20-month-old male presents with acute onset of emesis

Issue: February 2011

A 20-month-old male presents with acute onset of emesis, altered mental status and fever. Soon after admission to the PICU, he began having seizures and became obtunded.

His past medical history was positive for being recently hospitalized with lobar pneumonia (Figure 1) 2-weeks earlier, and he had just finished a course of oral antibiotics a few days earlier. He also had a history of a seizure 5 months earlier with a negative work-up. Otherwise, he has been a healthy child, with no history of recurrent ear, sinus or pulmonary infections.

James H. Brien

His immunizations are up to date, and there has been no travel or sick contacts. He lives with his parents and there are no pets. He does attend day care.

Examination revealed a pale, obtunded child with a temperature of 99·F, BP=137/100, pulse=150, respirations=70. His neurologic exam revealed some mild left-sided weakness and possible left facial droop. His cardiac exam revealed a normal sinus rhythm without a murmur and normal pulses. The rest of the exam was unremarkable.

Lab tests included a CBC with an elevated white blood cell count, a normal comprehensive metabolic profile and urinalysis. A chest radiograph on admission is shown in Figure 2. An MRI of the brain is shown in Figures 3 to 6.

What’s Your Diagnosis?

A. Taenia solium

B. Staphylococcus aureus

C. Streptococcus milleri

D. Pseudomonas aeruginosa


X-ray from 2 weeks prior shows lobar pneumonia.	The patient’s chest radiograph taken on admission.


Figures 3-6: MRI images of the patient’s brain. Images: Brien JH

This is a child with multiple brain abscesses from hematogenously spread Streptococcus milleri (C), which grew from the peripheral abscess in the right parietal area. Although no organism was recovered during the hospitalization a couple of weeks earlier, it was likely the cause of the lobar pneumonia he experienced at that time. That is probably when the brain was “seeded.” If you take all comers, streptococci leads the list of causes of brain abscesses in children, especially those that are hematogenous in origin, and S. milleri has become the most common type of strep isolated from brain abscesses in both adults and children. These abscesses are often associated with congenital or acquired heart disease with high-grade bacteremia; however, this patient had no clinical or echocardiographic evidence of any heart problem. In fact, he had a detailed evaluation of his heart, sinuses, pulmonary and immune systems, without discovering anything abnormal. He ended up being treated with 130 days of IV ceftriaxone, mostly at home via several peripherally inserted central catheters (PICC). His serial MRIs revealed almost complete resolution of even the largest of the abscesses (Figure 7). He remains well, more than a year later.

S. aureus may be less common, but may look the same, which is why a positive culture is so important, as the treatment is obviously significantly different.

P. aeruginosa is most likely to be associated with a complicated ear infection, usually with mastoiditis, as shown in Figure 8, a patient who had a Pseudomonas abscess in the temporal lobe as a complication of a mastoidectomy.

T. solium is the pork tapeworm and the cause of neurocysticercosis, which can result in similar-appearing brain lesions (Figure 9) when embryonated ova are ingested. The eggs hatch under the influence of bile and stomach acid, releasing the oncospheres (larvae), which penetrate the gut wall and travel through the circulation to distant sites and develop into cysticerci. However, they tend not to be as large as some of the brain abscesses, and radiologists can often distinguish the scolex within the cyst. If there are multiple lesions, one can sometimes detect serum antibody against T. solium, but solitary lesions are often sero-negative.

Serial MRIs revealed almost complete resolution of even the largest of the abscesses.

Image shows a complicated ear infection with mastoiditis, most likely associated. P. aeruginosa.

The presentation of a brain abscess is also likely to be more dramatic with fever and neurologic symptoms, such as mental status changes, especially if multiple, whereas neurocysticercosis tends to present with seizures and/or headache, but about 15% will have some mental status changes. Symptoms tend to be provoked by the edema associated with breakdown of the cyst, which can take months to years. This was discussed in some detail in the January 2003 What’s Your Diagnosis. Perhaps it’s time to present another case to discuss diagnosis and treatment in more detail. There can obviously be significant overlap between brain abscess and neurocysticercosis, challenging the clinician and radiologist.

T. solium is the pork tapeworm and the cause of neurocysticercosis, which can result in similar-appearing brain lesions when embryonated ova are ingested.

As this patient demonstrated, these lines can present several problems, including infection of the line and/or the insertion site, obstruction, leaking, breaking and accidental removal.

Columnist comments: This patient was successfully treated with prolonged IV antibiotics through several PICC lines. Obviously, an abscess that can be drained, should be drained. But as this patient demonstrated, that’s not always possible, as most of his abscesses were not accessible without significant risk from the procedure, and if you treat long enough, they will usually shrink to the point of disappearance. However, PICC lines are not the answer for all patients requiring home therapy for serious infections. As this patient demonstrated, these lines can present several problems along the way, including infection of the line and/or the insertion site (Figure 10 from the same patient), obstruction, leaking, breaking and accidental removal.

As a result, we are rediscovering what John D. Nelson, MD, George H. McCracken Jr., MD, and others taught us in the 1980s about the effectiveness of high-dose oral therapy in certain serious infections using sequential IV to oral therapy, guided by serum bactericidal titers. I’m not suggesting that a patient with brain abscesses should be treated with oral antibiotics, but we are sending fewer children home with PICC lines nowadays in favor of oral therapy as long as they fit the following criteria: No central nervous system or heart infection, no gastrointestinal absorption problems, infection with known bacteria with susceptibilities or clear clinical and laboratory improvement on single antibiotic therapy, a suitable oral analogue with at least 90% bioavailability and good parental compliance. We don’t use serum bactericidal titers anymore because they are fairly labor-intensive and not any better than using trends in the inflammatory markers, such as C-reactive protein, along with clinical improvement.

These guidelines are taken in part from recommendations by Jim Todd, MD, at The Children’s Hospital of Denver during the 28th Annual Conference on Pediatric Infectious Diseases, an excellent pediatric infectious diseases update held at Vail, Colo., each summer. This year, it will be from July 31 to Aug. 5. For more details, contact Kris Beam at beam.kris@tchden.org, or go to the site for The Children’s Hospital at http://www1.thechildrenshospital.org/Events/index.aspx.

Look for more trends back in the direction of sequential IV–PO therapy for bone and joint infections, as well as complicated pneumonias and other serious infections.

Next month, the 45th Annual Uniformed Services Pediatric Seminar will be held in Washington, D.C. Go to the following site for details: www.aap.org/sections/uniformedservices/usps.htm.

It’s a great AAP-sponsored CME opportunity.

James H. Brien, DO, is Vice Chair for Education at The Children’s Hospital at Scott and White and is the Associate Professor of Pediatrics at Texas A&M University, College of Medicine, Temple, Texas. e-mail: jhbrien@aol.com.

Disclosure: Dr. Brien reports no direct financial disclosures.