Intra-abdominal abscess in the 1980s

Prompt recognition, early localization, and adequate drainage have contributed to the decreased morbidity and mortality rates associated with intra-abdominal abscess in the last decade. The physical examination, ultrasonography, computed tomography, and radionuclide scans provide information that leads to early detection and localization of abscess in almost all patients. Percutaneous drainage should be the initial procedure unless specific indications for surgery exist.     

Brain abscess

Opinion statement Optimal treatment of a brain abscess requires early clinical suspicion, and the diagnosis is usually made by identification of the abscess on contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI). The immediate first step is to reduce the potentially life-threatening brain mass (abscess and surrounding cerebral edema) and secure the diagnosis with culture specimens. This is usually accomplished by reducing the increased intracranial pressure (ICP) through surgical aspiration with or without drainage of the abscess pus. The surgical procedure chosen depends on several factors, including the location and type of abscess, multiplicity, and the medical condition of the patient. In addition, dexamethasone and hyperventilation may be required if brain herniation is imminent. The dexamethasone dose should be reduced as soon as the ICP is reduced because steroid administration may retard abscess capsule formation and decrease antibiotic concentrations within the abscess cavity. Antibiotic therapy should be started as soon as the diagnosis is made. Penicillin G or third-generation cephalosporins plus metronidazole are commonly given to treat both anaerobic and aerobic bacteria. The initial choice of antibiotic will vary on the basis of the suspected source of the brain organisms, which is most often either contiguous spread from a sinus or mastoid infection or hematogenous spread from a pulmonary, gastrointestinal, cardiac, or dental infection. Isolation and determination of the antibiotic sensitivities of the organism from abscess pus allow definitive antibiotic therapy. Patients should be managed in an intensive care unit. Phenytoin is often given to prevent seizures, which could further elevate the ICP. The duration of antimicrobial treatment is 4 to 8 weeks, during which time the patient should be monitored clinically and with repeated neuroimaging studies to ensure abscess resolution.     

Brain abscess in Saudi Arabia

There are significant variations among countries in the incidence of brain abscess. We report here 26 cases of brain abscess treated at the Neurosurgery Department of King Faisal University and Dammam Central Hospital Saudi Arabia over a six year period (1982–1988). This is 2.3% of total admissions to the two neurosurgery departments serving a population of approximately 1.2 million in the same period.Young males were most often affected (M/F ratio 3.3:1; 31% were less than 15 years old, 46% aged between 15–39 years, and 23% older than 40 years). Streptococcus was found to be the most common microorganism (38.4%). Mixed infection was seen in 15.3%, and sterile abscesses were found in 11.5% of the patients after aerobic and anaerobic cultures of the pus. Chronic otitis media and paranasal sinusitis predisposed the patients to abscess formation in 57.6% of the cases. The temporo-parietal area was the commonest site. Epilepsy was a complication in 30.7% of our patients, and the mortality rate was 15.3%.     

Brain abscess following intracerebral hematoma

A 53-year-old man fully conscious was admitted with lt. hemiparesis due to a rt. putaminal hemorrhage. A phlebitis of superficial vein at lt. leg was noted on the 7th hospital day. Following administration of antibiotics, he was afebrile three days after. But local inflammation of phlebitis and leukocytosis continued for over one week. He had no sign of infection thereafter. Four months later, the hemiparesis exacerbated. CT scan revealed a cystic lesion with ring-like enhancement at the site of the hematoma. He was afebrile and had no sign of meningeal irritation. The patient underwent a stereotaxic aspiration of brown turbid pus. The culture from the aspirate was positive for staphylococcus, and histopathological examination of the excised specimen demonstrated a brain abscess with hemosiderin deposits. Follow-up CT scan revealed a progressive diminution in the size of the abs cess. We felt the hematoma represented an area of locus minoris resistentiae and that bacterial seeding of the hematoma from phlebitis resulted in brain abscess formation. Brain abscess formation should be considered as having possibly developed in patients with clinical deterioration after cerebral vascular disease.     

Brain abscess: an overview

Intracranial abscess is a formidable entity. Despite the advent of newer antibiotics and surgical strategies, the overall outcome and quality of life issues in brain abscess patients still remain a continuous challenge for the neurosurgical community. It is a direct interplay between the virulence of the offending microorganism and the immune response of the host. An analysis of our experience in the 289 cases of surgically treated pyogenic brain abscess is presented along with an overview of intra-cranial abscess of varied etiology and in different locations. The etiology, pathogenesis, radiological advances and treatment modalities of brain abscess are discussed in light of current literature.     

Brain abscess as the presenting feature of melioidosis

Central nervous system involvement in melioidosis is rare and there are only a few reports of the causative organism, Burkholderia pseudomallei, causing a brain abscess. We report a patient who presented to us with a brain abscess due to this organism and emphasize the need for a high degree of suspicion for this disease in tropical countries and treatment with the appropriate antibiotics, as the mortality associated with this disease is very high.