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Multiple Brain Abscesses in a Neonate after Blood Stream Infection with Methicillin-Resistant Staphylococcus aureus
Multiple Brain Abscesses in a Neonate after Blood Stream Infection with Methicillin-Resistant Staphylococcus aureus
N
eonatal course of a preterm infant (29 weeks) was complicated by mechanical ventilation for the first 17 days of life and a blood stream infection with methicillin-resistant Staphylococcus aureus on day 13 of life. Sepsis work-up was performed on day 13 of life for repeated apnea and bradycardia. Lumbar puncture was performed approximately 48 hours after starting antibiotics; cerebrospinal fluid analysis was normal and culture remained negative. He was treated with a 14-day course of vancomycin. On day 52 of life, he was noted to have decreased activity and underwent a repeat sepsis work-up including complete blood count, C-reactive protein, and blood culture. His complete blood count revealed a white blood cell count of 15 000/dL with 1% bands, 34% neutrophils, and 51% lymphocytes. C-reactive protein was <2.90 mg/L and blood culture remained negative. A routine head-ultrasound performed at that time demonstrated new foci of increased echogenicity in the right cerebral parenchyma raising the possibility of focal parenchymal hemorrhages (Figure 1). Magnetic resonance imaging of the brain revealed multiple ring-enhancing lesions with large areas of vasogenic edema within the white matter (Figure 2). These findings were consistent with multiple brain abscesses. He was treated with a 6 weeks course of vancomycin and rifampin. Follow-up magnetic resonance imaging performed after completion of treatment showed complete resolution of ring-enhancing lesions. There are limited reports of staphylococcal brain abscesses in neonates,1,2 with only 1 report of methicillin-resistant Staphylococcus aureus-associated brain abscesses in a 3-month-old ex-26 weeks premature infant, who eventually
Figure 2. Magnetic resonance imaging of the brain showing multiple ring-enhancing lesions with areas of vasogenic edema.
died.3 Our case emphasizes the importance of performing a complete sepsis evaluation including a lumbar puncture prior to starting antibiotics in neonates with suspected sepsis.4 Another important message is the need to thoroughly evaluate any suspicious findings on head ultrasound, especially if the timeline and location do not fit a typical description of intracranial hemorrhage. n Prem Arora, MD, FAAP Vaneet Kumar Kalra, MD Athina Pappas, MD, FAAP
Figure 1. Head-ultrasound with foci of increased echogenicity in the right cerebral parenchyma.
The Carman and Ann Adams Department of Pediatrics Division of Neonatal-Perinatal Medicine Wayne State University School of Medicine Detroit Medical Center Children’s Hospital of Michigan Hutzel Women’s Hospital Detroit, Michigan
References available at www.jpeds.com J Pediatr 2012;161:563. 0022-3476/$ - see front matter. Copyright ª 2012 Mosby Inc. All rights reserved. 10.1016/j.jpeds.2012.04.016
563
THE JOURNAL OF PEDIATRICS
www.jpeds.com
References 1. Regev RH, Dolfin TZ, Zamir C. Multiple brain abscesses in a premature infant: complication of Staphylococcus aureus sepsis. Acta Paediatr 1995; 84:585-7. 2. Vartzelis G, Theodoridou M, Daikos GL, Dellagrammaticas H, Syriopoulou VP. Brain abscesses complicating Staphylococcus aureus sepsis in a premature infant. Infection 2005;33:36-8.
563.e1
Vol. 161, No. 3 3. Woodlief RS, Markowitz JE. Unrecognized invasive infection in a neonate colonized with methicillin-resistant Staphylococcus aureus. J Pediatr 2009; 155:943-943.e1. 4. Garges HP, Moody MA, Cotton CM, Smith PM, Tiffany KF, Lenfestey R, et al. Neonatal meningitis: what is the correlation among cerebrospinal fluid cultures, blood cultures, and cerebrospinal fluid parameters? Pediatrics 2006;117:1094-100.
Arora, Kalra, and Pappas
N
eonatal course of a preterm infant (29 weeks) was complicated by mechanical ventilation for the first 17 days of life and a blood stream infection with methicillin-resistant Staphylococcus aureus on day 13 of life. Sepsis work-up was performed on day 13 of life for repeated apnea and bradycardia. Lumbar puncture was performed approximately 48 hours after starting antibiotics; cerebrospinal fluid analysis was normal and culture remained negative. He was treated with a 14-day course of vancomycin. On day 52 of life, he was noted to have decreased activity and underwent a repeat sepsis work-up including complete blood count, C-reactive protein, and blood culture. His complete blood count revealed a white blood cell count of 15 000/dL with 1% bands, 34% neutrophils, and 51% lymphocytes. C-reactive protein was <2.90 mg/L and blood culture remained negative. A routine head-ultrasound performed at that time demonstrated new foci of increased echogenicity in the right cerebral parenchyma raising the possibility of focal parenchymal hemorrhages (Figure 1). Magnetic resonance imaging of the brain revealed multiple ring-enhancing lesions with large areas of vasogenic edema within the white matter (Figure 2). These findings were consistent with multiple brain abscesses. He was treated with a 6 weeks course of vancomycin and rifampin. Follow-up magnetic resonance imaging performed after completion of treatment showed complete resolution of ring-enhancing lesions. There are limited reports of staphylococcal brain abscesses in neonates,1,2 with only 1 report of methicillin-resistant Staphylococcus aureus-associated brain abscesses in a 3-month-old ex-26 weeks premature infant, who eventually
Figure 2. Magnetic resonance imaging of the brain showing multiple ring-enhancing lesions with areas of vasogenic edema.
died.3 Our case emphasizes the importance of performing a complete sepsis evaluation including a lumbar puncture prior to starting antibiotics in neonates with suspected sepsis.4 Another important message is the need to thoroughly evaluate any suspicious findings on head ultrasound, especially if the timeline and location do not fit a typical description of intracranial hemorrhage. n Prem Arora, MD, FAAP Vaneet Kumar Kalra, MD Athina Pappas, MD, FAAP
Figure 1. Head-ultrasound with foci of increased echogenicity in the right cerebral parenchyma.
The Carman and Ann Adams Department of Pediatrics Division of Neonatal-Perinatal Medicine Wayne State University School of Medicine Detroit Medical Center Children’s Hospital of Michigan Hutzel Women’s Hospital Detroit, Michigan
References available at www.jpeds.com J Pediatr 2012;161:563. 0022-3476/$ - see front matter. Copyright ª 2012 Mosby Inc. All rights reserved. 10.1016/j.jpeds.2012.04.016
563
THE JOURNAL OF PEDIATRICS
www.jpeds.com
References 1. Regev RH, Dolfin TZ, Zamir C. Multiple brain abscesses in a premature infant: complication of Staphylococcus aureus sepsis. Acta Paediatr 1995; 84:585-7. 2. Vartzelis G, Theodoridou M, Daikos GL, Dellagrammaticas H, Syriopoulou VP. Brain abscesses complicating Staphylococcus aureus sepsis in a premature infant. Infection 2005;33:36-8.
563.e1
Vol. 161, No. 3 3. Woodlief RS, Markowitz JE. Unrecognized invasive infection in a neonate colonized with methicillin-resistant Staphylococcus aureus. J Pediatr 2009; 155:943-943.e1. 4. Garges HP, Moody MA, Cotton CM, Smith PM, Tiffany KF, Lenfestey R, et al. Neonatal meningitis: what is the correlation among cerebrospinal fluid cultures, blood cultures, and cerebrospinal fluid parameters? Pediatrics 2006;117:1094-100.
Arora, Kalra, and Pappas