Cerebral Empyema Research Articles

Streptococcus gordonii infective endocarditis complicated by brain abscess in a patient with a congenital bicuspid aortic valve: a case report

Abstract Background Infective endocarditis is associated with significant morbidity and mortality. Oral trauma through dental procedures can result in infective endocarditis through displacement of commensal organisms into the bloodstream. Streptococcus gordonii is an oral commensal and is rarely implicated as a cause of infective endocarditis but should be considered in febrile patients with a recent history of odontological procedures. Case summary We present a case of a previously healthy 26-year-old woman who presented with a 2-month history of fevers. Blood cultures on admission were positive for S. gordonii. Echocardiography demonstrated a congenital bicuspid aortic valve with vegetations and abscess, supporting a diagnosis of infective endocarditis. A magnetic resonance imaging (MRI) brain revealed a small cerebral empyema. She was treated with intravenous antibiotics and underwent an aortic valve replacement. Discussion Bicuspid aortic valve predisposes to infective endocarditis, and these patients have higher incidence of requiring cardiac surgery. Streptococcus gordonii belongs to the viridans group streptococci that are recognized as causative organisms for infective endocarditis particularly where dental sources are suspected. Patients with infective endocarditis may develop neurological sequelae including cerebrovascular accidents or central nervous system infections. If risk of haemorrhagic transformation is low, surgical intervention for valve replacement should not be delayed.

Treatment of Primary Cerebral Ventricular Abscess: Use of Dual Catheters and Ommaya Reservoir

An isolated ventricular abscess is a rare event, and its treatment is a real challenge. We report such case in a 52-year-old man that was successfully managed with aid of occipital approach and ventricular access device. This patient presented with the chief complaint of headache and fever of 3-day duration. Magnetic resonance imaging showed fluid-filled layering within the posterior horns of the lateral ventricle without contrast enhancement. Blood test and cerebrospinal fluid analysis was consistent with acute bacterial ventriculitis. Using stereotactic technique guided by electromagnetic navigation, the occipital horns were bilaterally targeted and catheterized, and then the abscess and debris was evacuated. The Ommaya reservoir implanted at the left entry was intermittently punctured for preventing the recollection. The pus culture was positive for Streptococcus pneumoniae. He received an antibiotic therapy and the reservoir aspiration leading to rapid recovery and remission of clinical manifestations. There was no evidence of the recurrence within the ventricles on follow-up scans after discharging. This modification, occipital approach and reservoir placement, is effective treatment for improving the cure rate in the selected cases with intraventricular cerebral empyema.

Streptobacillus moniliformis subdural empyema in a homeless patient

• The social precariousness in which homeless persons live is a medical challenge. • A homeless man was diagnosed with empyema due to Streptobacillus moniliformis . • MALDI-ToF spectrometry and gene sequencing helps identification. Streptobacillus moniliformis, which is transmitted through rodents, is an emerging zoonotic pathogen among homeless persons. Untreated, the disease can persist for weeks or months; mortality rate ranges from 7% to 13% and can be as high as 53% in endocarditis. We report here the case of a homeless patient with a history of chronic subdural hematoma, who suffered rat’s bites on his face. He presented to our hospital with a picture of cerebral empyema due to Streptobacillus moniliformis that occurred through contiguous spread from the superinfected skin lesions due to the rat bite. Given the technical growth difficulties, S. moniliformis was identified through MALDTI-ToF mass spectrometry. The patient was successfully treated with a 6-weeks course of intravenous then oral amoxicillin. Besides the fact that cerebral empyema is an uncommon complication of S. moniliformis infection, this case highlights the usefulness of 16S RNA PCR and mass spectrometry to identify rare bacterium, as well as the possibility of using amoxicillin instead of intra muscular penicillin in S. moniliformis infections. Contact with rats in homeless patients carries a risk of transmission of Streptobacillus moniliformis . Physicians should be aware of this specific exposure and of this zoonotic disease. The microbiology laboratory has to be informed of the suspected diagnosis, given the difficulty of growth of this pathogen.

Osteitis and cerebral empyema in sickle cell disease: About two cases

Subdural empyema or brain abscess are infectious lesions which can complicated meningitis or frontal sinusitis infection. Spontaneous cranial vault osteomyelitis or osteitis followed by cerebral empyema are rare intracranial complications which can occured in sickle cell disease and immune compromise due to intravenous drug abuse. Sickle cell disease is a hemoglobinopathy responsible for many complications that are sometimes severe. Importance or early diagnosis and proper treatment is the key for the managment for these complications. The authors reported two cases of subdural empyema which were surgically evacuated and treated with adapted antibiotics with good outcomes.

Necrotising otitis externa: A single centre experience

IntroductionNecrotising otitis externa (NOE) is a rare infection of the ear canal with frequent bone erosion. This study’s objective is to describe the different features of NOE as well as its management in an ear-nose-throat department. We also tried to identify the particularities of the fungal infection. Patients and methodsIt is an observational cohort that included all the patients hospitalised for the management of NOE. The study was carried out in the ear-nose-throat Department of Mahdia University Hospital in Tunisia between January 2006 and december 2019. ResultsA total of 40 patients were included. The mean age was 65 ± 12.9 years and the sex ratio was 0.9. Ninety percent of the patients included were diabetics. The most common signs found were oedema of the external canal (97.5%) and auricular discharge (92.5%). The main pathogen isolated was Pseudomonas aeruginosa (61.7%). Fungi were isolated in 9 cases (26.47%). Computed tomography was performed for 32 patients (80%). Bone erosion was seen in 26 cases (81.3%). The main complications were cerebral venous thrombosis, retropharyngeal abscess and cerebral empyema. Thirty one patients received only antibiotics, 2 received only antifungal treatment, and 7 received both antibiotics and antifungal treatment. All patients had a favorable outcome. Univariate analysis showed a higher median erythrocyte sedimentation rate was associated with fungal infections. No other differences were noted. ConclusionOur management protocol seems to be efficient since all patients had initial favorable outcome. A higher median erythrocyte sedimentation rate was associated with fungal infections.

Cerebral empyema and abscesses due to Cutibacterium acnes

IntroductionCutibacterium acnes is a commensal bacterium of the skin, frequently reported in prosthetic shoulder or spinal implant infections, but rarely in cranial and intracranial infections. MethodsWe retrospectively reviewed patients with intracranial samples positive to Cutibacterium acnes managed in the neurosurgical units of our hospital of Lyon, France, between 2008–2016. ResultsWe included 29 patients, of whom 23 had empyema (with or without abscess), 17 had cranial osteomyelitis, and six only had abscess. Prior neurosurgery was reported in 28 patients, and the remaining patient had four spontaneous abscesses. Twelve patients had polymicrobial infections, including methicillin-susceptible Staphylococcus in 11 cases. The clinical diagnosis was difficult because of indolent and delayed symptoms: a CT scan or MRI was required. Thirteen patients (52%) had material at the infection site. All patients with bone flap implant or bones from biological banks had a bone flap-associated infection. Drainage was surgically performed in 25 cases or by CT scan-guided aspiration in four cases. All patients received an adapted antibiotic therapy (from three weeks to six months). The outcome was favorable in 28 patients. Three patients relapsed during the antibiotic therapy, requiring further surgery. ConclusionCutibacterium acnes can be responsible for postoperative empyema and cerebral abscesses, with particular indolent forms, which make their diagnosis difficult. They are often polymicrobial and associated with bone flap osteomyelitis. Their outcome is favorable after drainage and adapted antibiotic therapy.

Cerebral Empyema Complicating a Dental Abscess

Cervico-facial cellulitis can cause serious complications including neuro-meningeal infections. Among these neuro-meningeal infections are intracranial empyemas, which are rarer than brain abscesses. We report the case of a young patient of 25 years, immunocompetent, having presented a cerebral empyema secondary to diffuse cervicofacial cellulitis of dental origin. The diagnosis was suspected in the presence of cervicofacial cellulitis, febrile meningeal syndrome and consciousness disorder, confirmation was reported by brain MRI. The evolution was favorable after the recourse to the surgical treatment.

Sinus dermique : une urgence neurochirurgicale

Spinal dysraphisms include various types of congenital malformations. About 10% are dermal sinuses, i.e., a connection between the skin elements and intradural space through an open tract. The major complication of this malformation is a central nervous system infection that occurs most frequently before the age of 5 years. We report the case of a lumbosacral skin defect initially described as a coccygeal pit, which happened to be a dermal sinus with a tethered cord after ultrasound imaging in a newborn infant. No indication for surgery was recognized. Later, the infant experienced cerebral empyema and spinal cord edema when he was 5 months old, while a second infection, with a medullar abscess, occurred 7 months later. Both infections began with high fever and were complicated by neurologic deficits. An emergency surgery was performed during the second myelitis. The operative findings confirmed a dermal sinus and a tethered cord. Moreover, they found a dermoid cyst next to the tract. After 2 years of recovery, the child has neurologic deficits including lower limb paraplegia with neurological bladder and bowel. This observation recalls the importance of the differential diagnosis between a coccygeal pit and a dermal sinus, the latter being associated with a dermoid cyst in 50% of cases. Serious neurologic consequences due to the possible infectious complications can occur when a dermal sinus is neglected. A preventive operative excision of both the dermal sinus and a possible cyst is a surgical emergency for spinal dysraphism.

Les empyèmes intracrâniens : aspects épidémiologiques, cliniques, paracliniques et thérapeutiques. Étude rétrospective de 100 observations

IntroductionIntracranial empyema is a frequent complication of ear-nose-throat (ENT)infections. Limited studies have been carried-out on cerebral empyema during recent years in Senegal. Despite new imaging techniques, diagnostic and therapeutic problems as well as outcome still remain in our regions. We report our experience compared to that of the literature. The study focused on epidemiological aspects, difficulties in diagnosis and treatment as well as prognosis of this condition. MethodsThis was a retrospective study conducted from January 2008 to December 2011 of 100 clinical cases. Diagnosis was made based on contrast CT-scan. Twenty-one percent of patients received medical treatment alone, while 79% underwent surgery. The duration of the treatment varied from 4 to 8 weeks. The follow-up was clinical and radiological with a mean follow-up time of 12 months. ResultsCerebral empyema represented 44.4 % of all intracranial suppuration cases and the mean age was 21 years. The etiology was ENT in 35%, meningitis 10%, unknown 25%. Localization was sub-dural in 57%, extra-dural in 22%, inter-hemispheric in 10% of the cases. Empyema was associated with an abscess in 7 cases. One case was located in the posterior fossa. The evolution was favorable in 78% of the cases and in 12.5% some neurologic sequelae were observed. Eleven patients died and 3% of the patients had recurrences. ConclusionThe frequency of intracranial empyema is still high in Senegal. Difficulties in diagnosis, therapeutics and low economic incomes account for the gravity of intracranial empyema. In spite of these risks, early stage and effective treatment is necessary to reduce the morbi-mortality, especially in young aged children.

A misleading case of encephalitis in cirrhotic diabetic patient: The importance of early diagnosis

We present the case of a 67 year-old cirrothic man, referred to our hospital for disorientation, hyporexia, nausea, vomiting and hyperglycemia. At admission he was pyretic and disoriented, no neurological signs were present and laboratory examination showed mild hyperammonemia with normal inflammatory markers. Chest X-ray demonstrated a probable pneumonia and urinary infection was found, therefore systemic antibiotic therapy was initiated. After one week of antibiotic therapy, despite hyperammonemia resolution, the patient remained pyretic with progressive worsening of his mental state. Head CT scan was performed, demonstrating a large hypodense area in temporal lobe confirmed by brain MRI. Lumbar puncture was immediately performed and CSF PCR revealed HSV1-DNA positivity. Antiviral therapy with acyclovir at dosage of 10 mg/kg daily was initiated and continued for three weeks with complete defervescence, partial improvement of the state of consciousness and negativity of HSV1-DNA on CSF control. Two months later the patient was hospitalized again for urinary sepsis and developed a fatal frontal-parietal-temporal cerebral empyema. In cirrothic encephalopatic patient with persistent hyperpyrexia and normal or slight incremented inflammatory markers, herpetic encephalitis must be suspected even without neurological signs. Diagnosis retardation could be associated with elevated morbidity and mortality.

Group Milleri Streptococci in Paediatric Infections

Group Milleri Streptococci (GMS), a subgroup of viridans streptococci, are commensals of the human respiratory, gastrointestinal and urogenital tracts. GMS tend to cause purulent infections often resulting in abscess formation. Little is known about the significance of these organisms in children. For this retrospective study, a collection of 636 GMS positive isolates from 475 patients was used to identify 39 (8.2 %) paediatric patients (age < 18 years) with GMS infections (46 isolates) during a four-year period. There were 19 intra-abdominal, eleven dental/oropharyngeal, seven soft tissue and two central nervous system infections. Thirty-five patients (95 %) underwent primary surgical interventions. Furthermore, two patients - one with GMS meningitis that progressed to cerebral empyema and another with a liver abscess - initially treated with antibiotic agents alone eventually required surgical intervention to cure the infection. Only two children were treated with antibiotics alone. Polymicrobial infection was found in 22 (48 %) isolates; polymicrobial infection was most common in patients with intra-abdominal infection with 74 % and lowest in dental/oropharyngeal patients with 9 % (p = 0.001); Escherichia coli (n = 9) and Bacteroides fragilis (n = 9) were the most common secondary pathogens. Complications due to GMS infections were found in five cases (13 %). No patient died from GMS infection. Preferred antibiotics were penicillins (56 %) and cephalosporins (37 %). GMS tested susceptible to penicillin, cephalosporins, carbapenems in 100 % and clindamycin in 93 %. GMS infections in paediatric patients usually require both antibiotic therapy and surgical drainage. These infections may become life-threatening if not diagnosed in a timely fashion and treated aggressively.