Giant Brain Abscess in a Neonate Managed with External Drainage

Address for correspondence Dr. Gopal Sedain, Assistant Professor Neurosurgery Unit, Department of Surgery Tribhuvan University Teaching Hospital, Kathmandu Nepal E mail: gsedain@rediffmail.com How to cite this article ? Sedain G, Ali N, Bhattachan M, Sharma MS, Shilpakar SK. Giant Brain Abscess in a Neonate Managed with External Drainage. J Nepal Paediatr Soc 2013;33(1):55-56. Giant Brain Abscess in a Neonate Managed with External Drainage


Introduction
B rain abscesses in neonates are rare complications of bacterial meningitis and sepsis.The most common causative organism is Gram-negative bacteria.Although brain abscess mortality is decreasing, morbidities caused by hemiparesis, seizures, visual fi eld defects, and learning diffi culties remain high.The current treatment for brain abscess involves combined medical and surgical therapy.We report a neonate with giant brain abscess which was successfully managed with aspiration and drainage with concurrent intravenous antibiotics.

The Case
A 26 day neonate was admitted with fever, irritability and poor suckling.He was full term, home delivered with birth weight of 2 kg.At the time of presentation, he was febrile (100 degrees F), lethargic, weak cry and bulging fontanelles.He had no cranial nerve or sensori motor defi cits.There was no identifi able focus of infection and no features of cyanotic heart disease.CT head revealed a large hypodense capsulated lesion suggestive of left frontal lobe abscess (Figure 1).He was operated emergently and around 80ml of purulent material was aspirated.An external ventricular drain (EVD) catheter was placed in the cavity and kept in place.Gram stain revealed gram negative organisms in pus however organisms could not be isolated in culture.Blood culture was sterile.
Intracavity antibiotic (Gentamycin 3mg) was given daily through the drainage catheter for a week.
He received empirical i/v antibiotics (Ceftriaxone, vancomycin and metrondazole).Serial CT scans were done (Figure 2,3,4) to evaluate the effi cacy of treatment which revealed decreasing size of the abscess and no hydrocephalus.The EVD catheter was removed on day 12. Vancomycin and ceftriaxone were continued for 6 weeks.At 6 weeks, there was resolution of abscess and the child was playful and feeding well.

Discussion
Common causes of brain abscess are sinusitis, otitis media, osteomyelitis and pulmonary infections.However, in infants and neonates common causes are neonatal meningitis and septicemia.In a series of 30 cases, Renier et al 1 .reported meningitis in 20 patients and septicemia in 13.In rare cases, brain abscess can be a complication of cyanotic heart disease, compound head injury and ventriculoperitoneal shunts in children.The general presentation of patients with brain abscess includes focal defi cits in 50%-80%, high-grade fever in 50% and signs of meningitis in 20% of cases.Common organisms in neonatal meningitis and brain abscess are reported to be Proteus mirabilis, Citrobacter and Serratia marcescens 1,2 .In rare cases Klebsiella pneumoniae, Enterococci faecalis, Staphylococcus aureus have also been isolated from the pus of neonatal brain abscesses 2,3,4 .Narendra et al 5 reported the optimal management of brain abscess involves surgical drainage for medium to large abscesses with eradication of the primary source.Surgical drainage was performed in 97.1% of the cases; the outcomes were good for 81.3% of them.Renier et al 1 .reported the following good prognostic factors in neonatal brain abscess: sterile CSF, normal ventricle on CT scan, absence of seizure and early aspiration of the abscess.
Clinical features, supported by ultrasound evaluation and CT brain scan fi ndings, usually confi rm the diagnosis and ultrasound also helps in aspiration of the brain abscess.CT scan is invaluable in diagnosis, evaluation of multiplicity and in establishing the associated pathology such as ventriculitis, hydrocephalus and infarct.
The long-term outcome of neonates with brain abscess is not very promising.Carey et al 6 .reported impaired scholastic ability in 70% of children tested 6 years after surgery.It also seems that the younger the child at the time of diagnosis, the worse is the prognosis for intellectual development.Renier et al 1 performed IQ testing in 22 children-among them eight had an IQ above 80 and another eight patients had an IQ less than 60.Thus there is a very high risk of mental subnormality in these children.

Conclusion
Brain abscess in neonate is relatively uncommon but has high mortality and morbidity.Early intervention and management can yield good results.

Fig 1 :
Fig 1: NCCT head at presentation showing a huge left fronto-parietal abscess.Midline shift to the right with non visualisation of left lateral ventricles can be noted.

Fig 4 :Fig 3 :
Fig 4: CT head at 6 weeks showing complete resolution of abscess

Fig 2 :
Fig 2: CT head at post op day 3 showing reduction in size of abscess.The catheter tip can be seen inside the cavity.