Bifrontal brain abscesses secondary to orbital cellulitis ...
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CLINICAL IMAGE Open Access Bifrontal brain abscesses secondary to orbital cellulitis and sinusitis extension David Traficante * , Alexander Riss and Steven Hochman Abstract Background: Intracranial abscesses are rare and life-threatening conditions that typically originate from direct extension from nearby structures, hematogenous dissemination or following penetrating cerebral trauma or neurosurgery. Findings: A 36-year-old male presented to our emergency department with complaints of left eye swelling, headache and drowsiness. On physical exam, the patient was febrile and his left upper eyelid was markedly swollen with fluctuance and drainage. Maxillofacial computed tomography was obtained to evaluate for orbital pathology but revealed bifrontal brain abscesses. Conclusions: Brain abscesses should be considered in the differential diagnosis for patients who present with the classic triad of headache, fever and neurological deficit. Keywords: Brain abscess, Emergency medicine, Infectious disease, Orbital cellulitis, Sinusitis Findings Case synopsis A 36-year-old Hispanic male presented to the emergency department (ED) with complaints of left eye swelling, headache and drowsiness. The patient had been seen two weeks prior to this visit at another emergency de- partment for left eye swelling. At that time, he was diag- nosed with a periorbital abscess and discharged home from the ED on a course of oral antibiotics. Over the fol- lowing two weeks, the patient’ s symptoms progressed to headache and increasing lethargy. The patient now also reported worsening left upper eyelid swelling with dis- charge and painful range of motion of the left globe. He reported no vision changes. In the ED, the patient was febrile, temperature was 102 °F. The left upper eyelid was swollen, erythematous, and fluctuant with pointing and purulent yellowish discharge. Visual acuity was 20/20 in both eyes. There were no focal motor or sensory deficits on exam. However, the patient did exhibit mental status changes including indifference to his current condition and a flat affect which was inconsistent with his baseline. Computed tomography (CT) maxillofacial was initially obtained due to concern for orbital cellulitis and/or intraorbital abscess (Fig. 1). The study revealed two rim- enhancing fluid collections seen within the frontal lobes bilaterally. Magnetic resonance imaging (MRI) of the brain subsequently confirmed the presence of bifrontal brain abscesses, as well as left orbital cellulitis, periorbital abscess, and pansinusitis (Fig. 2, Fig. 3). The patient was managed with IV antibiotics, bilateral burr holes for brain abscess drainage followed immediately by bilateral endo- scopic ethmoidectomy, antrostomy, sphenoid sinusotomy, frontal sinusotomy and incision and drainage (I&D) of the left upper eyelid abscess. Brain abscess cultures were posi- tive for Streptococcus anginosus and Prevotella intermedia. The patient was seen in the ED six months after initial presentation for an unrelated complaint and at that time had no residual deficits. Bifrontal brain abscesses Brain abscesses are focal pyogenic intracerebal infections which may present as life-threatening emergencies [1]. Infections can occur within the brain by direct extension from nearby structures, hematogenous dissemination or following penetrating cerebral trauma or neurosurgery [2]. Immunocompromised hosts are at particular risk, with etiologies in these patients commonly secondary to amebic or fungal infection. The classic triad for the clinical presentation of brain abscess includes headache, * Correspondence: [email protected] Department of Emergency Medicine, St. Joseph’s Regional Medical Center, 703 Main St., Paterson, NJ 07030, USA International Journal of Emergency Medicine © 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Traficante et al. International Journal of Emergency Medicine (2016) 9:23 DOI 10.1186/s12245-016-0117-4
Transcript of Bifrontal brain abscesses secondary to orbital cellulitis ...
CLINICAL IMAGE Open Access
Bifrontal brain abscesses secondary toorbital cellulitis and sinusitis extensionDavid Traficante* , Alexander Riss and Steven Hochman
Abstract
Background: Intracranial abscesses are rare and life-threatening conditions that typically originate from directextension from nearby structures, hematogenous dissemination or following penetrating cerebral trauma orneurosurgery.
Findings: A 36-year-old male presented to our emergency department with complaints of left eye swelling,headache and drowsiness. On physical exam, the patient was febrile and his left upper eyelid was markedly swollenwith fluctuance and drainage. Maxillofacial computed tomography was obtained to evaluate for orbital pathologybut revealed bifrontal brain abscesses.
Conclusions: Brain abscesses should be considered in the differential diagnosis for patients who present with theclassic triad of headache, fever and neurological deficit.
Keywords: Brain abscess, Emergency medicine, Infectious disease, Orbital cellulitis, Sinusitis
FindingsCase synopsisA 36-year-old Hispanic male presented to the emergencydepartment (ED) with complaints of left eye swelling,headache and drowsiness. The patient had been seentwo weeks prior to this visit at another emergency de-partment for left eye swelling. At that time, he was diag-nosed with a periorbital abscess and discharged homefrom the ED on a course of oral antibiotics. Over the fol-lowing two weeks, the patient’s symptoms progressed toheadache and increasing lethargy. The patient now alsoreported worsening left upper eyelid swelling with dis-charge and painful range of motion of the left globe. Hereported no vision changes. In the ED, the patient wasfebrile, temperature was 102 °F. The left upper eyelid wasswollen, erythematous, and fluctuant with pointing andpurulent yellowish discharge. Visual acuity was 20/20 inboth eyes. There were no focal motor or sensory deficitson exam. However, the patient did exhibit mental statuschanges including indifference to his current conditionand a flat affect which was inconsistent with his baseline.Computed tomography (CT) maxillofacial was initially
obtained due to concern for orbital cellulitis and/or
intraorbital abscess (Fig. 1). The study revealed two rim-enhancing fluid collections seen within the frontal lobesbilaterally. Magnetic resonance imaging (MRI) of the brainsubsequently confirmed the presence of bifrontal brainabscesses, as well as left orbital cellulitis, periorbitalabscess, and pansinusitis (Fig. 2, Fig. 3). The patient wasmanaged with IV antibiotics, bilateral burr holes for brainabscess drainage followed immediately by bilateral endo-scopic ethmoidectomy, antrostomy, sphenoid sinusotomy,frontal sinusotomy and incision and drainage (I&D) of theleft upper eyelid abscess. Brain abscess cultures were posi-tive for Streptococcus anginosus and Prevotella intermedia.The patient was seen in the ED six months after initialpresentation for an unrelated complaint and at that timehad no residual deficits.
Bifrontal brain abscessesBrain abscesses are focal pyogenic intracerebal infectionswhich may present as life-threatening emergencies [1].Infections can occur within the brain by direct extensionfrom nearby structures, hematogenous dissemination orfollowing penetrating cerebral trauma or neurosurgery[2]. Immunocompromised hosts are at particular risk,with etiologies in these patients commonly secondary toamebic or fungal infection. The classic triad for theclinical presentation of brain abscess includes headache,
* Correspondence: [email protected] of Emergency Medicine, St. Joseph’s Regional Medical Center,703 Main St., Paterson, NJ 07030, USA
International Journal ofEmergency Medicine
© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made.
Traficante et al. International Journal of Emergency Medicine (2016) 9:23 DOI 10.1186/s12245-016-0117-4
fever and focal neurological deficit, although thewhole triad is seen in less than 50 % of cases [3].This patient’s presentation with flat affect interestinglycoincides with the psychopathology of the abscesslocation in the frontal lobes. Diagnosis is made byimaging studies including CT and MRI but is some-times seen on radionuclide scans. Typically, imageswill reveal a ring-enhancing lesion with variablesurrounding edema [4]. Treatment of brain abscessesrequires a combination of drainage and antimicrobial
therapy. Until gram stain results are available, anti-biotic regimens should be based on the presumptivesource of the infection.
AbbreviationsED, emergency department; I&D, Incision and drainage; CT, computedtomography; MRI, magnetic resonance imaging
AcknowledgementsNone.
Authors’ contributionsDT drafted the manuscript. AR treated the patient and revised themanuscript. SH helped to draft the manuscript and revised it.All authors read and approved the final manuscript.
Authors’ informationDT is a third year Emergency Medicine resident physician at St. Joseph’sRegional Medical Center. AR is an attending physician in the Department ofEmergency Medicine at St. Joseph’s Regional Medical Center. SH is anattending physician and faculty in the Department of Emergency Medicineat St. Joseph’s Regional Medical Center and New York Medical College.
Competing interestsThe authors declare that they have no competing interests.
Consent for publicationWritten informed consent was obtained from the patient for publication ofthis case report and any accompanying images. A copy of the writtenconsent is available for review by the Editor-in-Chief of this journal.
Received: 8 May 2016 Accepted: 28 June 2016
Fig. 1 CT maxillofacial, axial view, demonstrating the finding ofbifrontal rim-enhancing fluid collections
Fig. 2 MRI brain, saggital view. Note the hyperintensity extendingfrom the frontal sinus to the abscess cavity
Fig. 3 MRI brain, axial view
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References1. Muzumdar D, Jhawar S, Goel A. Brain abscess: an overview. Int J Surg.
2011;9(2):136–44.2. Bernardini GL. Diagnosis and management of brain abscess and subdural
empyema. Curr Neurol Neurosci Rep. 2004;4(6):448–56.3. Menon S, Bharadwaj R, Chowdhary A, Kaundinya DV, Palande DA. Current
epidemiology of intracranial abscesses: a prospective 5 year study.J Med Microbiol. 2008;57(Pt 10):1259–68.
4. Kastrup O, Wanke I, Maschke M. Neuroimaging of infections. NeuroRx.2005;2(2):324–32.
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