Hyperbaric oxygen for intracranial abscess.

The term "intracranial abscess" (ICA) includes cerebral abscess, subdural empyema, and epidural empyema, which share many diagnostic and therapeutic similarities and, frequently, very similar etiologies. Infection may occur and spread from a contiguous infection such as sinusitis, otitis, mastoiditis, or dental infection; hematogenous seeding; or cranial trauma. In view of the high morbidity and mortality of ICA and the fact that hyperbaric oxygen therapy (HBO2) is relatively non-invasive and carries a low complication rate, the risk-benefit ratio favors adjunct use of HBO2 therapy in selected patients with intracranial abscess.

[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.

Pathological laughter and crying in patients with pontine lesions.

Pathological laughter and crying (PLC) has been widely documented in the medical literature in association with various pathological processes in the brainstem, particularly infarction. However, it remains poorly understood. The authors present a case report and analyze all the cases in the literature to try to localize a putative faciorespiratory center. This 13-year-old girl developed a pontine abscess subsequent to sphenoid sinusitis. This increased in size despite antibiotic treatment, and she developed PLC. The abscess was then stereotactically aspirated, with resolution of the symptoms. A PubMed search of the term "pathological laughter and crying" was performed. From these papers all reported cases of PLC were identified. Cases without neuroimaging were excluded. The remaining cases were categorized as small lesions permitting accurate localization within the pons, or large nonlocalizing lesions. All images of localizing lesions were magnified to the same size and placed on a grid. From this an area of maximal overlap was identified. The authors identified 7 cases of small localizing lesions with adequate imaging. The area of maximal overlap was in the region of the anterior paramedian pons. All the lesions involved this region of the pons. There were 28 further reports of large lesions that either resulted in gross compressive distortion of the pons or diffusely infiltrated it, and thus, although implicating involvement of a pontine center, did not allow for localization of a specific region of the pons. The authors report a case of PLC caused by a pontine abscess. Symptoms were reversible with stereotactically assisted aspiration and antibiotic administration. Analysis of the lesions reported in the literature showed a pattern toward a regulatory center in the pons. The most consistently involved region was in the anterior paramedian pons, and this may be the site of a faciorespiratory center.

Neisseria elongata endocarditis complicated by brain embolism and abscess.

We report a case of Neisseria elongata endocarditis with thalamic septic embolization and subsequent brain abscess formation, which to the best of our knowledge has never been reported in the literature. The brain abscess completely resolved after a surgical repair of the infected mitral valve and an additional 4 weeks of antimicrobial therapy. Based on a review of all previous reports of N. elongata endocarditis, including ours, this will remind physicians that invasive N. elongata infections should be managed and followed up cautiously, as surgical intervention is often required.

Pyogenic brain abscess following haematogenous seeding of a thalamic haemorrhage.

We report the rare occurrence of a pyogenic brain abscess at the site of a preceding intracerebral haemorrhage in a 58-year-old man. The diagnosis was based on clinical observations, isolation of Staphylococcus aureus from blood cultures, and characteristic cerebrospinal fluid and cerebral computed tomography findings. The patient had a favourable response to antibiotic therapy.

Breakthrough Scedosporium apiospermum (Pseudallescheria boydii) brain abscess during therapy for invasive pulmonary aspergillosis following high-risk allogeneic hematopoietic stem cell transplantation. Scedosporiasis and recent advances in antifungal therapy.

Systemic scedosporiasis due to the anamorph or asexual form Scedosporium apiospermum (Pseudallescheria boydii) has become an important cause of opportunistic mycosis, especially in patients undergoing high-risk hematopoietic stem cell transplantation. We report a case of rapidly progressive cerebellar hyalohyphomycosis due to Scedosporium apiospermum in an allogeneic marrow graft recipient receiving treatment for severe graft-versus-host disease. This fatal breakthrough intracranial abscess, due to amphotericin B-resistant (minimum inhibitory concentration > 16 micro g/ml) mold, developed during the course of systemic antifungal therapy given for multicentric pulmonary aspergillosis. Despite treatment with high-dose Abelcet (10 mg/kg daily), free amphotericin B was not detected in postmortem cerebellar tissue. A broad-spectrum triazole-based agent (voriconazole/UK-109, 496--Vfend), and a novel fungal cell wall inhibitor, an echinocandin/pneumocandin analog (caspofungin/MK-0991--Cancidas), which exhibit excellent in vitro activity against most clinical Pseudallescheria boydii-Scedosporium apiospermum isolates, have recently become available in the United States and may provide much needed treatment options for patients at risk.

Troy, Mycenae, and the otologic demise of Herr Heinrich Schliemann.

Heinrich Schliemann (1822-1890) was a self-made man with a remarkable aptitude for language and an excellent business mind. He was also the founder of Aegean archeology, providing a factual base for the writings of Homer, which until then had been considered merely a collection of mythologic poems. During his life, Schliemann suffered from ear trouble, ultimately dying from an otogenic temporal lobe brain abscess. He consulted many of the most famous 19th century otologists and was eventually operated on by the famous Professor Schwartze. We present the life and death of arguably the most famous man of his day as drawn from a number of biographic sources and speculate on the ear pathology that ultimately lead to his demise.

Brain abscess caused by Salmonella enteritidis in an immunocompetent adult patient: successful treatment with cefotaxime and ciprofloxacin.

A previously healthy 43-y-old man, who had spent 2 weeks in northern India, was admitted to hospital after a 2-day history of pyrexia, confusion and frontal headache. Cranial computerized tomography (CT) showed an abscess in the right parietal lobe. Spinal fluid and blood cultures gave growth of Salmonella enteritidis within 24 h. Treatment with cefotaxime was initiated, but ceased after 3 weeks due to drug fever, and ciprofloxacin was then given orally for 4 months. After 6 months, the patient was considered cured. Cases of salmonella brain abscesses are reviewed.

[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.

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.

Rhinocerebral mucormycosis with cerebral extension successfully treated with adjunctive hyperbaric oxygen therapy.

Rhinocerebral mucormycosis is a devastating fungal disease with a high mortality rate. Extensive surgical débridement and amphotericin B are currently the mainstays of therapy. When cerebral extension of the fungus occurs, the disease is almost invariably fatal. Two patients with rhinocerebral mucormycosis had progression of their infection to brain abscesses despite aggressive débridement surgery and amphotericin B therapy. Both patients showed marked clinical improvement with the addition of adjunctive hyperbaric oxygen therapy. Both patients remained free of their disease 21 months after hospital discharge.

Hyperbaric oxygen in the treatment of rhinocerebral mucormycosis.

Hyperbaric oxygen therapy was utilized in a case of fulminant mucormycosis of the maxilla, orbit and temporal bone. The patient had refused radical surgery and death seemed iminent in spite of aggressive medical management of diabetic ketoacidosis, amphotericin B and wide surgical drainage of the maxillary and ethmoid sinuses with orbital decompression. Hyperbaric oxygen was instituted on the following theoretical premises: 1. It would provide oxygenation of tissues distal to occluded arteries, thereby increasing local survival and decreasing acidosis, 2. resultant lessening of acidosis would slow or inhibit rapid growth of the organism, and 3. oxygen in sufficient concentration is fungicidal. The rapid progress of the mucormycosis was arrested. Cultures of tissue prior to hyperbaric oxygen treatment produced heavy growth of Rhizopus, and tissues cultured after therapy grew only bacterial contaminants. The patient survived for 3 mo. only to succumb to Pseudomonas meningitis secondary to necrotic bone and epidural abscess of the middle cranial fossa. Rhinocerebral mucormycosis is a fulminant and frequently fatal disease. No survivors were reported before extensive surgical debridement was utilized. Survival improved to 50% with the addition of amphotericin B. Early diagnosis and correction of underlying acidosis has further improved this to 85%. The response to hyperbaric oxygen in this case report possibly introduces a promising new adjunct to therapy of this serious disease.

The operation and death of Henry Schliemann.

Henry Schliemann's reputation as an archeologist, a linquist, a financial genius and a scholar is seldom recognized by Americans. His discovery of the ruins of Troy changed Homeric myths and legends into history and made him the founder of Aegean archeology. Recent popular books on Schliemann sketchily describe him otologic problems which eventually led to his death of an otogenic brain abscess. From a number of bibliographic sources, the details of Schliemann's ear history and the final months of his illness are recounted. The important information of Schliemann's ear operation by the famous Professor Swartze is presented.

Intrasellar abscess.

A case of intrasellar abscess in a 31-year-old male, with pituitary insufficiency, visual field and acuity disturbances, is reported. In the pus extracted at surgery E. coli and Staphylococcus haemolyticus were identified. The patient died 20 days after the operation. Necropsy revealed the fibrous capsule of an abscess in the hypophyseal region and putriform tissue at the level of the hypothalamus, with three small tumours one of which proved to be a craniopharyngioma.