The treatment of nosocomial meningitis and brain abscess by carbapenem-resistant Klebsiella pneumonia.

We report the fourth case of Carbapenem-resistant Klebsiella pneumoniae (CRKP) meningitis and the only one associated with brain abscess formation. A 29-years-old male patient developed septic shock 13 days after a right nasopharyngeal AVM resection. CRKP was grown from CSF with a MIC for meropenem ≥16 mg/L. Intravenous tigecycline and amikacin, combined with intrathecal amikacin and oral sulfamethoxazole were given. CSF culture was sterile on the 23rd day post operation. A right temporal lobe brain abscess formed by day 38 and was drained. Antibiotics were changed to oral sulfamethoxazole and minocycline for four weeks. The patient was cured with no relapse to date. With few cases reported we can only carefully recommend the combinational use of intravenous antibiotics with high dose intrathecal/intraventricular aminoglycosides.

The concept of "Four Walls, Two Poles" in the lesions of the thalamus and ganglion regions: case report and literature review.

BACKGROUND: There are few articles about the surgical techniques of thalamic glioma and the lesions in the basal ganglia area. According to three existing cases and the literature review (Twelve articles were summarized which mainly described the surgical techniques), we discuss the surgical characteristics of lesions of the thalamus and basal ganglia area and summarize the relevant surgical skills. CASE PRESENTATION: Of the three cases, two were thalamic gliomas and one was brain abscess in basal ganglia. According to the three-dimensional concept of the "Four Walls, Two Poles", lesions of the thalamus and basal ganglia were surgically removed, and the operative effect was analysed by relevant surgical techniques. Surgical resection of the lesions of the thalamus and basal ganglia area according to the three-dimensional concept of the "Four Walls, Two Poles" has achieved good surgical results. Relevant surgical techniques, such as the use of retractors, the use of aspirators, the choice of surgical approaches, and the haemostasis strategy, also played an important role in the operation process. CONCLUSIONS: In the presented three cases the three-dimensional concept of the "Four Walls, Two Poles" allowed for safe surgical resection of lesions of the thalamus and basal ganglia.

MR Navigation and Tractography-Assisted Transcranial Neuroendoscopic Aspiration of Pediatric Thalamic Abscess.

AIM: Management of thalamic abscess is being considered as a contentious issue in neurosurgery. Regarding these lesions, besides removing the abscess, the most minimal morbidity is targeted during surgery and planning. MATERIAL AND METHOD: A 5-year-old female presented with the symptoms of altered consciousness and left hemiparesis. Her medical history pointed out that she was being followed up for a congenital cardiac anomaly consisting of transposition of the great arteries and a ventricular septal defect. A cranial MRI revealed 2 masses with peripheral contrast enhancement in the right frontal and thalamic regions. She was operated immediately and the right frontal mass, compatible with abscess, was totally excised with frontal mini craniotomy. The patient was hospitalized and followed up under intensive parenteral antibiotics. Control cranial imaging revealed progression in the size of the thalamic abscess, which was corroborative with the increased left hemiparesis. MR tractography was obtained and the patient underwent MR navigation and tractography combined neuronavigation-assisted transcranial neuroendoscopic aspiration of the thalamic abscess. RESULTS: The patient was stable in the early and late postoperative periods and her hemiparesis showed a dramatic recovery with no additional neurological deficits. CONCLUSION: Neuronavigation is considered as one of the techniques that aid the neurosurgeon to augment the success of surgery and minimize the morbidity, especially in critically localized lesions, i.e., eloquent areas. Combining MR navigation with MR tractography images and using them during neuronavigation to assist endoscopic procedures may decrease the surgical morbidity as much as possible.

The Utility of Local Anesthesia for Neurosurgical Interventions in a Low-Resource Setting: A Case Series.

INTRODUCTION: Trauma is a major contributor to global morbidity and mortality, and injury to the central nervous system is the most common cause of death in these patients. While the provision of surgical services is being recognized as essential to global public health efforts, specialty areas such as neurosurgery remain overlooked. METHOD: This is a retrospective case review of patients with operable lesions, such as extra-axial hematomas and unstable depressed skull fractures that underwent neurosurgical interventions under local anesthesia. RESULTS: A total of 13 patients underwent neurosurgical intervention under local anesthesia. Two and three patients with burr hole decompression of epidural and subdural hematomas, respectively; seven patients had elevation of depressed skull fractures and lastly one patient had an aspiration of a brain abscess. All patients survived with and without residual neurological deficits. CONCLUSION: Access to resources and staff required to deliver general anesthesia is challenging in resource-poor settings. We have therefore begun performing emergent interventions under local anesthesia, with or without conscious sedation. While some patients had some minor residual weakness after the procedure, the degree of neurological deficit was improved from that observed before the procedure in all patients.

Fatal thalamic abscess secondary to dental infection.

We present the case of poor neurological recovery and subsequent death secondary to a thalamic abscess in a 53-year-old man. This patient initially presented with sudden dysarthria and left hemiparesis while driving. Neuroimaging showed a multilobular abscess involving the right thalamus with oedema extending to the basal ganglionic region and brainstem. The source of the abscess was initially unknown and it required draining multiple times while the different causes were being explored. The patient's neurological state along with intubation made for a difficult and inconclusive oral examination. It was only after neuroimaging included tooth-bearing areas that it became evident that this patient had extensive periodontal disease with multiple areas of periapical radiolucencies. The patient underwent complete dental clearance alongside repeated drainage of the abscess. Despite initial postoperative improvement, the patient never recovered from the neurological damage and died 3 weeks later.

[FEATURES OF OTOGENIC INTRACRANIAL COMPLICATIONS AT THE PRESENT STAGE].

A retrospective analysis of treatment was made in 127 adult patients with acute and chronic otitis media complicated by suppurative-inflammatory pathology of the brain. Purulent meningitis was revealed in 52 (40.9%) of hospitalized patients. Meningoencephalitis was often diagnosed in the cases of acute otitis media (15.4%) and in cases of chronic otitis (22.7%). The otogenic brain abscess was detected in 13.5% of otitis media cases and it was noted to be twice frequent (33.3%) in cases of purulent otitis media. The patients 124 (97.6%) have been operated. An extended mastoidotomy and antromastoidotomy were performed in the acute purulent otitis media. An extended radical operation on the ear was applied in case of chronic otitis media. Performance of craniotomy and complete removal of the abscess using modern systems of neuronavigation showed a higher clinical efficacy as compared with transtemporal approach during sanitizing intervention on the ear including the opening and abscess drainage in surgery of otogenic abscesses of the brain.

Pott's puffy tumor in children.

INTRODUCTION: Pott's puffy tumor is characterized by subperiosteal abscess associated with osteomyelitis of frontal bone. Reports are limited for this rare entity in the antibiotics era but increase during past decade. METHODS: We had clinical analysis of a series with six consecutive pediatric patients of Pott's puffy tumor during 20 years in a tertiary medical center via retrospective chart review. One case was described in detail. RESULTS: Male-to-female ratio was 5:1. The mean age at the time of diagnosis was 13 years-3 months. The risk factors were acute sinusitis in two (33%), chronic sinusitis in two (33%), recent head trauma in two (33%), and acupuncture therapy on skull in one (17%). The commonest presenting symptoms were fever, headache, forehead tenderness, vomiting, and fatigue/malaise (100%). Pott's puffy tumor was diagnosed on average the seventh day after fever, and half had intracranial involvement at diagnosis. All had intracranial infections, and most of them had subdural empyema. The most often involved sinus was frontal sinus (100%). The frontal lobe was the most common site of intracranial infection (100%), two thirds of which are polymicrobial from two or more sites. The initial operation was performed on average on the 5.8th days after diagnosis. Half of the patients underwent reoperation. The mortality rate was 17% (one of six). CONCLUSION: The symptoms of Pott's puffy tumor are inconspicuous even though early intracranial involvement often occurred. The importance of early diagnosis and aggravated and prompt treatment with prolonged antibiotic therapy is emphasized for better outcome.

First-line stereotactic treatment of thalamic abscesses: report of three cases and review of the literature.

Solitary pyogenic thalamic and basal ganglia abscesses are relatively uncommon. Even if widespread antibiotic therapy and modern imaging technologies combined with minimally invasive techniques have improved the outcome in patients with brain abscesses, this is counterbalanced by an increasing population of immunocompromised patients. Basal ganglia, thalamic, brainstem or multiple abscesses are usually of hematogenous origin with an underlying source of infection which can include congenital heart disease, thoracic sepsis or, less frequently, an odontogenic or otogenic source. However, no evident foci of sepsis or predisposing factors may be found. Only a few studies are reported in the literature, because midline abscesses are usually included in studies dealing on the treatment of abscesses in general. Different treatment options and the timing of treatment are described. We report our experience in 3 consecutive cases of thalamic abscess, treated by stereotactic puncture as the first step, followed by histological analysis, external drainage and targeted intrathecal and systemic antibiotic therapy. Deep-seated abscesses seem to behave differently as they are associated with an increased risk of intraventricular rupture and antibiotic resistance, a fact which justifies a more aggressive and immediate surgical treatment. We review the literature on this topic in the last 20 years.

Deep brain stimulation for Holmes' tremor related to a thalamic abscess.

BACKGROUND: Medical treatment is usually ineffective for Holmes' tremor, and surgery is the treatment of choice for many patients. Here we report the case of a 14-year-old girl who developed Holmes' tremor related to a thalamic abscess and was successfully treated with thalamic deep brain stimulation. CASE REPORT: The patient presented with left hemiparesis and headache and was hospitalized. Investigation revealed a thalamic abscess in the left cerebral hemisphere. The abscess was drained via stereotactic surgery and a course of antibiotic treatment was completed. Four months after treatment, the patient developed Holmes' tremor in her left upper extremity. When attempts at medical treatment with levodopa, clonazepam, and trihexyphenidyl all failed, an implant was placed and deep brain stimulation of the ventral intermediate nucleus of the thalamus was initiated. During 2.5 years of follow-up, her tremor diminished by 90%. CONCLUSION: This case demonstrates that medically resistant Holmes' tremor related to a thalamic lesion can be successfully treated with thalamic deep brain stimulation.

Primary Nocardia farcinica brain abscess with secondary meningitis and ventriculitis in an immunocompetent patient, successfully treated with moxifloxacin.

We report a rare case of Nocardia farcinica occipital brain abscess in an immunocompetent patient with no underlying risk factors successfully treated with the antibiotic moxifloxacin. The patient underwent craniotomy and abscess drainage. Initial post-operative treatment with co-trimoxazole produced a limited response. Despite the development of skull base meningitis and ventriculitis subsequent addition of moxifloxacin produced an excellent outcome.

Nocardiosis in a teaching hospital in the Central Anatolia region of Turkey: treatment and outcome.

Predisposing factors, antimicrobial susceptibility patterns, treatment and outcome were analysed for nine consecutive patients with nocardiosis. Predisposing factors were identified in six (67%) of the nine patients. Clinical syndromes of nocardial infection were pulmonary infection (three patients), cerebral infection (five patients) and disseminated infection (one patient). The predominant (60%) species was Nocardia farcinica rather than the Nocardia asteroides complex. Treatment was started empirically, modified according to the antimicrobial susceptibility pattern, and then continued for 6-12 months. Overall mortality was 33%, with death being caused by the Nocardia infection in two cases.

[Nocardia cyriacigeorgici: First report of invasive human infection]. / Nocardia cyriacigeorgici: Erstbeschreibung als invasive Infektion.

BACKGROUND: Diagnostic laboratories increasingly offer bacterial identification to the species level. The 17 nocardia species known to date differ in their clinical presentation, antibiotic resistance patterns and geographic distribution. The discovery of a new species with pathogenicity for humans calls for the characterization of its clinical and epidemiological properties. PATIENTS AND METHODS: Nocardia isolated from multifocal brain abscesses of an immunocompromised patient were further identified by the analysis of their cellular fatty acids and sequencing of the 16S ribosomal DNA. Quantitative antibiotic resistance testing was performed with E-tests. RESULTS: The 16S ribosomal DNA analysis showed a 99 % homology to Nocardia cyriacigeorgici. This is the first report of this species as an invasive human pathogen. N. cyriacigeorgici was found susceptible for meropenem, amikacin, ceftriaxon and cotrimoxazole. The combination of surgical drainage and antibiotic treatment for 13 months was curative. CONCLUSIONS: N. cyriacigeorgici has the potential to cause invasive infections at least in immunocompromised patients. Comparing clinical and in vitro characteristics with N. asteroides, the main causative agent of nocardial infections in Europe, we found no clinically relevant differences.

Successful treatment of a brain abscess due to Trichoderma longibrachiatum after surgical resection.

A case of brain abscess due to Trichoderma longibrachiatum in a leukemic patient with prolonged neutropenia is reported. Definitive cure was achieved after neurosurgical resection of the abscess and prolonged antifungal therapy. Trichoderma is a filamentous fungus species, which is only exceptionally pathogenic in humans. This genus and particularly the species Trichoderma longibrachiatum should be added to the growing list of fungi causing infection in immunocompromised patients.

[Spontaneous brain abscess--bacteriology, therapy and prognosis]. / Spontane Hirnabszesse--Bakteriologie, Therapie und Prognose.

Spontaneous intracranial abscesses are quite rare in western industrial countries. According to the recently published papers, each neurosurgical centre is expecting 2 to 4 cases a year. Whereas in the last three years we only operated on one or two cases a year we treated 8 cases in the first ten months of 1994. Although this remarkable increase is not statistically significant, further observations seem to be indicated. In 5 cases the origin of the abscess remained unknown. 3 patients had odontogeneous focuses, 2 middle ear and 2 pulmonary infections. One patient was operated on for spontaneous liver abscess few days before. Streptococcus was found in 9 cases, Bacteroides, Nocardia and Rhodoturola in 1 case each. For one patient no pathogen could be detected. In regard of our results, minimal invasive neurosurgical aspiration of the abscess with adjacent longterm antibiotic therapy gives a good prognosis with little morbidity. In contrast the mortality rate rises if diagnostic procedures are delayed or if the detected microorganism is highly resistant to current antibiotics.

Prevention of intracranial problems in ear and sinus surgery: a possible role for cefotaxime.

Cases of intracranial sepsis of otorhinogenic origin presenting to a regional neurosurgical centre from 1984 to 1992 were examined with regard to their microbiology and antibiotic sensitivities. The results lead us to believe that cefotaxime may have a role in the initial ENT management of the potentially complicated case of ear or sinus sepsis.

Solitary pyogenic thalamic abscess--two case reports.

We report two patients with solitary thalamic abscesses, occurring among 91 consecutive patients (2.2%) with computed tomography (CT)-diagnosed and surgically-verified brain abscess experienced in our college during 1975 to 1991. A 9-year-old girl with congenital heart disease experienced frequent vomiting followed by left hemiparesis and deterioration of consciousness. CT demonstrated a right thalamic ring-enhanced lesion. Purulent material was aspirated via a burr hole. She died of heart failure on the 5th postoperative day. Autopsy disclosed diffuse brain swelling and an encapsulated abscess in the right thalamus, which had ruptured into the third ventricle. A 30-year-old female experienced headache, nausea, and vomiting, which progressed to somnolence and right hemiparesis. CT demonstrated a left thalamic ring-enhanced lesion. Purulent material was aspirated by stereotactic procedures. All symptoms had resolved by the end of the 2nd postoperative week.

Non-traumatic brain abscess.

Between 1953 and 1989 eighty cases of non-traumatic brain abscess were treated in our department. We have re-examined the clinical and neuroradiological features of this pathological process and present our therapeutic approach and results. We believe that the optimal treatment for brain abscess consists of surgical removal. The prognosis for these lesions has undergone a marked improvement over the last two decades in response to neuroradiological, microbiological and surgical advances. The most influential prognostic factor seems to be preoperative clinical status.

Penetration of cefotaxime and desacetylcefotaxime into brain abscesses in humans.

Since clinical trials comparing the efficacies of different antibiotic regimens for treatment of brain abscesses are difficult to perform, the choice of antibiotics must rely on the antibacterial spectrum and the ability of the drug to penetrate into the abscess fluid. The aim of this investigation was to study the ability of cefotaxime and its active metabolite desacetylcefotaxime to penetrate into brain abscesses. Eight patients were given 3 g of cefotaxime intravenously every 8 h. Abscess fluid samples, obtained at surgery at various times after dosing, and blood samples were analyzed for their concentrations of cefotaxime and desacetylcefotaxime by using a newly developed microbiological assay. The brain abscess concentrations of cefotaxime and desacetylcefotaxime were 1.9 +/- 1.7 and 4.0 +/- 2.2 mg/liter, respectively. Simultaneous concentrations in plasma were 2.0 +/- 1.0 and 3.9 +/- 1.8 mg/liter, respectively. With increasing time following cefotaxime dosing there was a significant increase in the abscess:plasma concentration ratio of desacetylcefotaxime. Since both cefotaxime and desacetylcefotaxime penetrate well into the brain abscess, reaching concentrations above the MIC for probable bacteria except gram-negative anaerobes, it is concluded that cefotaxime in combination with metronidazole may be used as an alternative in the treatment of brain abscesses.