- Department of Infectious Diseases and Clinical Microbiology, MoH Okmeydanı Training and Research Hospital, İstanbul, Turkey
Department of Infectious Diseases and Clinical Microbiology, MoH Okmeydanı Training and Research Hospital, İstanbul, Turkey
DOI:10.4103/2152-7806.141891Copyright: © 2014 Yıldırmak T. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Taner Yıldırmak, Gedik H, Funda Şimşek, Arzu Kantürk. Community-acquired intracranial suppurative infections: A 15-year report. Surg Neurol Int 26-Sep-2014;5:142
How to cite this URL: Taner Yıldırmak, Gedik H, Funda Şimşek, Arzu Kantürk. Community-acquired intracranial suppurative infections: A 15-year report. Surg Neurol Int 26-Sep-2014;5:142. Available from: http://sni.wpengine.com/surgicalint_articles/community-acquired-intracranial-suppurative-infections-a-15-year-report/
Background:The aim of this study was to retrospectively evaluate the characteristics, treatment, and prognosis of patients with intracranial suppurative infection (ISI) by review of clinical, radiological, and laboratory findings.
Methods:The data collected from all patients who had been diagnosed with ISI and followed up at the Infectious Diseases and Clinical Microbiology Department of the study site between 1998 and 2013 were reviewed.
Results:Of the 23 ISI patients identified, the mean age was 38.21 ± 12.61 years (range: 19–67 years, median: 34) and mean symptom duration was 22.25 ± 20.22 days. Headache was the most common symptom, the frontal lobe the most common localization of ISI, and mastoiditis due to chronic suppurative otitis media the most common source of infection causing ISI. Proteus mirabilis, Pseudomonas spp., Peptostreptococcus spp., Enterococcus avium, Mycobacterium tuberculosis complex, and Toxoplasma gondii were isolated from the specimens collected from 6 (37.5%) of the 16 patients who underwent invasive procedures. Of these 16 patients, 2 underwent craniotomy, 12 burr hole aspiration, and 2 stereotactic biopsy. The rate of recurrence was 0% and the rates of sequelae and fatality were both 8%.
Conclusions:ISI should be considered in male patients presenting with headache and neurological signs and symptoms, whether with or without fever, on admission for early diagnosis and provision of timely, adequate therapy and, if required, surgical intervention to reduce mortality and sequelae rates.
Keywords: Epidural abscess, HIV, intracranial abscess, intracranial suppurative infection, spinal cord abscess, subdural empyema, toxoplasmosis, tuberculosis
Intracranial suppurative infection (ISI) is an infection of the central nervous system (CNS) that includes intracerebral abscess, spinal cord abscess, subdural empyema, epidural abscess, and suppurative intracranial phlebitis. ISI is reported in 1 case per 1000 patients admitted to the hospital and is primarily diagnosed in male patients.[
Adjacent focus and hematogenous spreading have been found to lead to development of ISI. Pia mater has been identified as a strong barrier against invasion of bacteria that cause bacterial meningitis, and rupture of the abscess into ventricle or subarachnoid space resulting in rapid deterioration of the clinical condition and neck stiffness.[
To further examine these findings, this study retrospectively evaluated the characteristics, treatment, and prognosis of ISI patients who presented at the study site between 1998 and 2013 in review of their clinical, radiological, and laboratory data.
All patients with ISI who had been treated and followed up at the Infectious Diseases and Clinical Microbiology Department at the study site between 1998 and 2013 were retrospectively evaluated by review of the data, including physical examination, laboratory (biochemistry and microbiology) testing, and radiological examination collected. All ISI patients had been treated and followed up at a tertiary hospital with an 800-bed capacity. ISI had been diagnosed on the basis of the review of radiological findings obtained by computed tomography (CT) initially performed to detect intracranial masses or hemorrhage and of magnetic resonance imaging (MRI) generally used for differentiation of masses or other lesions. Review of the findings and specimen testing of the patients who had undergone surgical intervention were performed to confirm diagnosis. All cases with postoperative brain abscess or epidural abscess were excluded from this study.
Each sample of the abscess was examined by microscopy with Gram, Ehrlich–Ziehl–Neelsen (EZN), and May–Grunwald staining for the trophozoite form of Toxoplasma gondii. Blood samples drawn from the veins or by catheter for culture were inoculated in bottles and processed manually or automatically using the BactAlert 3D (bioMérieux, Marcy-L’Etoile, France) or BACTEC system (Becton Dickinson, Sparks, MD), depending on availability. Fluid samples, including abscess, urine, and sputum samples, were inoculated onto 5% sheep-blood agar (Salubris Inc., Istanbul, Turkey), chocolate agar (Salubris Inc., Istanbul, Turkey), and MacConkey agar (Salubris Inc., Istanbul, Turkey). Susceptibility testing was performed using disc diffusion and an automated broth microdilution method (Vitek 2; bioMérieux, Marcy-L’Etoile, France) for bacteria. If required, the results were confirmed using the E test method (AB BIODISK, Solna, Sweden). The breakpoints defined by the Clinical and Laboratory Standards Institute were used to evaluate the results. Pus samples were incubated in an anaerobic jar with the GasPak System (BBL Microbiology Systems, Becton, Dickinson and Co., Cockeysville, MD, USA) equipped with a GasPak hydrogen and carbon dioxide-generating envelope for a period of at least 7 days.
Lumbar puncture had been performed in cases with suspected acute purulent meningitis on admission if there had been no contraindication. Each CSF sample collected from lumbar puncture, which contained at least 5 ml of fluid was centrifuged, and a portion of the deposit was examined by microscopy with Gram, EZN, and India ink staining. The remaining deposit was cultured on blood and chocolate agar and Löwenstein-Jensen medium (Salubris Inc., İstanbul, Turkey), as well as inoculated in a mycobacteria growth indicator tube (BBL MGIT medium, BD, Sparks, MD, USA) for later examination when the BACTEC system became available. Patients at high risk for HIV infection were tested for HIV and Toxoplasma gondii antibodies. Leukocytosis was defined as any value above 10,000 cells/mm3 .
Standard descriptive statistical methods were used. Patient age was described in terms of range, median, and mean ± standard deviation.
A total of 23 patients, of whom 17 (73%) were male, of a mean age of 38.21 ± 12.61 years (range: 19-67 years, median: 34) with a mean symptom duration of 22.25 ± 20.22 days were identified and evaluated retrospectively. The distribution of cases by year was 11 cases between 1998 and 2000, 3 cases between 2001 and 2003, 4 cases between 2004 and 2008, and 5 cases between 2009 and 2013. Headache was the most common symptom [
Ceftriaxone(2 g intravenously every 12 h) combined with metronidazole (500mg intravenously every 8 h) was administered to patients between 21 and 120 days until clinical signs and resolution of radiological findings. Initial standard treatment was changed to a combination therapy including, vancomycin and meropenem in five patients and to meropenem therapy in two patients for 2 weeks owing to the severity of symptoms at admission and the deterioration of signs and symptoms under standard combination therapy. Toxoplasma encephalitis was diagnosed and treated with pyrimethamin (a loading dose of 200 mg followed by 7.5 mg/day), clindamycin (600 mg 4 times/day intravenously), and folinic acid (20 mg/day) in a patient with a multifocal abscess who was confirmed to have HIV infection after surgical intervention. A patient with multifocal intracranial abscess secondary to tuberculous meningitis was administered 300 mg/day of isoniazid, 600 mg/day of rifampicin, 2 g/day of pyrazinamide, 1.5 g/day of ethambutol, and 1 g/day of streptomycin for 5 months owing to a persistent abscess. Dexamethasone was administered intravenously for 4 weeks, followed by 2 weeks of oral prednisolone. Isoniazid and rifampicin were continued for 12 months in patient with tuberculous meningitis.
Two patients underwent surgery after admission and 16 patients required surgical intervention between 3 and 18 days (range: 8 days) of medical treatment. Patients whose lesions are small and/or difficult to access were followed up with medical treatment and radiologically. One patient underwent surgical intervention twice and one underwent surgical intervention thrice, but only one patient underwent burr hole aspiration twice due to deterioration of signs and symptoms or lack of regression of the abscess under medical therapy. Persistent fever, lack of regression in the size of the abscess, deterioration of signs and symptoms, appearance of cranial nerve deficits or seizures may indicate failure of therapy. Mastoidectomy was performed in seven patients and functional endoscopic sinus surgery in three patients in addition to medical treatment. Anticonvulsive therapy was initiated in nine patients, of whom seven had undergone surgical drainage and two had multifocal intracerebral abscesses. Four of these patients continued to undergo anticonvulsive therapy regularly, while the other five underwent it for between 2 and 4 years until recovery of electroencephalography and radiological findings. Sequelae developed in two (8%) patients as generalized convulsive seizure in one patient and as both abducens paralysis and hemiplegia in the other patient who were admitted with pontobulbar abscess and hemiparalysis, respectively. Relapse did not occur in any patient. Two (8%) patients died, one of hydrocephalus developing in spite of ventricular shunting and surgical drainage and one of toxoplasmosis encephalitis and abscesses related to AIDS.
ISI is the most common suppurative infection of CNS requiring neurosurgical intervention.[
Fever and headache, which are also the main signs of acute bacterial meningitis, should be considered in the differential diagnosis of ISI. The concurrence of acute purulent meningitis with ISI is rarely observed as a complication of meningitis, as observed in the present study. Lumbar puncture performed to diagnose acute purulent meningitis should be avoided in patients who have neurological findings and headache accompanied by convulsions, focal neurological signs, and papilloedema owing to its hazards, including uncal herniation, rupture of an abscess cavity into the ventricle, etc., as evidenced by the death of 25 of the 140 ISI patients who underwent lumbar puncture.[
A combination of isotope scanning and computerized axial tomography has been reported to allow for identification of an appropriate approach to treatment that can result in an immediate reduction in mortality in approximately 10% of ISI patients.[
Blood culture has been reported to yield microorganisms in 35% of ISI cases.[
Tuberculous abscess is rarely seen and usually presents acutely in the third and fourth decades in the supratentorial location with focal neurologic signs.[
Ceftriaxone combined with metronidazole achieved cure among our patients, without the need for a broader spectrum antibiotic. As this finding indicates, treatment of ISI should be based on antimicrobial therapy active against possible causative pathogens and able to penetrate the blood–brain barrier. Infected brain tissue and abscess are treated with only antimicrobial therapy for 4–6 weeks for patients with abscesses <2 cm in diameter, high-density lesions, multiple abscesses, unsuitable lesions, or poor conditions for surgical intervention.[
ISI accompanied by subdural empyema was the most common cause for surgical intervention in our cases. Our surgical intervention rate (69.5%) was both higher and lower than previously reported rates (62% and 76%).[
Delayed diagnosis of ISI, rapid progression of disease, coma, multiple lesions, intraventricular rupture, lower Glasgow coma score at admission, and fungal etiology have been reported as poor prognostic factors.[
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