10. REFERENCE #3: Murphy EC, Frick I-M. Gram-positive anaerobic cocci – commensals and opportunistic pathogens. FEMS Microbiology Reviews. 2013;37(4):520–53. DISCLOSURES: No relevant relationships by Benjamin Carmel, source=Web Response No relevant relationships by Mauricio Danckers, source=Web Response No relevant relationships by Davide Fox, source=Web Response No relevant relationships by Daniel Heller, source=Web Response No relevant relationships by Vijay Srinivasan, source=Web Response