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Original Article a Case Series of Brain Abscesses: an Eleven-Year Original Article A case series of brain abscesses: an eleven-year retrospective single center study Rami Waked1, Hassan Tarhini1,2, Hussein Mansour1, Gebrael Saliba1, Nabil Chehata1, Marie Chedid1, Elie Haddad1, Jacques Choucair1 1 Department of Infectious Diseases, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon 2 Department of Infectious Diseases, Bichat-Claude Bernard Hospital, APHP, Paris, France Abstract Introduction: We lack data on the epidemiology and management of brain abscesses in the Middle East. The aim of this study is to report a case series of brain abscesses admitted at a tertiary care center in Lebanon, between January 2008 and December 2018. Methodology: This retrospective study aimed at determining the demographic data, treatment, and correlations between different studied variables with prognosis of patients that received treatment. Results: Forty-one patients (30 males) were included with a median age of 37 years (2-85). The analysis showed that the classic triad of fever, headache and neurologic deficit was only present in 12% of patients on admission. The source of infection was contiguous in 36.5%, post surgical in 32%, and distant in 17% of cases. Stereotactic biopsy was performed in 41.5% of patients, and craniotomy in 19.5%. A microorganism was isolated in 63% of patients (26 cases). The most used antibiotics were carbapenems (46%) and glycopeptides (66%). Eighty percent of patient (33) had a good outcome. A worse prognosis was significantly correlated with immunosuppression and multiple cerebral abscesses. Conclusions: Brain abscess remains a relatively rare condition. Key words: Brain abscess; stereotactic biopsy; human immunodeficiency virus; antibiotics; patient prognosis. J Infect Dev Ctries 2021; 15(6):791-797. doi:10.3855/jidc.12816 (Received 14 April 2020 – Accepted 06 September 2020) Copyright © 2021 Waked et al. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction The treatment and outcome of intraparenchymal Intracranial abscesses can be divided into several abscesses has improved in the recent years, and this can categories depending on their anatomic location: be attributed to the modern neurosurgical techniques, intraparenchymal brain abscesses, subdural and including stereotactic brain biopsy, better culture extradural empyema. Intraparenchymal abscess is a techniques, antibiotics, and modern non-invasive focal collection of pus caused by bacteria, neuro-radiological imaging. Eradication of the main mycobacteria, fungi, protozoa, or helminths in the foci of infection is critical for favorable outcome parenchyma of the brain [1]. This infection is highly [2,7,8]. debilitating and associated with high mortality [2]. It The annual incidence of this disease has rarely been can arise from a contiguous (otogenic infection, dental reported in the literature: 0.9 per 100,000 persons-years infection, sinusitis or mastoiditis) or from a distant in Denmark and Minnesota [9,10]. This incidence is spread of a source of infection (congenital cyanotic higher in the immunocompromised population [11]. cardiomyopathy, endocarditis, pulmonary infection, Despite its severity, brain intraparenchymal etc.) [3]. These infections can also complicate a head infection has not been extensively studied in Middle injury, neurosurgery, or meningitis [3]. Intracranial Easter population. The aim of this study is to report the infections remain without any obvious source in cases of brain abscess recorded in a tertiary care center approximatively 25% to 35% of cases [4,5]. Direct in Beirut, Lebanon, between January 2008 and spread accounts for around 50 percent of cases [1]. December 2018. These cases were reviewed to Distant bacteremia is characterized by multiple cerebral document the epidemiology, possible causes, lesions [6]. treatments, and prognostic factors associated with Waked et al. – Brain abscess case series in a tertiary center J Infect Dev Ctries 2021; 15(6):791-797. outcome. The long-term outcome was not assessed in appropriate treatment. The overall mortality was this study. defined as death happening during hospitalization. Immunosuppression was defined by the presence of any Methodology of the following: poorly controlled diabetes, any This study was performed in a tertiary care vasculitis or other autoimmune disease that was treated university hospital. We retrospectively assessed with immunosuppressive agents, positive HIV status electronic medical records for the past eleven years with CD4 count of less than 200 mm3. (between January 2008 and December 2018) searching for “brain abscess”, “brain abscesses”, “cerebral Statistical Analysys abscess” and “cerebral abscesses” keywords using the Data were entered in IBM Statistical Package for International Classification of Diseases (ICD) 10 Social Sciences for Windows (SPSS version 25) and all discharge codes. Only patients that received treatment the data were analyzed. Ordinal scale data were were selected. analyzed as mean with standard deviation or median. We identified a total of forty-one cases. The The χ2 test was used for comparison of groups with following variables were retrospectively assessed by qualitative variables on nominal scale. A p value of 0.05 medical record review using a standardized data or less was considered significant and confidence collection form: sex, age, human immunodeficiency interval of 95% was selected for the analysis. virus (HIV) status, predisposing medical factors, radiologic images with location of the abscess, Ethics approval and consent to participate symptoms, microbiologic cultures, treatment, and The study was approved by the institutional review outcome. board at Saint Joseph University, Beirut (approval Brain abscess was defined as a localized lesion, number TFEM/2018/57). visible on a computerized tomography (CT) or magnetic resonance image (MRI) scan, located in the Results cerebrum, cerebellum, or midbrain, which met at least Between January 2008 and December 2018, 41 one of the following criteria: cases of brain abscesses were diagnosed and treated. A positive culture of intracerebral material or brain There was 30 (73.2%) males and 11 (26.8%) females abscess at histology or neuroradiological findings (ratio 3:1) with a median age of 37 years (range from 2 suggesting brain abscess plus radiological and clinical to 85 years). Age and sex distribution are shown in response to antimicrobial therapy. Figure 1. Contiguous focus of infection was defined as secondary to otogenic infection, dental infection, Clinical findings sinusitis, or mastoiditis. A poor outcome was defined as Neurologic deficit was the most common symptom death or invalidating neurological sequala despite on admission occurring in 24 (58.5%) patients. Twenty- three (56%) patients had fever and 22 (53.6%) Figure 1. Age and sex distribution of patients with brain presented with confusion and drowsiness. The classic abscesses. triad of fever, headache and neurologic deficit was only present in five cases (12%). Patients receiving corticosteroids or other immunosuppressive treatments did not present with initial fever. Laboratory findings Two biological serum markers were assessed on admission: white blood cells count and C-reactive protein (CRP) level. The CRP was within the normal range (< 3.5 mg/dL) in 17 patients (41.4%) with a mean of 68 mg/dL. Only 15 patients (36.5%) presented with hyperleukocytosis (defined as white blood cells count of more than 11,000×109 cells per liter). 792 Waked et al. – Brain abscess case series in a tertiary center J Infect Dev Ctries 2021; 15(6):791-797. Neuroradiological imaging and source of abscess A microorganism was isolated in 26 patients (63%). Intracerebral abscesses were detected on CT scans Eleven patients had organisms that are usually seen in in 22 patients (53%), and on MRIs in 16 patients (39%). immunocompromised hosts (Toxoplasma gondii, MRI was used in addition to CT in four patients (9.7%) Cryptococcus sp., Pneumocystis jirovecii, and because of image ambiguity. Twenty-eight patients mucormycosis). Toxoplasma gondii and Pneumocystis (68.3%) had a single brain abscess and 13 patients jirovecii were mostly isolated in HIV infected patients. (31.7%) had multiple abscesses detected. The most common site of infection was the frontal lobe (23 patients). Table 1. Characteristics of 41 patients with brain abscess. Source of infection was identified in 22 patients Characteristics No. (%) of cases (53.6%), out of which 15 had a contiguous and seven Presenting complaints: Fever 23 (56) had a distant foci of infection. The most prevalent Focal neurological deficit 22 (53.6) anatomical source for contiguous foci of infection was Headache 21 (51.2) the ear, nose, and throat (ENT) sphere (12 patients). Six Convulsion 21 (51.2) patients had a distant infection (4 pneumonias, 2 Nausea/vomiting 19 (46.3) endocarditis). Unconscious 17 (41.5) Decreased level of consciousness 10 (24.3) 1 Comorbidities and associated factors Location of the abscess : Immunosuppression (18 patients, 44%) and history Frontal 23 (56) Temporal 11 (26.8) of neurosurgery (13 patients, 32%) were the most Parietal 11 (26.8) frequent associated factors. Steroid usage and diabetes Occipital 9 (21.9) were amongst the main causes of immunosuppression Thalamus 3 (7.3) (12 and 11 patients respectively). Eight patients had Cerebellum 2 (4.8) HIV infection
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