Large brain abscess in a newborn.

Dear Sir,

Brain abscess in newborns is a very rare disease. It is a focal, intracerebral infection that begins as a localized area of cerebritis and develops into a collection of pus surrounded by a well-vascularized capsule. Early capsulation is seen in 10–13 days. We report a case of large well-encapsulated brain abscesses diagnosed in a neonate on postnatal day 7. Such a large well-encapsulated brain abscess in a neonate of 7 days makes it interesting.

A male child on postnatal day 7 was referred to our hospital with history of irritability, vomiting, poor feeding and convulsion for last 4 days. He was delivered by normal vaginal route at 37 weeks of gestation with a weight of 2250 g. He cried immediately after birth, his head circumference was 35 cm with prominent and bulging anterior fontanelle. The gestational period was uneventful, and the mother was being followed regularly by an obstetrician who identified urinary tract infection in mother in last trimester, for which she was prescribed antibiotic. On postnatal day 3, the child became irritable and was not feeding well with frequent vomiting and generalized tonic-clonic seizures. He was initially treated at a primary healthcare center with intravenous fluid and anticonvulsant. On examination, we observed that he was febrile, irritable, crying vigorously when lying down, and his parents had not been able to stop his crying. The anterior fontanelle was tensely bulging, and the suture line was widened. There was neither an evidence of dermal sinus anywhere in the body nor any portal of entry of infection. The serological markers were negative for toxoplasma, cytomegalovirus, rubella, and herpes viruses. A complete blood count revealed a hemoglobin level 12 g/dl, hematocrit 25%, white blood cell count 19,000/mm3 with 70% neutrophils, 125,000/mm3 thrombocytes. Computerized tomography scan of brain revealed large well-encapsulated left frontal brain abscess and midline shift [Figures 1 and 2]. An emergency aspiration was undertaken, through a left frontal burr hole under local anesthesia and about 300 ml of thin yellow pus was evacuated slowly. An infant feeding tube was left inside abscess cavity for subsequent drainage of residual pus. Pus smear showed Gram-negative cocci and culture grew Escherichia coli sensitive to a large number of antibiotics, including cephalosporines and nitrofurantoin. The patient received intravenous ceftriaxone for 14 days. Subsequently, his temperature became normal, and the level of consciousness improved. Oral antibiotic, nitrofurantoin were continued for 4 weeks. At follow-up, 12 months later the patient was doing well with normal milestones [Figure 3].

Figure 1

Axial contrast computerized tomography scan of brain showing a large well-encapsulated left frontal brain abscess of size (90.5 mm × 76 mm) with mass effect

Figure 2

Sagittal contrast computerized tomography scan of brain showing the above said large brain abscess

Figure 3

Axial plain computerized tomography scan at 1 year follow-up showing, left frontal encephalomalacic change at abscess site

Common source of infection in brain abscess are sinusitis, otitis media, osteomyelitis and pulmonary infections.[12] However, in infants and neonates common causes are neonatal meningitis and septicemia.[3] The present case is a unique report of a brain abscess in a neonate on postnatal day 7; that might be the result of an intrauterine infection (urinary tract infection in mother in last trimester).

The therapeutic management of neonatal brain abscess requires a multidisciplinary approach involving intensivists, neurosurgeons, radiologists.[45] Treatment with broad-spectrum intravenous antibiotics and early neurosurgical drainage performed by experienced hands seems to be the most effective approach in these high-risk pediatric patients.