Pyogenic brain abscess

Treatment of cerebral ventriculitis with a new self-irrigating catheter system: narrative review and case series

Cerebral ventriculitis is a life-threatening condition that requires prompt and effective pharmacological intervention. The continuous irrigation of the cerebral ventricles with fluid and its drainage is a system to remove toxic substances and infectious residues in the ventricles; this system is called IRRAflow®. We used this kind of ventricular irrigation/drainage system to treat two patients with post-surgical cerebral ventriculitis and a patient with bacterial meningitis complicated with ventriculitis. In this case series, we discuss the management of these three cases of cerebral ventriculitis: we monitored cytochemical parameters and cultures of the cerebrospinal fluid of patients during their ICU stay and we observed a marked improvement after irrigation and drainage with IRRAflow® system. Irrigation/drainage catheter stay, mode settings, and antibiotic therapies were different among these three patients, and neurological outcomes were variable, according to their underlying pathologies. IRRAflow® system can be applied also in other types of brain injury, such as intraventricular hemorrhage, intracranial abscess, subdural hematomas, and intracerebral hemorrhage, with the aim to remove the hematic residues and enhance the functional recovery of the patients. IRRAflow® seems a promising and useful tool to treat infectious and hemorrhagic diseases in neuro-intensive care unit.

Robot-Guided Stereotactic Puncture and Drainage in the Treatment of Thalamic Abscess

Brain abscess is rare in clinic, the reported incidence is only 0.4 to 0.90 per 100,000 population, and most of them have a history of prodromal infection. Headache and fever are the most common clinical symptoms, and only a few are accompanied by neurological disorders. For the treatment of brain abscess, the most commonly used treatment is stereotactic puncture drainage and antibacterial therapy. A patient with a left thalamic abscess with no history of prodromal infection was reported. Stereotactic puncture and drainage were performed under the guidance of the Ruimi robot. The bacterial culture of the abscess was Streptococcus constellation (Streptococcus constellatus). The patient was discharged after 4 weeks of antibacterial treatment with vancomycin. The patients were followed up half a year after the operation, the prognosis was good and there was no recurrence.

Plasma Microbial Cell-Free DNA (CF-DNA) Next-Generation Sequencing in Diagnosing Intracranial Abscesses: Pathophysiology and a Scoping Review of the Literature

Plasma microbial cell-free DNA (cf-DNA) from next-generation sequencing (NGS) provides improved sensitivity and specificity compared to standard microbial blood cultures. cf-DNA sequencing also has an improved turnaround time (TAT) and allows quicker commencement of antibiotics in life-threatening infections such as a brain abscess. Brain abscesses carry significant morbidity and mortality. Empiric treatment and management are critical in improving functional neurological outcomes. Reported here is the case of a severe central nervous system (CNS) infection with multiple ring-enhancing lesions seen throughout the cerebrum on magnetic resonance imaging (MRI). Standard microbial blood cultures were inconclusive and definitive identification of the pathogen was achieved through microbial cf-DNA NGS. 

Brain abscesses develop in four distinct phases: early cerebritis, late cerebritis, early capsule formation, and late capsule formation. The pathogenesis of cerebral abscess involves direct parenchymal inflammation of the pathogen, the recruitment of inflammatory CNS cell types (microglia, inflammatory astrocytes, etc), and the chemotaxis of immune cells. cf-DNA is released into the bloodstream in response to pathogen opsonization and immune-mediated cell death. A scoping literature review includes cases of intracranial abscesses diagnosed via cf-DNA NGS.

Continuous Antibiotic Administration Using IRRAflow® Catheter for Treatment of Intracranial Abscess

Intracranial abscesses are rare lesions with an incidence of approximately 4 per 1 million people. The optimal surgical management of these lesions is still unclear. We present the case of a patient who was discovered to have an intracranial abscess after presenting with right-sided weakness. He was treated via a combination of open craniotomy and continuous antibiotic irrigation using an IRRAflow® catheter (IRRAS, Stockholm, Sweden). Use of the IRRAflow® in this fashion has not yet been described in the literature. This novel approach appears to be safe and resulted in continued decrease in the abscess burden following surgical drainage.

Ciprofloxacin and dexamethasone in combination attenuate S. aureus induced brain abscess via neuroendocrine-immune interaction of TLR-2 and glucocorticoid receptor leading to behavioral improvement

Staphylococcus aureus induced brain abscess is a critical health concern throughout the developing world. The conventional surgical intervention could not regulate the abscess-induced brain inflammation. Thus further study over the alternative therapeutic strategy for treating a brain abscess is of high priority. The resident glial cells recognize the invading S. aureus by their cell surface Toll-like receptor-2 (TLR-2). Glucocorticoid receptor (GR) was known for its immunosuppressive effects. In this study, an attempt had been taken to utilize the functional relationship or cross-talking between TLR-2 and GR during the pathogenesis of brain abscesses. Here, the combination of an antibiotic (i.e. ciprofloxacin) and dexamethasone was used to regulate the brain inflammation either in TLR-2 or GR blocking condition. We were also interested to figure out the possible impact of alternative therapy on behavioral impairments. The results indicated that combination treatment during TLR-2 blockade significantly reduced the bacterial burden and abscess area score in the infected brain. However, marked improvements were observed in anxiety, depression-like behavior, and motor co-ordination. The combination treatment after TLR-2 blocking effectively scavenged free radicals (H₂O₂, superoxide anion, and NO) through modulating antioxidant enzyme activities that ultimately control S. aureus induced glial reactivity possibly via up-regulating GR expression. The exogenous dexamethasone might regulate the GR expression in the brain by increasing the corticosterone concentration and the GC-GR mediated signaling. Therefore, this in-vivo study demonstrates the possible regulatory mechanism of bacterial brain abscess that involved TLR-2 and GR as a part of neuroendocrine-immune interaction.

Multiple Brain Abscesses of Odontogenic Origin. May Oral Microbiota Affect Their Development? A Review of the Current Literature

In the last few years, the role of oral microbiota in the setting of oral diseases such as caries, periodontal disease, oral cancer and systemic infections, including rheumatoid arthritis, cardiovascular disease and brain abscess (BA), has attracted the attention of physicians and researchers. Approximately 5–7% of all BAs have an odontogenic origin, representing an important pathological systemic condition with a high morbidity and mortality. A systematic search of two databases (Pubmed and Ovid EMBASE) was performed for studies published up to 5 January 2021, reporting multiple BAs attributed to an odontogenic origin. According to PRISMA guidelines, we included a total of 16 papers reporting multiple BAs due to odontogenic infections. The aim of this review is to investigate the treatment modality and the clinical outcome of patients with multiple BAs due to odontogenic infections, as well as to identify the most common pathogens involved in this pathological status and their role, in the oral microbiota, in the onset of oral infections. A multidisciplinary approach is essential in the management of multiple BAs. Further studies are required to understand better the role of microbiota in the development of multiple BAs.

Trueperella pyogenes Induced Cerebral Abscess in a West Highland White Terrier

Cerebral abscesses are occasionally seen in animals, however are rare in dogs. Among the pyogenic bacteria causing cerebral abscesses Trueperella pyogenes is relatively scarce. In this report, a case of T. pyogenes induced cerebral abscess in a West Highland White Terrier was presented with histopathological and bacteriological findings. Two foci of cerebral abscesses located at the level of the thalamus, and the frontal and temporal lobes were described on necropsy. Severe suppurative meningoencephalitis and ventriculitis were noted on microscopic view. T. pyogenes was isolated and identified in bacteriological investigation. This report states that T. pyogenes can be a causative agent of cerebral abscesses in dogs.

Rare Case of Pyogenic Brain Abscess after Transarterial Chemoembolization in a Patient with Hepatocellular Carcinoma: Case Report and Literature Review

Transarterial chemoembolization (TACE) is a useful treatment option for hepatocellular carcinoma (HCC). TACE can particularly be used as a treatment for localized HCC, where surgical resection is impossible due to decreased liver function. However, TACE is associated with several complications, including vascular complications, liver failure, non-target embolization, infection, and death. The main risk factor for complications after TACE is decreased liver function. There have been only few reports of brain abscesses after TACE that are difficult to be distinguished from hepatic encephalopathy. Here, we report a rare case of brain abscess caused by Klebsiella pneumoniae that occurred after TACE.

Intracranial infections: lessons learned from 52 surgically treated cases

OBJECTIVE

Intracranial infections are serious and life-threatening health problems. They may present as subdural empyemas or intracerebral abscesses. Surgical drainage and subsequent antibiotic treatment is the main technique for a satisfactory clinical outcome. The aims of this study were to present a 10-year intracranial infection series and discuss the surgical characteristics in the light of literature.

METHODS

Fifty-two patients with intracranial infection underwent surgical treatment between 2008 and 2018. Eleven patients were female and 41 patients were male. The mean age was 40.46 years (range 10-75 years). Eighteen patients had intracerebral abscesses, and 34 had subdural empyemas. All patients underwent surgical treatment as well as an antibiotic regimen.

RESULTS

No etiological agent was isolated in 29 (56%) cases. Bacterial agents were detected in 20 cases, while fungi were observed in 3 cases. Staphylococci species were the most common agents and were isolated in 8 (15%) cases. Endoscopic aspiration was performed in 3 cases, while surgical drainage and capsule resection via craniotomy was performed in 49 cases. An associated intracranial tumor was diagnosed in 2 patients with brain abscesses. Four (8%) patients died despite surgical and medical treatments.

CONCLUSIONS

Surgical treatment via craniotomy is an older method, but it is still the best to treat the intracranial infections not only for decompression of the brain but also to attain an accurate diagnosis. The abscess wall should always be histologically examined after surgery to rule out any intracranial tumor.

What you need to know about brain abscesses

A brain abscess is a focal accumulation of pus in the brain parenchyma arising from direct inoculation, contiguous spread from local anatomical structures or haematogenous seeding from a remote source of infection. It can result in significant morbidity and mortality, making early diagnosis and treatment vital. Only one fifth of patients present with the classic triad of headache, fever and focal neurological symptoms. More commonly patients show signs and symptoms of raised intracranial pressure alone, such as confusion or reduced conscious level, headache, nausea and vomiting, which can be a presentation of many intracranial pathologies. Distinguishing an abscess from other pathologies such as meningitis and tumours is crucial, as clinically these can present in similar ways, but their management and outcomes are very different. Diffusion-weighted magnetic resonance imaging brain scans can help localise the lesion and differentiate ring-enhancing lesions caused by a brain abscess from malignant tumours. Cerebral abscesses are considered a neurosurgical emergency; early stabilisation, diagnosis and management in a neurosurgical centre is important in reducing morbidity and mortality.

Successful management of intraventricular rupture of pyogenic brain abscess (IVROBA): Systematic review and illustrative case

OBJECTIVES

Intraventricular rupture of brain abscess (IVROBA) is one of the most dreaded complications of pyogenic brain abscess due to its high mortality rate. Because of its relative infrequency and poor outcome, the optimal management of this condition remains to be determined.

PATIENTS AND METHODS

We report the case of a 5-year old female with a presumptive diagnosis of IVROBA who was discharged with good neurologic outcome after completing intravenous antibiotic treatment and undergoing insertion of an external ventricular drain (EVD) and later, a ventriculoperitoneal (VP) shunt. We also performed a systematic review of the SCOPUS and PubMed databases for case reports and series documenting patients who survived after undergoing treatment for IVROBA.

RESULTS

A total of 24 cases of IVROBA survivors were reported in the literature, including the present case. The median age was 48.5 years (range: 5-71), with a male predilection (3:1). The most common location of the brain abscesses was temporal while the most common route of spread was hematogenous. Surgery was performed in 92% of cases, with EVD being the most common surgical procedure. Twenty nine percent of cases required a VP shunt. The duration of systemic antibiotic treatment ranged from 31 to 180 days (median: 56 days) while intraventricular antibiotics were given for 8-42 days (median: 14 days).

CONCLUSION

The management of IVROBA in this series varied widely, with surgery playing an important role. Although IVROBA is still a devastating complication of intracranial abscess, a good neurologic outcome may still be possible with treatment.

Anaerobic bacteriological profile of brain abscess in a tertiary care center in southern India

Brain abscess accounts for 8% of all intracranial insults in developing countries. Anaerobic infections are missed in most cases due to difficult isolation techniques. This study was done to determine the anaerobic bacteriological profile of brain abscess, their distribution according to sociodemographic variables, anatomical location, management and the outcome during the subjects' stay in a neurosciences' speciality hospital. We included 190 cases of confirmed anaerobic brain abscess from the year 1998-2017. The median age was 22 years with more males (73% of 190 cases) than females. The Bacteroides spp. were the most common (64%) anaerobic organisms isolated followed by Gram positive anaerobic cocci (51%). While 67% of the samples showed purely anaerobic bacteria on culture, remaining were mixed. Chronic suppurative otitis media (CSOM) was the most common predisposing factor.

A Rare Complication of Chronic Otitis Media: Cerebellar Abscess

Chronic otitis media (COM) and its associated complications are currently less common because of the popularity of imaging modalities such as computed tomography and magnetic resonance imaging and the increased use of antibiotics. Patients can be treated without any complications owing to early diagnosis. Despite all these new developments and opportunities, complications of autogenous cerebellar abscess may develop and be fatal. In this case report, we present our own clinical experience regarding a patient with cerebellar abscess as a complication of COM.

Brain Abscess Showing a Lack of Restricted Diffusion and Successfully Treated with Linezolid

A 59-year-old patient with a history of hepatocellular carcinoma presented with decreased consciousness and left hemiparesis. A rim-enhanced mass lesion without diffusion restriction was observed in contrast-enhanced MRI including diffusion-weighted imaging. Based on these findings, metastatic brain tumor was suspected. However, brain abscess (BA) was diagnosed after multiple bacterial colonies were observed in aspiration biopsy. Initial conventional antibiotic treatment including vancomycin had failed, so linezolid was used as second-line therapy. As a result, infection signs and clinical symptoms were resolved. We report a case with atypical imaging features and antibiotic susceptibility of a BA in an immunocompromised patient undergoing chemotherapy.

Neuroimaging in Central Nervous System Infections

Radiologic imaging is often employed to supplement clinical evaluation in cases of suspected central nervous system (CNS) infection. While computed tomography (CT) is superior for evaluating osseous integrity, demineralization, and erosive changes and may be more readily available at many institutions, magnetic resonance imaging (MRI) has significantly greater sensitivity for evaluating the cerebral parenchyma, cord, and marrow for early changes that have not yet reached the threshold for CT detection. For these reasons, MRI is generally superior to CT for characterizing bacterial, viral, fungal, and parasitic infections of the CNS. The typical imaging features of common and uncommon CNS infectious processes are reviewed.

Nocardia farcinica Brain Abscess: Report of 3 Cases

BACKGROUND

Central nervous system nocardial infection is a rarely reported disease that usually affects patients with predisposing and debilitating conditions but also the immunocompetent population. The most common variant affecting the brain is Nocardia farcinica. Management of brain nocardiosis is troublesome and requires consideration of the severity of the underlying systemic disease, the difficulties in identifying the bacterium, and the frequent delay in initiating adequate therapy.

CASE DESCRIPTION

We present 3 cases of N. farcinica brain abscess (single, multiloculated, and multifocal) diagnosed in 3 patients with predisposing factors that could be successfully cured. The patients underwent craniotomy, evacuation of the purulent collection, and partial resection of the abscesses' walls. Confirmation of N. farcinica species was achieved using specific polymerase chain reaction sequencing of the 16S ribosome RNA gene. Antibiotic therapy was selected on susceptibility tests and was maintained for 10 months (1 case) and 12 months (2 cases).

CONCLUSIONS

Brain nocardiosis needs to be suspected primarily (though not exclusively) in immunocompromised patients presenting with neurologic deficit and harboring intracerebral lesions resembling brain tumors. Early identification of the specific species is paramount in order to initiate long-term antibiotic therapy, acknowledging the inherent resistance of N. farcinica to third-generation cefalosporins and its susceptibility to trimethoprim-sulphamethoxazole. According to the literature, surgical excision or aspiration of the brain abscess seems to provide good chances of eradication of the disease. In our experience, successful outcome was achieved with subtotal resection and prolonged and adequate antibiotic therapy.

Evaluation of Continuous Irrigation and Drainage with a Double-Cavity Sleeve Tube to Treat Brain Abscess

BACKGROUND

Brain abscesses carries a high morbidity and mortality, and despite medical advances, it continues to pose diagnostic and therapeutic challenges worldwide. The traditional surgical approaches to treating brain abscess (burr hole aspiration and craniotomy) have both advantages and disadvantages and remain controversial. Here we report a single institution's experience with a new surgical approach for brain abscess.

METHODS

We retrospectively analyzed 46 patients with intracranial abscess who underwent continuous irrigation and drainage through a double-cavity sleeve tube placed surgically in conjunction with a 4-week course of intravenous cefotaxime and metronidazole at Renmin Hospital of Wuhan University between January 2008 and December 2016. The patients' medical records were analyzed for demographic data, clinical presentation, predisposing factors, imaging findings, microbiological test results, treatments, surgical techniques, and outcomes.

RESULTS

The 46 patients included 29 males and 17 females, ranging in age from 22 to 74 years. A single abscess was detected in 34 patients, whereas 12 patients had multiple abscesses. The average duration of hospitalization was 12.6 days. After treatment, 38 of the 46 patients resumed a normal life despite minor deficits (Glasgow Outcome Score [GOS] 5), 6 patients exhibited slight neurologic deficits (GOS 4), and 2 patients died of severe systemic infection and multiorgan failure. In particular, a patient with a brain abscess broken into the ventricle recovered well (GOS 5). No patient required repeat aspiration or surgical excision.

CONCLUSIONS

Continuous brain abscess cavity irrigation and drainage with a double-cavity sleeve tube is an effective treatment for brain abscess and produces excellent results, especially for an abscess broken into the ventricle. It combines the advantages of burr hole aspiration and open craniotomy excision. It is easy to perform and reduces costs and damage to the patient, and also shortens hospitalization time and antibiotic treatment time, greatly reducing the likelihood of reoperation. This approach may be the optimal choice to treat brain abscess.

Brain abscess mimicking brain metastasis in breast cancer

61 year old female presented with chief complaints of headache for 30 days, fever for 10 days, altered behavior for 10 days and convulsion for 2 days. She was diagnosed and treated as a case of carcinoma of left breast 5 years ago. MRI brain showed a lobulated lesion in the left frontal lobe. She came to our hospital for whole brain radiation as a diagnosed case of carcinoma of breast with brain metastasis. Review of MRI brain scan, revealed metastasis or query infective pathology. MR spectroscopy of the lesion revealed choline: creatinine and choline: NAA (N-Acetylaspartate) ratios of ∼1.6 and 1.5 respectively with the presence of lactate within the lesion suggestive of infective pathology. She underwent left fronto temporal craniotomy and evacuation of abscess and subdural empyema. Gram stain showed gram positive cocci. After 1 month of evacuation and treatment she was fine. This case suggested a note of caution in every case of a rapidly evolving space-occupying lesion independent of the patient's previous history.

Magnetic resonance features of pyogenic brain abscesses and differential diagnosis using morphological and functional imaging studies: a pictorial essay

The aim of this paper is to illustrate the potential of magnetic resonance imaging (MRI) in diagnosis, differential diagnosis, treatment planning and evaluation of therapy effectiveness of pyogenic brain abscesses, through the use of morphological (or conventional) and functional (or advanced) sequences. Conventional MRI study is useful for the identification of lesions, to determine the location and morphology and allows a correct hypothesis of nature in the most typical cases. However, the differential diagnosis from other brain lesions, such as non-pyogenic abscesses or necrotic tumors (high-grade gliomas and metastases) is often only possible through the use of functional sequences, as the measurement of diffusion with apparent diffusion coefficient (DWI-ADC), proton magnetic resonance spectroscopy ((1)H-MRS) and perfusion weighted imaging (PWI), which complement the morphological sequences and provide essential information on structural, metabolic and hemodynamic characteristics allowing greater neuroradiological confidence. Modern diagnostic MRI of pyogenic brain abscesses cannot be separated from knowledge, integration and proper use of the morphological and functional sequences.

Multiple brain abscesses in an immunocompetent patient after undergoing professional tooth cleaning

BACKGROUND

Dental disorders and dental treatment are among the variety of causes of brain abscess.

CASE DESCRIPTION

The authors present the case of a patient who developed multiple brain abscesses after undergoing professional tooth cleaning. The results of a diagnostic work-up ruled out an underlying immunodeficiency. After receiving neurosurgical intervention and intensive care treatment by means of local and intravenous antibiotics for 24 days, the patient was transferred to another hospital for rehabilitation. Six months after the treatment, the patient still had moderate residual paresis of the left leg.

PRACTICAL IMPLICATIONS

Although it happens rarely, professional tooth cleaning may be considered a cause of brain abscesses even in otherwise healthy patients.

Panel 8

Background and Objectives

Although serious complications of otitis media (OM) such as brain abscess are rare, sequelae of OM such as tympanic membrane perforation and atelectatic tympanic membrane are quite common. Inner ear sequelae can cause hearing loss and speech and language problems. The objectives of this article are to provide a state-of-the-art review on recent articles on complications and sequelae of OM in different anatomic locations, from the tympanic membrane to intracranial sites, as well as hearing loss and speech and language development.

Data Sources

Primarily PubMed supplemented by Ovid MEDLINE and the Cochrane Database.

Review Methods

All types of articles related to OM complications and sequelae published in English between January 2007 and June 2011 were identified. A total of 127 relevant quality articles are summarized and included in this report.

Results

Key findings are summarized based on the following major anatomic locations and categories: tympanic membrane; cholesteatoma; ossicular problems; mucosal sequelae; inner ear sequelae; speech and language development; extracranial areas, including mastoiditis and facial nerve paralysis; intracranial complications; and future research goals. New information and insights were gained to prevent complications and sequelae.

Conclusion and Implications for Practice

Over the past 4 years, progress has been made in advancing the knowledge on the complications and sequelae of OM, which can be used to prevent and treat them effectively. Areas of potential future research have been identified and outlined.

Open craniotomy for brain abscess: A forgotten experience?

Background:

Brain abscess carries a high morbidity and mortality despite medical advances. In this paper, we present a single institution's experience with the surgical treatment of brain abscess.

Methods:

We retrospectively analyzed 33 cases of intracranial abscess who underwent surgical treatment between January 2001 and December 2009. Patients were treated with aspiration through a single burr hole, open aspiration with ultrasound guidance, or complete abscess resection. The medical records were analyzed for demographics, clinical presentation, predisposing factors, imaging, microbiological investigations, treatment, and outcomes.

Results:

There were 26 male and 7 female patients, aged between 12 and 78 years. The most common predisposing factor was head trauma. Surgical excision of the abscess was performed in 22 patients, open aspiration in 9 patients, and burr-hole aspiration in 2 patients. Repeat surgical procedure was required in six patients. Mortality in this series was 21%. A favorable outcome (Glasgow outcome scale 4 and 5) was achieved in 54%. There was no significant correlation between outcome and age, predisposing factor, treatment modality, or culture results.

Conclusions:

In this series, most patients were treated with an open technique, either by surgical excision or open aspiration of brain abscess. An open technique may reduce the need for additional imaging, surgical treatment, and length of antibiotic therapy. In resource-limited settings, excision of brain abscess may play a more important role in patient management while maintaining favorable outcomes.

Effect of all-transretinoic acid on Th17 and T regulatory cell subsets in patients with ankylosing spondylitis

OBJECTIVE

We compared Th17 and T regulatory cells in patients with ankylosing spondylitis (AS) and in healthy controls. The effect of all-transretinoic acid (ATRA) was studied on cultured CD4+ T cells of patients with AS compared to controls.

METHODS

Eighteen patients with AS and 18 age- and sex-matched healthy controls were included. CD4+ T cells were separated and cultured in conditions of anti-CD3 and anti-CD28 stimulation with and without ATRA. Intracellular and secreted cytokines, transcription factors, and gene expression were evaluated after 72 h.

RESULTS

The frequency of CD4+IL-17+ T cells was significantly higher in patients with AS compared to controls, and ATRA could significantly decrease it. The frequency of forkhead box protein 3 (FOXP3)+ retinoic acid-related orphan receptor γt (RORγt) negative T-bet negative CD4+ cells was significantly lower in cases compared to controls. Intracellular and secreted interferon-γ (IFN-γ) was not significantly different between cases and controls. ATRA significantly increased intracellular IFN-γ in cases but not in controls. Tumor necrosis factor-α (TNF-α) secretion was significantly higher and interleukin 10 secretion was significantly lower in culture supernatant of cases compared to controls. ATRA could significantly decrease TNF-α secretion in cases.

CONCLUSION

Our findings favor a pathogenic role for Th17 cells in AS. Th1 cells did not seem to contribute in the pathogenesis of this disease. The effect of ATRA as an immunomodulator on deviated immune cells was associated with decreased inflammatory markers. This association could be a reason for a clinical trial of ATRA in patients with AS.

Pyogenic brain abscess, a 15 year survey

Background

Brain abscess is a potentially fatal disease. This study assesses clinical aspects of brain abscess in a large hospital cohort.

Methods

Retrospective review of adult patients with pyogenic brain abscess at Rigshospitalet University Hospital, Denmark between 1994 and 2009. Prognostic factors associated with Glasgow Outcome Score (GOS) (death, severe disability or vegetative state) were assessed by logistic regression.

Results

102 patients were included. On admission, only 20% of patients had a triad of fever, headache and nausea, 39% had no fever, 26% had normal CRP and 49% had no leucocytosis. Median delay from symptom onset to antibiotic treatment was 7 days (range 0–97 days). Source of infection was contiguous in 36%, haematogenous in 28%, surgical or traumatic in 9% and unknown in 27% of cases. Abscess location did not accurately predict the portal of entry. 67% were treated by burr hole aspiration, 20% by craniotomy and 13% by antibiotics alone. Median duration of antibiotic treatment was 62 days. No cases of recurrent abscess were observed. At discharge 23% had GOS ≤3. The 1-, 3- and 12-month mortality was 11%, 17% and 19%. Adverse outcome was associated with a low GCS at admission, presence of comorbidities and intraventricular rupture of abscess.

Conclusions

The clinical signs of brain abscess are unspecific, many patients presented without clear signs of infection and diagnosis and treatment were often delayed. Decreased GCS, presence of comorbidities and intraventricular rupture of brain abscess were associated with poor outcome. Brain abscess remains associated with considerable morbidity and mortality.

Hyperbaric oxygen is effective in early stage of healing of experimental brain abscess in rats

OBJECTIVES

Current therapy of brain abscess (BA) includes a combined approach that involves antibiotics and minimal invasive surgery, but also hyperbaric oxygen treatment (HBOT) as a supportive measure. Optimum treatment is still a matter of significant controversy.

METHODS

The experiment, previously approved by a relevant ethical committee, involved 80 female Wistar rats. BA was experimentally induced by inoculation of Staphylococcus aureus. The animals were randomized into groups and treated either with antibiotics, HBOT, or with a combination of both.

RESULTS

Beneficial effect of HBOT was evident in groups treated with HBOT or with a combination of antibiotic+HBOT. It was mainly manifested on days three and five of the experiment and was evident as statistically significant increase of a number of newly formed blood vessels, increase in mean vascular density, and smaller abscess necrotic core.

DISCUSSION

Although the results of the present study should be interpreted cautiously, they suggest that HBOT has an important but limited role in the treatment of BA.

Otogenic brain abscess presenting with gait ataxia

Although the occurrence of otogenic brain abscess has been considerably reduced through improvements to antibiotics, brain abscesses remains one of the most significant life threatening complications of chronic otitis media. We report the case of a 67-year-old male patient who presented with gait ataxia and dizziness. Imaging studies revealed a left cerebellar abscess and extensive destructive changes to the labyrinth due to chronic otitis media. We conclude that otogenic brain abscess should be considered as differential diagnosis in patients with chronic otitis media who develop central vertigo.

Management outcome of NPC-related and non-NPC-related brain abscess in Hong Kong

OBJECTIVES

(1) To review the patient profile, management outcome and prognostic factors of brain abscess; (2) To compare the neurological outcome of nasopharyngeal carcinoma (NPC)-related brain abscess with non-NPC related brain abscess.

METHOD

Retrospective review of consecutive patients diagnosed (radiologically and/or microbiologically) with brain abscess in a regional neurosurgical center in Hong Kong over a nine year period.

RESULTS

Fifty-four patients were recruited into this study. There were 37 male and 17 female patients. Eighteen (33%) patients had previous radiotherapy for nasopharyngeal carcinoma. Only 31 (57%) patients had fever on presentation. White cell count and/or C-reactive protein, was raised in 41 (76%) patients on admission. Surgical drainage was carried out in 49 (91%) patients, either by aspiration through a craniotomy, by drainage with corticotomy, or excision of the abscess. Abscess culture was positive in 45 (83%) patients. Common organisms isolated included Streptococcus species (35%) and Peptostreptococcus species (18%). Anaerobes were isolated in 50% of the NPC-related abscesses. The mean follow-up time was 34 months. At the 6 months interval, 24 (44%) patients had good recovery. Favorable outcome was achieved in 30 (55%) patients. NPC-related brain abscess was associated with unfavorable neurological outcome (33%, p = 0.04). There was also a trend towards higher in-patient mortality in patients with NPC-related brain abscess (22%, p = 0.08).

CONCLUSION

Brain abscess carried a substantial morbidity and mortality despite aggressive surgical and medical treatment. Patients with NPC-related brain abscess had a higher mortality and unfavorable neurological outcome.

Transethmoidal drainage of frontal brain abscesses

BACKGROUND

The frontal lobe is the second most common location for brain abscess after the temporal lobe. Since the advent of computed tomography and magnetic resonance imaging scanning, diagnosis has become easier, but the prognosis of brain abscess is still poor. Treatment is based on antimicrobial therapy and neurosurgical evacuation, but controversy still remains as to the merits place of each.

METHODS

This study describes 2 cases of patients with frontal abscesses treated by endonasal transethmoidal sinus surgery (ESS) and reviews the literature on this topic.

RESULTS

Follow-up revealed no cerebrospinal fluid leak in both patients, complete abscess drainage in one patient, and incomplete drainage in the other.

CONCLUSIONS

ESS drainage of frontal abscesses is feasible in intracerebral and epidural abscesses if they have a thick shell and are in contact with the skull base. The procedure is minimally invasive and relatively simple. It allows for rapid microbial identification and an effective drainage.

HLA-B35 upregulates endothelin-1 and downregulates endothelial nitric oxide synthase via endoplasmic reticulum stress response in endothelial cells

The presence of the HLA-B35 allele has emerged as an important risk factor for the development of isolated pulmonary hypertension in patients with scleroderma, however the mechanisms underlying this association have not been fully elucidated. The goal of our study was to determine the molecular mechanisms that mediate the biological effects of HLA-B35 in endothelial cells (ECs). Our data demonstrate that HLA-B35 expression at physiological levels via adenoviral vector resulted in significantly increased endothelin-1 (ET-1) and a significantly decreased endothelial NO synthase (eNOS), mRNA, and protein levels. Furthermore, HLA-B35 greatly upregulated expression of chaperones, including heat shock proteins (HSPs) HSP70 (HSPA1A and HSPA1B) and HSP40 (DNAJB1 and DNAJB9), suggesting that HLA-B35 induces the endoplasmic reticulum (ER) stress and unfolded protein response in ECs. Examination of selected mediators of the unfolded protein response, including H chain binding protein (BiP; GRP78), C/Ebp homologous protein (CHOP; GADD153), endoplasmic reticulum oxidase, and protein disulfide isomerase has revealed a consistent increase of BiP expression levels. Accordingly, thapsigargin, a known ER stress inducer, stimulated ET-1 mRNA and protein levels in ECs. This study suggests that HLA-B35 could contribute to EC dysfunction via ER stress-mediated induction of ET-1 in patients with pulmonary hypertension.

A Challenging Picture of Cancer-and Inflammation-Related Changes

The authors describe a diagnostically challenging case where a patient with previous squamous cell carcinoma of the tonsil developed a putative second primary squamous cell carcinoma in the lung (stage IV with lung and bone metastases). During palliative chemotherapy several episodes of severe infection occurred, eventually resulting in abscess formation in the hip and brain. The dilemma of distinguishing between metastasis and abscess and the therapeutic implications are discussed.