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Medically complex 3-year-old female presents with fever, seizures
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A 3-year-old female with multiple health problems, including chronic lung disease with a tracheostomy and requiring total parenteral nutrition-via a central port, presents with fever and seizures. The patient had not been diagnosed with seizures in the past. Additionally, the patient is frequently receiving oral antimicrobial therapy for various problems, including at the time of this presentation, a fever.
Examination revealed fever (temperature of 102° F) and mental status consistent with a post-ictal state, along with the tracheostomy and central line noted above. Otherwise, there are no new findings noted.
Lab tests reveal a CBC with an elevated white blood cell count of 23,000 and an erythrocyte sedimentation rate of more than 100. Because of the patient’s altered mental status, a brain MRI was performed before a lumbar puncture — shown in Figure 1 — revealing a ring-enhancing lesion measuring 19.8 mm in diameter. Spinal fluid was obtained that revealed a white blood cell count of 250 with a predominance of granulocytes, a protein of 65 mg/dL, glucose of 58 and a negative Gram’s stain. Culture of the spinal fluid and blood are pending. A chest radiograph is shown in Figure 2. An echocardiogram reveals left ventricular papillary muscle vegetation (Figure 3).
What’s Your Treatment?
A. Ampicillin plus cefotaxime
B. Nafcillin plus ceftriaxone plus clindamycin
C. Imipenem plus vancomycin
D. Meropenem plus vancomycin
Case Discussion
Of the choices listed above, empiric treatment for a brain abscess with endocarditis, caused by a central line is best with meropenem plus vancomycin. Treatment must include therapy with bactericidal agents against Staphylococcus aureus, as well as other multiple possibilities, with good central nervous system (CNS) penetration. Clindamycin is never a good choice for a CNS infection. Meropenem has excellent CNS penetration, with broad-spectrum activity against anaerobes and aerobes alike, including many gram-negative and gram-positive organisms, and is generally less toxic in children.
Vancomycin is the drug of choice for S. aureus infections that may include MRSA of the CNS pending sensitivity testing. Additionally, for treatment of the endocarditis, as is usually recommended, gentamicin was added for the first 2 weeks of therapy for synergy. Meropenem and vancomycin were continued for a total of 8 weeks, with complete resolution of both sites of infection.
A shorter course of therapy might be possible with drainage of the brain abscess; however, the location and size made medical therapy preferred. Most neurosurgeons adhere to the 2-cm rule when it comes to draining brain abscesses, if they can be reached. At 1.98 cm, the above-mentioned abscess was considered too small and too deep within the brain to drain safely.
Source: James H. Brien, DO
Management of brain abscesses have been featured in my column on several occasions: First in January 1999, then in December 2004, and most recently in February 2011. In this last column, I discussed a case of an infant with 11 discrete abscesses due to Streptococcus milleri in the brain, which were successfully treated with medical therapy alone over a 6-month period (Figures 4 to 5). Surgical drainage certainly allows for a shorter course of therapy, but rescanning showing resolution of the abscess and normalization of inflammatory markers is always advisable before discontinuing antimicrobial therapy.
- For more information:
- James H. Brien, DO, is with the department of infectious diseases at McLane Children’s Hospital, Baylor Scott & White Health, Texas A&M College of Medicine in Temple, Texas. He also is a member of the Infectious Diseases in Children Editorial Board. Brien can be reached at: jhbrien@aol.com.
Disclosure: Brien reports no relevant financial disclosures.
Columnist Comment
Get your flu shot, and I hope to see you in New York at the 30th Annual Infectious Diseases in Children Symposium next month (November 18-19). There is a cavalcade of all-star speakers lined up on the agenda, for great CME and a good time.