Case Report

MULTIPLE BRAIN ABSCESSES IN A NEW-BORN FOLLOWING AN

UMBILICAL INFECTION

Handrianto Setiajaya, Aditya, Agus Y., Djoko Riadi

Service of Neurosurgery, Department of Neurosurgery
Gatot Soebroto Army Central Hospital, Jakarta Indonesia

ABSTRACT

Objective: Brain abscess is a rare and dangerous condition in infants, usually solitary and
need surgical intervention. A case of multiple brain abscesses are very rare in the pediatric
age-group and surgical drainage is lifesaving.
Clinical Presentation: This is a report of one case of multiple brain abscesses in a 30 days-
old baby who presented with seizures and enlargement of head with history of umbilical
infection (omphalitis). Cerebro-cerebellar Computed Tomography (CT) scan and Magnetic
Resonance Imaging (MRI) reflect multiple abscesses in both hemispheres and posterior fossa.
Intervention: Surgical drainage of the abscesses was performed. Intrathecal vancomycin and
intravenous meropenem was given. The patient’s course was uneventful.
Conclusion: A case of multiple brain abscesses is rare and life-threatening, particularly in
children. Surgical drainage combined with specific antibiotic therapy is recommended in
these patients.
Keywords: newborn – multiple – brain - abscesses – infection - umbilical

INTRODUCTION CASE REPORT

Multiple brain abscesses are very rare and can
be responsible for enlarging heads in infants.11
The treatment of this group of abscess consists
of surgical drainage and antibiotic therapy.
The prognosis is poor in cases of large or
multiple abscesses.11 This is a case-report of
multiple brain abscesses in a baby aged 30
days. At the age of 3 weeks, seizures begun
and progressively worsening. The diagnosis
was made by CT. Surgical drainage was
utilizing multiple burr holes, obtaining a good
outcome.
-------------------------------------------------------
Handrianto Setiajaya ( )
Departemen of Neurosurgery, Gatot Soebroto Army
Hospital, Jakarta, Indonesia.
e-mail: drhandrianto@yahoo.com
From a rural hospital, one 30 days old baby
was referred to emergency room, had been
having seizures and progressive enlargement
of the head since three weeks after birth. He
had been having umbilical infection since the
seventh day after his normal birth. On
admission, his occipital frontal circumference
was 42 cms, while the anterior fontanel was
tight. Neurologically, he was fine and his
psychomotor development was also normal. A
cranio-cerebellar CT scan was already taken at
that mentioned hospital (fig.1). He was
admitted, and following further radiological
evaluation of the patient, the decision for
surgery was made. Under general anesthesia,
the abscesses were drained surgically (fig. 2)
through the right and left parietal as well as
through the left temporal regions. A necrotic,
yellowish and purulent fluid collection was
drained amounting to a total of 80 ml.

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MEDICINUS · Vol. 3 No. 1 Februari 2009 – Mei 2009
excision via craniotomy. But craniotomy is an
appropriate technique for traumatic abscesses,
abscesses with foreign bodies, mycotic
abscesses and abscesses which are
multiloculated.2,6Operative evacuation by
craniotomy is recommended by some authors
for children above 3 years of age with mature
brain abscesses.16
In general, each case must be individualized
and treated in its own right with consideration
to the factors outlined above. For this patient,
craniotomy was avoided, instead a
craniostomy was preferred utilizing a twist
drill for surgical drainage and a good result
was obtained. A craniotomy was not done as
this particularpatient was considered too
young for such an invasive method. The
decission was also taken in the risk of
bleeding as well as spreading the infection
hematogenously, may be hazardous for this
child. The duration of craniotomy is also too
long for a child 30 days of age.
Brain edema may occur as a result of
inflammation of the brain after infection or
compression of the brain by abscesses. Even
as the brain was swollen, the intracranial
pressure was low, sulci at the frontal lobe was
deep and right lateral ventricle slightly
enlarge. A shunt is usually not required
because of the absence of signs and symptoms
of increase in intracranial pressure.17 On the
other hand, the infectious manifestations
would still continue even if the surgical
procedures were completed. As ventriculitis
may be present and therefore
ventriculoperitoneal shunt procedure may be
hazardous to the patient, we did not perform
any shunt procedure. The distinction between
ventricumegaly (without elevated intracranial
pressure) and hydrochepalus (elevated
intracranial pressure) is important, especially
for the infants.17
The origin and the agents of infection in
intracerebral abscesses are usually hard to
find. In this particular case, the initial
infection was a local umbilical cord infection
(omphalitis) (Fig. 4) which typically presents
itself as a superficial cellulitis that progresses
to necrotizing fasciitis, myonecrosis and later
becomes systemic. Omphalitis is
predominantly neonatal by nature. The freshly
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cut umbilical cord is the prime site of bacterial
colonization that progress to local signs of
infection including pus discharge, redness,
swelling, or foul odor. Hospital –based studies
from developing countries have report of
varying dominance of gram positive and
anaerobic bacteria. Approximately 85 % of
cases are polymicrobial. Aerobic bacteria are
present in approximately 85 % of infection,
predominantly by Staphylococcus aureus,
group A Streptococcus, Escheria coli,
Klebsiella pneumoni, and Proteus mirabilis.
Figure 4.
In this reported patient, he had a history of
previous omphalitis, later became systemic,
and microbiologically due to the Proteus
species, which are gram positive,
polymorphic, and have a fine, threadlike rod,
poassesing very active motility. Proteuses are
toxic (develop an endotoxin) and have
hemolytic properties and various degree of
biochemical activity. Proteuses are rather
steady in an external environment and even
are capable to keep their vital activity in weak
solution of phenolum and other disinfectants
as well as resistant to many antibiotics. The
duration of antibiotic therapy for this patient is
similar to those in the literature. Sharma et al.,
found that in their series of 38 patients with
multiple pyogenic brain abscesses, 24% had
Staphylococcus aureus as the inciting
organism in their series, and also most patient
were adults and only 9 out of 38 were
infants.19 In the series of Kratimenos,
staphylococci were found as the second
commonest agent with 21% in 14 patients.12
21

Figure 3. Follow up CT Scan Showing two small abscesses and edema in the right hemisphere
periods.18,20 Furthermore, multiple location for
brain abscess are a poor prognostic factor,
especially in infants for such state of the art
procedure.18
Clinical presentation of brain abscess is
usually similar to other intracranial space-
occupying lesions. However, the symptoms of
an abscess tend to be more rapidly progressing
as compared to those associated with a
neoplasm.2 Headache, nausea and vomiting,
alteration of the level of consciousness,
seizures, neurological disturbances according
to the location of abscess and increased fever
are the commonest presentations characteristic
of brain abscesses in adults. Infants usually
present with a combination of enlarging head
circumference, bulging fontanel, separation of
cranial sutures, vomiting, irritability, seizures
and poor feeding.2 This patient presented only
with seizures and enlarged head
circumference, while his feeding was adequate
and his neurological status was normal on
admission. Neither fever nor seizure was
observed during his hospital stay. This is an
interesting syndrome and not reported until
today in the literature.
Sharma et al. reported their experiences during
12-year period with multiple pyogenic brain
abscesses and their overall mortality rate was
32%.19 Level of consciousness at the time of
admission was the most significant factor
affecting the outcome. Surgery is the
definitive therapy and life saving in the
management of multiple pyogenic abscesses.
Systemic treatment is required for multiple
abscesses. In this reported case, the patient’s
level of consciousness level was preserved and
therefore, we obtained a good surgical
20
MULTIPLE BRAIN ABSCESSES
outcome combined with specific antibiotic
therapy. Multiple abscesses have been noted in
10 to 50% of all bacterial brain abscesses.13
CT and MRI are the best diagnostic tools in
such patients.
Combined therapy of surgical drainage and
specific antibiotics is the generally accepted
treatment protocol by the majority of
authors.5,7,13,15,21,23 The indication for surgery
and the type of surgery are still a point of
contention among neurosurgeons. Various
procedures have been used in the operative
management of brain abscesses.
The choice of procedure over another may be
influenced by age, neurological condition of
patient, location, stage of the abscesses and
also whether multiple lesions are present.
Minimally invasive methods are mainly
preferred for easy accessible lesions while
stereotactic aspiration is appropriate for deep
situated abscesses.14,20 Aspiration via single
burr hole does have a number of advantages,
including a rapid and safe drainage of abscess
material, minimal damage to cerebral tissue
and immediately lowering intracranial
pressure. Additionally, rapid removal of
purulent material allows a more favorable
local environment in which antibiotics would
effectively function.
Although aspiration has often proved
successful, excision via formal craniotomy has
also been effective.3,8,9,10,22 But craniotomy
also has some disadvantages as follows:
inappropriate technique for lesions would lead
to an early cerebritis, ill advised for deep
abscess and abscess in eloquent regions of the
brain. Multiple lesions are not amenable to
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MEDICINUS · Vol. 3 No. 1 Februari 2009 – Mei 2009

Figure 1. Pre operative CT scan with contrast showing multilobulated with different
density at both of hemispheres

Figure 2. The abscesses were drained surgically through the right

and left parietal and temporal regions.

Microbiological culture yields the Proteus complication. Outpatient follow-ups were

species. Via catheter drain, vancomycin HCl
was administered intrathecally 15mg every 48
hours for 10 days, while intravenous
meropenem was for 21 days. Shunt procedure
was ruled-out for two reasons : the absence of
sign of hydrocephalus and the concern was
raised regarding the risk of spreading of
infection via cerebro spinal fluid (CSF) route
would lead to sepsis. His occipito-frontal
circumrerence had been getting smaller to 38
cm, while his anterior fontanel was evidently
relaxed. Post operative CT scan (fig.3) and
follow up CT scan before discharge (fig. 3)
were all evidences of a sucessfull surgery.
Later the patient was discharged without any
every two weeks. The baby was well without
any neurological deficit, while his head size is
in the normal range. He still had seizures but
without the evidence of any infection.
DISCUSSION
Brain abscesses are rare in the newborn and
the first line treatment for such lesions is still
in debate.11,15,20,23 Although stereotactic
aspiration of these lesions has gained ground
as a valid alternative to traditional medical
and/or surgical treatment, recurrence of the
abscess occurred in some cases after a few

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 MULTIPLE BRAIN ABSCESSES

CONCLUSION Surgical drainage is the procedure of choice in

Multple brain abscesses usually situated in one
hemisphere and seldom spread-accross to
other one. Although rare, but it is life
threatening particularly in children.
these patients, combined with specific
antibiotic therapy. For multiple abscesses
located at many sites of brain, surgical
drainage in several sessions should be
considered.

REFERENCES

1. Anderson D, Strong AJ, Ingham HR, et al. Fifteen-year Review of the Mortality of Brain
Abscess. Neurosurgery. 1981; 8: 1-5.

2. Britt RH. Brain Abscess. In Wilkins RH, Rengachary SS (Ed): Neurosurgery. New York:
MCGraw Hill.1985; 1928-1956.

3. Choudhury AR, Taylor JC, Whitaker R. Primary Excision of Brain Abscess. Br Med J. 1977; 2:
1119-1121.

4. Dyste GN, Hitchon PW, Menezes AH. Stereotactic Surgery in the Treatment of Multiple Brain
Abscesses. J Neurosurg. 1988; 69: 188-194.

5. Ersahin Y, Mutluer S, Guzelbag E. Brain Abscess in Infants and Children. Childs Nerv Syst.
1994; 10: 185-189.

6. Hagan RE. Early Complications Following Penetrating Wound of the Brain. J Neurosurg.1971;
34: 132-141.

7. Hoffman I, Kesmarki I, Kincses J, et al. Non-invasive Management of Multiple Brain Abscesses:

Case Report and Review of the Literature. ORV Hetil; 1999; 140: 2111-2115.

8. Hubsmann OR, Weisbrot FJ, Smith LG. Multiple Streptococcal Brain Abscesses Successfully
Treated by Craniotomy and Neddle Aspiration. Surg Neurol. 1982; 17: 56-61.

9. Jooma OV, Pennybacker JB, Tutton GK. Brain Abscess: Aspiration, Drainage or Excision? J
Neurol Neurosurg Psychiatry. 1951; 14: 308-313.

10. Kobrine AL, Davis DO, Rizzoli HV. Multiple Abscesses of the Brain: Case Report. J Neurosurg.
1981; 54: 93-97.

11. KrajeweskiR, Stelasiak Z. Brain Abscess in Infants. Child Nerv Syst. 1992; 8: 279-280.

12. Kratimenos G, Crockhard HA. Multiple Brain Abscess: A Review of Fourteen Cases. BR J
Neurosurg. 1991; 5: 153-161.

13. Mamelak AN, Mampalam TJ, Obana WG, et al. Improved Management of Multiple Brain
Abscesses: A Combined Surgical and Magical Approach. Neurosurgery. 1995; 36: 76-85.

14. Mampalam TJ, Roseblum ML. Trends in the Management of Bacterial Brain Abscesses: Review
of 102 Cases Over 17 years.

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