By Courtney Porter, RN and Katrina Walker, RN
Nationwide Children’s Hospital
A six year old male presented to Urgent Care with chief complaints of fever and headache. His mother reported that he had been having fevers consistently for nine days. Other symptoms included cough and diarrhea, which had improved through the duration of his illness. On the day of the visit, he complained of headache and fatigue, and his mother reported that his appetite was poor.
The patient’s vital signs upon arrival were: Temp 37.7C (99.9F), HR 124, RR 24, BP 91/58, SpO2 97%. He was fatigued and generally ill appearing, but his cardiac, respiratory, and neurological exams were all normal. Mother reported that the patient had been seen previously at his PCP office, where he tested negative for both strep and flu. Due to the history of prolonged fever and recent cough, the provider ordered a chest x-ray which was normal. He was given juice and snacks at Urgent Care and reported that he was feeling better, so he was discharged to home with a diagnosis of viral illness.
Immediately following his departure from Urgent Care, the patient and his parents went to dinner. During dinner, the patient started to exhibit facial droop, confusion, and limp. Parents brought patient back to Urgent Care, where he was taken immediately to an exam room and was assessed by a provider.
His return vital signs were: Temp 37.3C (99.2F), HR 116, RR 24, BP 94/67, SpO2 99%. During his re-assessment, the patient was alert, oriented, and able to move all extremities. He was noted to have slight droop of the left side of his face compared to the right, which was particularly pronounced when he was asked to smile. Based on these concerning changes in his condition, the patient was transferred to NCH Main ED for further evaluation.
In the ED, the patient’s labs revealed an elevated WBC and CRP. MRI of his brain demonstrated findings consistent with multiple cerebral abscesses. He was admitted to PICU and he had a complicated hospital stay which included brain surgery. His care was a collaboration that involved multiple specialty services, including infectious disease, ophthalmology, neurology, GI, hematology, neurology, and neurosurgery. After 21 days at NCH, he was discharged home with a PICC and close follow-up. His neurological status had returned to baseline by the time of discharge.
Patient identifiers, including name, date of birth, and medical record number have been omitted from this case study in order to protect patient privacy.
What is a brain abscess?
As the immune system fights bacteria that targeted your brain, inflammation occurs. Waste from your immune system (dead cells, bacteria or fungi) collects in an area of your brain. Tissue grows around the waste material (pus) to form an abscess.
Causes
The more common causes include viruses, fungi, and bacteria. Bacteria is the most common of the 3 and typically causes more significant damage.
There are three ways a virus or bacteria can enter the body and infect the brain:
- Infection is spread from another area of infection in the body, usually from a nearby site; typically, this might be an ear infection, sinus infection, or dental infection.
- Infection is spread through the blood stream from the lung or chest area.
- Viral or bacterial germs enter directly into the brain through an open wound in the head.
Occurrence
How common are brain abscesses?
- Not common.
- Estimated 1,500 to 2,500 cases each year in the U.S. (adults and children combined)
- 10% – 30% are deadly
Risk Factors
- Congenital heart disease
- Meningitis
- Chronic middle ear and sinus infections
- Dental or jaw infections
- Infections of the face or scalp
- Head injury or skull fracture
- Having a VP shunt
- Diabetes
- Immunosuppression
Symptoms
Symptoms can happen suddenly or gradually (several days to a couple of weeks).
Babies & Younger Children:
- Fever
- A full or bulging fontanelle
- Lethargy
- Increased irritability
- High-pitched cry
- Poor feeding
- Projectile vomiting
- Seizures
Older Children:
- Fever
- Severe headaches
- Nausea and vomiting
- Changes in personality or behavior
- Changes in speech
- Problems walking
- Limb spasticity
- Seizures
Treatment
Specific treatment is based on:
- Child’s age, overall health and medical history
- The severity and size of the abscess
- Your child’s tolerance for specific medications, procedures, or therapies
The key to treating a brain abscess is early detection and treatment.
- Immediate hospitalization is required
- Early antibiotic administration
- Possible surgery
Goals of treatment
- Reduce pressure in the head
- Drain the abscess/kill the infection
- Control other symptoms (seizures, fever, etc.)
References
Children’s Hospital of Philadelphia
https://www.chop.edu/conditions-diseases/brain-abscess
Cleveland Clinic
https://my.clevelandclinic.org/health/diseases/brain-abscess
