Childhood brain abscess in Saudi Arabia

Clinical characteristics and outcomes of children with non-sinogenic Brain infections

BACKGROUND

Central Nervous System (CNS) suppurative infections are serious but rare conditions in the paediatric population. Data on long-term neurocognitive and quality of life outcomes in children recovering from these infections are lacking.

METHODS

A retrospective cohort review of children <16 years with non-sinogenic infections undergoing neurosurgery was conducted. Data for patients admitted to Children's Health Ireland at Temple St between 2008-2021 were analysed for clinical and microbiological profiles. Follow-up reviews evaluating neurological and academic sequelae and quality of life were performed. Categorical variables were analysed for unfavourable outcome with a p < 0.05 significance value.

RESULTS

Forty patients were included with a mean age of 4.5 years and equal gender distribution. Fever (68%) and vomiting (58%) were the most common presenting complaints. Only fourteen (35%) patients presented with the classic triad of fever, headache, and focal neurological deficit. Meningitis/Encephalitis was the most common cause of suppurative infection (40%). Predisposing factors included congenital heart disease (18%), prematurity (15%) and immunocompromised status (10%). More patients received an initial Burr hole aspiration (73%) than Craniotomy (27%). The re-operation rate was higher in the craniotomy group (45%) compared to the burr hole group (34%), but this was not statistically significant (p = 0.522). Four patients died (10%) including two intra-hospital deaths (5%). Male gender (p = 0.047) and multiple abscesses (p = 0.041) were associated with unfavourable outcome at discharge. Mobility impairment was the most affected determinant of quality of life.

CONCLUSION

CNS suppurative infections are associated with long-term neurocognitive sequelae in children. Multiple abscesses and male gender are associated with unfavourable GOS on discharge. Children are still left with mobility impairment (25%), personality changes (23%) and intellectual disability (18%) at an average of 5 years. Long-term follow up with multidisciplinary input is required. Further research should focus on evaluating long-term HRQoL in children.

Early switch to oral antimicrobials in brain abscess: a narrative review

BACKGROUND

Early switch to oral antimicrobials has been suggested as a treatment strategy in patients with brain abscess, but the practice is controversial.

OBJECTIVES

This review aimed to summarize the background, current evidence, and future perspectives for early transition to oral antimicrobials in patients with brain abscess.

SOURCES

The review was based upon a previous systematic review carried out during the development of the ESCMID guidelines on diagnosis and treatment of brain abscess. The search used 'brain abscess' or 'cerebral abscess' as text or MESH terms in PubMed, EMBASE, and the Cochrane Library. Studies included in the review were required to be published in the English language within the last 25 years and to have a study population of ≥10 patients. Other studies known by the authors were also included.

CONTENT

In this review, the background for some experts to suggest early transition to oral antimicrobials in patients with mild and uncomplicated brain abscess was clarified. Next, results from observational studies were summarized and limitations discussed. Indirect support for early oral treatment of brain abscess was described with reference to other serious central nervous system infections and general pharmacological considerations. Finally, variations within and between countries in the use of early transition to oral antimicrobials in patients with brain abscess were highlighted.

IMPLICATIONS

Early transition to oral antimicrobials in patients with uncomplicated brain abscess may be of benefit for patients due to convenience of treatment and potential decreased risks associated with prolonged hospitalization and intravenous lines. The strategy may also confer a more rational allocation of healthcare resources and decrease expenses. However, the benefit/risk ratio for this strategy remains unresolved at present.

[Brain abscess revealing trilogy of Fallot in a child: about a case at the University Teaching Hospital of Parakou, Benin]

Les abcès cérébraux sont pourvoyeurs d'une importante morbidité chez les patients atteints de cardiopathie cyanogène. Dans les pays à ressources limitées leur prise en charge est difficile et leur pronostic réservé. Nous rapportons ici un cas d'abcès cérébraux révélant une forme rare de cardiopathie cyanogène, la trilogie de Fallot à Parakou au Nord du Bénin. Il s'est agi d'un garçon de 9 ans, référé d'un hôpital primaire pour une hémiparésie gauche. L'interrogatoire et l'examen physique avaient permis de retrouver une symptomatologie évoluant depuis deux mois faite de céphalées intenses, de fièvre, de vomissements et d'une impotence fonctionnelle de l'hémicorps gauche. Un état général altéré, une cyanose généralisée; une hémiparésie gauche, un souffle systolique au foyer pulmonaire. Le scanner cérébral avait montré des abcès en région pariétale droite et temporale gauche et une hydrocéphalie. L'écho-doppler cardiaque avait montré une sténose pulmonaire serrée, une communication interauriculaire et une hypertrophie ventriculaire droite. Une antibiothérapie faite de ceftriaxone de gentamycine et métronidazole avait été démarrée en urgence et l'indication chirurgicale d'une trépano-ponction posée mais n'a pu être réalisée car l'évolution avait été rapidement défavorable. Les abcès cérébraux constituent une complication classique des cardiopathies cyanogènes. L'issue est fatale en l'absence de prise en charge adéquate d'où l'intérêt d'un diagnostic et d'une prise en charge précoces de ces cardiopathies.

Brain abscess

Brain abscess is a serious and life-threatening disease among children despite advances in diagnosis and management. Changes in the epidemiology of predisposing conditions for brain abscess are associated with changes in the patient population and causative organisms. Though still a potentially fatal infection, there have been recent improvements in diagnosis, treatment, and outcome. Although mortality appears to be decreasing, a significant percentage of children continue to have residual neurological deficits, including epilepsy, permanent motor or sensory dysfunction, visual field defects, and personality change. Some children also require placement of a ventriculoperitoneal shunt. The most common origin of microbial infection in children remains direct or indirect cranial infection arising from the middle ear, paranasal sinuses, or teeth. No prospective clinical trials have compared the various surgical and medical treatment strategies available to guide the management of cerebral abscesses in children. Most surgical and medical treatment guidelines are based on populations consisting primarily of adult patients. The use of corticosteroids for treatment of brain abscess is controversial. Anticonvulsants are recommended in children who have developed seizures potentially to prevent further episodes. Duration of anticonvulsant therapy should be individualized and guided by electroencephalographic (EEG) study in the follow-up phase of disease.

Intracerebral abscess in children: historical trends at Children's Hospital Boston

OBJECTIVES

A previous study performed at Children's Hospital Boston describing the natural history of intracerebral abscess between 1945 and 1980 demonstrated a decline in mortality after 1970. This current study examines the occurrence of intracerebral abscess at Children's Hospital Boston between 1981 and 2000, inclusive, and compares the results with the previous study. Our objectives were to determine whether there had been a change in the predisposing factors, whether there were changes in the microbiology of intracerebral abscesses, and whether mortality rate had continued to decline.

METHODS

To ensure that all occurrences of intracerebral abscess treated at Children's Hospital Boston between 1981 and 2000 were identified, we searched 4 separately maintained databases for the keywords "brain" or "abscess" or the International Classification of Diseases, Ninth Revision code 324.x. This search yielded the names of 386 patients. Of these 386 patients, a solitary intracerebral abscess or multiple noncontiguous intracerebral abscesses could be confirmed in 54 patients on the basis of cranial imaging (computed tomography or magnetic resonance imaging) or autopsy reports. The complete retrospective review of the medical records of these 54 patients constitutes the basis for this study.

RESULTS

Congenital heart disease was the most common predisposing factor during both eras. Compared with the previous era, important historical trends identified include a reduction in the number of abscesses that occurred in the settings of sinus or otitic infection (11% during 1981-2000 vs 26% during 1945-1980), an increase in number of intracranial abscesses in infants (18% vs 7%) and in the setting of immunosuppression (16% vs 1%), an increase in the number of children who were treated with antibiotics alone (22% vs 1%), a stable overall mortality rate (24% vs 27%), and the identification of Citrobacter and fungus as causes of intracranial abscess not observed during the previous era of 1945-1980. Citrobacter was observed only during the neonatal period. Fungi were the causative organisms predominantly in the setting of immunosuppression.

CONCLUSIONS

Intracerebral abscess in children continues to be associated with high rates of neurologic impairment and death. Because earlier detection may reduce morbidity and mortality, intracranial abscess should be considered when evaluating children with new-onset neurologic signs or symptoms, especially in children who have acute immunosuppression and disseminated fungal disease or fungemia.