After bout with pneumonia, toddler presents with emesis, altered mental status and fever
What’s your diagnosis?
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A 20-month-old male presents with acute onset of emesis, altered mental status and fever. Soon after admission to the pediatric ICU, he began having seizures and became obtunded.
His past medical history was positive for being hospitalized with lobar pneumonia (Figure 1) 2 weeks earlier, and he had just finished a course of oral antibiotics. Otherwise, he has been a healthy child, with no history of recurrent ear, sinus or other pulmonary infections.
His immunizations are up to date, there has been no travel or sick contacts, and he eats an age-appropriate diet. He lives with his parents, and there are no pets. He attends day care.
Examination revealed a pale, obtunded child with a temperature of 99°F/37.2°C, blood pressure of 137/100, a pulse of 150 and respirations of 70, with clear breath sounds. His neurologic exam revealed some mild left-sided weakness and possible left facial droop. His cardiac exam revealed a sinus tachycardia without a murmur and normal pulses. The rest of the exam was unremarkable.
Lab tests included a complete blood count with an elevated white blood cell count and a normal differential, a normal complete metabolic profile and normal urine analysis. A chest radiograph on admission showed clearing of the previously noted pneumonia. An MRI of the brain is shown in Figures 2 to 5. Material was surgically aspirated from the lesion in the right parietal area seen in Figure 5, and the culture on blood agar is growing small colonies with a surrounding greenish hue.
What’s your diagnosis?
A. Anginosus group streptococci
B. Pseudomonas aeruginosa
C. Staphylococcus aureus
D. Taenia solium
Answer and discussion:
This child had multiple brain abscesses (11 total). He was originally shown in this column in the February 2011 issue. The problem resulted from a hematogenously spread organism, which at that time was known as Streptococcus milleri — a gram-positive, facultative anaerobe that usually demonstrates alpha-hemolysis, thus the greenish color about the colonies and placing it into the viridans group. It is often part of the oral flora, where under compromising circumstances, it can spread to adjacent structures and hematogenously to various distant sites. In this case, the pneumonia probably occurred at or shortly before the organism “showered” the brain. The nomenclature of the organism changed a few years later to the anginosus group streptococci (answer A), which grew from aspirated material. This group includes three species: Streptococcus anginosus, Streptococcus intermedius and Streptococcus constellatus. Although no organism was recovered during the hospitalization for pneumonia a couple of weeks earlier, this organism was likely the cause of the lobar pneumonia he experienced at that time. If you consider all causes of brain abscesses in children, this group of streptococci leads the list, followed by staphylococci. Brain abscesses may be 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. His treatment was guided by serial MRIs, with a total of 130 days of IV ceftriaxone given mostly at home via several PICC lines (Figure 6).
The last MRI revealed essentially complete resolution of even the largest of the abscesses (Figure 7).
As noted, Staphylococcus aureus may be a bit less common but might look the same clinically, which is why a positive culture is so important, because the treatment would obviously be significantly different. The greenish color of the colonies on the culture plate made the organism consistent with being in the viridans group, and while this can be misleading, it is more consistent with the anginosus group streptococci.
Pseudomonas 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 left temporal lobe.
Taenia 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, including the brain, and develop into cysticerci. However, they tend not to be as large as some brain abscesses, and radiologists can often distinguish the scolex within the cyst, making the diagnosis visually. If there are multiple lesions, one can sometimes detect serum antibody against Taenia solium, but solitary lesions are often seronegative. The presentation of a brain abscess is also likely to be more dramatic with fever and neurologic symptoms, especially if there are multiple, whereas neurocysticercosis may be asymptomatic or tends to present with seizures and/or headache. Symptoms are most likely provoked by the surrounding edema associated with the breakdown of the cyst, which can take months to occur.
Columnist comments:
As the late Paul Harvey used to say, “and now the rest of the story.” By serendipity, I saw this patient’s mother recently, who spoke with me at some length about her child and how well he has done in all aspects of his life in the 12 years since the infection, and she gave me permission to use his pictures in this updated column.
After his prolonged course of ceftriaxone, he continued to have normal growth and development in every area (Figures 10 to 11).
He is now a sophomore in a very academically competitive high school and plays on the football team (Figure 12) and the soccer team and is active in raising animals with the Future Farmers of America (Figure 13).
He not only fully recovered, but he has excelled in life since this life-threatening infection. Since he has done so well, I would not suggest that having numerous brain abscesses with this organism is harmless but rather point to the incredible power a child has for recovery against the odds. If allowed, I hope to follow this incredible young man well into adulthood and marvel at his achievements.
For more information:
Brien is a member of the Healio Pediatrics Peer Perspective Board and an adjunct professor of pediatric infectious diseases at McLane Children's Hospital, Baylor Scott & White Health, in Temple, Texas. He can be reached at jhbrien@aol.com.