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Postcraniotomy gas-containing brain abscess: a neurosurgical emergency
Postcraniotomy Gas-containing Brain Abscess: A Neurosurgical Emergency CASE REPORT Jose´ E. Cohen, M.D.,* Rodrigo Mierez, M.D.,* and Eve C. Tsai, M.D.† *Departmento de Neurocirugı´a, Hospital de Emergencias “Dr. Clemente Alvarez”, Universidad Nacional de Rosario, Rosario, Argentina; and †Department of Neurosurgery, Sunnybrook Health Science Centre, University of Toronto, Toronto, Canada
Cohen JE, Mierez R, Tsai EC. Postcraniotomy gas-containing brain abscess: a neurosurgical emergency. Case report. Surg Neurol 1999;51:568 –70. BACKGROUND
Gas-containing brain abscesses are very rare, and the majority are caused by Clostridium perfringens. We report a case of gas-containing brain abscess that required urgent surgery after a craniotomy for a brain tumor. METHODS AND RESULTS
The patient was a 53-year-old male who presented with a cerebral neoplasm. A temporal lobectomy was performed and the diagnosis of low grade glioma was confirmed. Although the surgery was uneventful the postoperative course was complicated; the patient became agitated and febrile and deteriorated to a deep coma. A computed tomography scan demonstrated gas in the temporal fossa at the lobectomy site, producing mass effect. Urgent surgical debridement and drainage was performed and C. perfringens and mixed flora were found. Antibiotics were started and the patient’s condition markedly improved. He was awake and alert, followed commands adequately and was extubated; however, after a week he suffered massive gastrointestinal bleeding and died. CONCLUSIONS
Early recognition of a gas-containing brain abscess is of great interest to immediately start the appropriate treatment. Urgent surgical debridement and broad spectrum chemotherapy are major components in the management of this entity. © 1999 by Elsevier Science Inc. KEY WORDS
Anaerobic bacteria, brain abscess, Clostridium perfringens, craniotomy.
as-containing brain abscesses are very rare and the majority are caused by Clostridium perfringens [6]. A recent review of the literature
G
Address reprint requests to: Dr. Jose´ E. Cohen, Dorrego 851-2000 Rosario, Argentina. Received June 23, 1997; accepted August 12, 1997. 0090-3019/99/$–see front matter PII S0090-3019(97)00498-9
revealed only 21 cases of clostridial brain abscesses since 1963 [2,4,6 –9]. In most cases (84%) the source of the infection was a penetrating head injury involving military practice and civilian cases, resulting from seemingly trivial injuries [4,8]. Craniotomy was considered to be the cause in only three cases [1,8]. We report a case of gas-containing brain abscess attributable to C. perfringens that required urgent surgery after a craniotomy for a brain tumor.
Case Report A 53-year-old male was admitted to the Neurosurgery Department for a cerebral neoplasm. Two months before admission he had experienced a generalized tonic-clonic seizure. Neurological exam was normal except for an abnormal left plantar response. A computed tomography (CT) scan revealed a hypodense lesion in the right frontotemporal area. Magnetic resonance images showed the infiltrating frontotemporal tumor and the diagnosis of low-grade glioma was suspected. A temporal lobectomy was performed and the diagnosis was confirmed. Although the surgery was uneventful, the postoperative course was complicated and the patient remained confused and agitated. A CT scan was performed but no abnormal findings were seen. On the second postoperative day the patient continued to be agitated and became febrile with moderate stiffness of his neck. A lumbar puncture was done and the cerebrospinal fluid (CSF) findings were consistent with bacterial meningitis. The CSF results were as follows: xanthochromia was present; white cell © 1999 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
Postcraniotomy Gas-Containing Brain Abscess
Surg Neurol 569 1999;51:568 –70
cle, bone, and brain tissue were sent for cultures and C. perfringens sensitive to penicillin G, anaerobic streptococci, anaerobic corynebacteria and Staphylococcus aureus were isolated. Penicillin and ornidazol were started and after 3 days the patient’s condition improved markedly. He was awake and alert, followed commands adequately and was extubated. There was no fever, papilledema or meningismus, and spinal fluid pleocytosis was now predominantly lymphocytic. However, after a week of antibiotic therapy he developed severe gastrointestinal bleeding and died unexpectedly. Autopsy was not performed.
Discussion
CT scan demonstrating gas within the right temporal fossa as well as the brain parenchyma. Note the gas underneath the scalp and the swelling of the galea and temporalis muscle.
1
count was 1140 cells/mm3 (predominantly polymorphonuclear leukocytes); glucose was 60 mg/dl (blood glucose was 230 mg/dl); protein was 2.3 g/l. Gram stains failed to show any bacteria; however, vancomycin and ceftazidime were empirically started. Unexpectedly, on the third postoperative day, the patient became deeply comatose. The right pupil was dilated (6 mm) and the left was small (2 mm), and neither reacted to light. His limbs were held in a flexed position, with decerebrate posturing on the left side in response to painful stimuli. The patient was intubated, ventilated, and intravenous mannitol was given. A CT scan demonstrated gas under the swollen scalp as well as in the temporal fossa at the lobectomy site, producing mass effect and moderate surrounding edema (Figure 1). Urgent surgical debridement and drainage was performed and the necrotic tissue and fetid pus were radically removed. The gram stain from the draining fluid revealed Gram-positive bacilli and Gram-negative bacilli. Additional specimens of mus-
Gas within a brain abscess was seen only once in almost 300 cases of brain abscess [3,5,6]. Recently, a review of the literature confirmed the rarity of this condition [8]. C. perfringens is usually the organism responsible for brain abscesses; however, any of the pathogenic clostridial organisms in the gas gangrene group are perfectly capable of infecting the brain and producing gas [6,8]. The presenting symptoms began early in the postoperative course, mimicking an acute and severe meningoencephalitis with disturbance of consciousness. The radiological finding of intracranial air requires differentiating between a gas-containing abscess cavity and a postoperative pneumocephalus. An early complicated postoperative course, evidence of a swelling wound, the pattern of air distribution in soft tissues and intracranially, the increasing intracranial gas with no history of a sinus lesion, and the finding of associated brain edema and/or pus collection are valuable clues that suggest the diagnosis of a gas-containing abscess. Early recognition of this entity is of great importance to immediately start the appropriate treatment for this infectious emergency. Considering the seriousness of clostridial wound infections outside the central nervous system, it is surprising that brain abscesses caused by these organisms are not uniformly fatal [6]. Among the reviewed patients only 10.5% died, most of them before antibiotics became available [8]. In our case, the microbiological finding of mixed flora is consistent with previous reports. Almost half of the cases of clostridial brain abscesses are in fact polymicrobial [8]. Gram-negative bacilli, including Klebsiella, Escherichia coli, and Proteus contribute frequently to the suppurative process, and less often, Gram-positive cocci such as S. aureus, Strep-
570 Surg Neurol 1999;51:568 –70
Cohen et al
tococcus hemolyticus, and Streptococcus fecalis are involved in the infectious process [2,4,6 – 8]. Therefore, the spectrum of chemotherapy should be broad enough to cover the Gram-negative bacilli in particular [8]. Young and Frazee [9] considered gas within intracranial abscesses to be an indication for surgical excision. We consider surgical debridement and excision of the necrotic tissue a major component of the treatment of clostridial abscess, radically changing the ominous prognosis of the presented case. Surgery contributed to evacuation of the infectious process as well as the mass effect produced by the pus, necrotic tissue, and entrapped gas. Although lobectomy gave the clostridial infection extra room for gas accumulation, the gas volume surpassed the available space and was directly responsible for a considerable mass effect, adding an extra factor to this life-threatening infectious condition. REFERENCES 1. Ariza J, Casanova A, Viladrich PF, Linares J, Pallares R, Rufi G, Verdaguer R, Gudiol F. Etiological agent and primary source of infection in 42 cases of focal intracranial suppuration. J Clin Microbiol 1986;24:899 –902. 2. Domingo Z. Clostridial brain abscess. Br J Neurosurg 1994;8:691– 4. 3. Garfield J. Management of supratentorial intracranial abscess: review of 200 cases. Brit M J 1969;2:7–11. 4. Heineman HS, Braude AI. Anaerobic infection of the brain: Observations on eighteen consecutive cases of brain abscess. Am J Med 1963;35:682–97. 5. Loeser E, Scheimberg L. Brain abscesses: review of ninety-nine cases. Neurology 1957;7:601–9. 6. Norrell H, Howieson J. Gas-containing brain abscess. AJR Am J Roentgenol 1970;109:273– 6.
7. Russell JA, Taylor JC. Circumscribed gas-gangrene abscess of the brain: Case report together with an account of the literature. Br J Surg 1963;50:434 –7. 8. Tekko ¨ k IH, Higgins MJ, Ventureyra ECG. Posttraumatic gas-containing brain abscess caused by Clostridium perfringens with unique simultaneous fungal suppuration by Myceliophthora thermophila: Case report. Neurosurgery 1997;39:1247–51. 9. Young RF, Frazee J. Gas within intracranial abscess cavities: an indication for surgical excision. Ann Neurol 1984;16:35–9.
COMMENTARY
Infection by Clostridium perfringens carries a high mortality, particularly when combined with other bacteria, as was the case reported by Cohen et al. Despite the rarity of this agent in the general etiological picture of brain abscesses, its diagnosis must be strongly suspected whenever a gascontaining brain abscess is seen on neuroimaging studies, particularly after penetrating wounds or surgical procedures. It must be remembered that C. perfringens is by far the most frequent cause of gas-containing brain abscesses; thus, the lesson from the case reported by Cohen et al could be to immediately begin aggressive antimicrobial therapy against a potential infection by C. perfringens when a gas-containing abscess is revealed on neuroimaging studies after brain surgery or open trauma, even before the actual demonstration of the bacteria by microbiological methods. Julio Sotelo, M.D. Instituto Nacional de Neurologia y Neurocirugia Mexico City, Mexico
reatment of depression can improve a patient’s overall quality of life in several ways. It may enhance the ability to follow the treatment regimen for the co-occurring medical condition, decreasing complications and improving the eventual outcome. In addition, effective management of depression can lessen the degree to which the patient is irritable, demanding, or experiences overall problems in functioning, any of which may contribute to slower or more difficult recovery, and greater stress and disability from the medical condition. Finally, controlling the depression will often improve the cognitive symptoms that are a part of some illnesses.
T
—Depression Fact Sheet National Institute of Mental Health
Cohen JE, Mierez R, Tsai EC. Postcraniotomy gas-containing brain abscess: a neurosurgical emergency. Case report. Surg Neurol 1999;51:568 –70. BACKGROUND
Gas-containing brain abscesses are very rare, and the majority are caused by Clostridium perfringens. We report a case of gas-containing brain abscess that required urgent surgery after a craniotomy for a brain tumor. METHODS AND RESULTS
The patient was a 53-year-old male who presented with a cerebral neoplasm. A temporal lobectomy was performed and the diagnosis of low grade glioma was confirmed. Although the surgery was uneventful the postoperative course was complicated; the patient became agitated and febrile and deteriorated to a deep coma. A computed tomography scan demonstrated gas in the temporal fossa at the lobectomy site, producing mass effect. Urgent surgical debridement and drainage was performed and C. perfringens and mixed flora were found. Antibiotics were started and the patient’s condition markedly improved. He was awake and alert, followed commands adequately and was extubated; however, after a week he suffered massive gastrointestinal bleeding and died. CONCLUSIONS
Early recognition of a gas-containing brain abscess is of great interest to immediately start the appropriate treatment. Urgent surgical debridement and broad spectrum chemotherapy are major components in the management of this entity. © 1999 by Elsevier Science Inc. KEY WORDS
Anaerobic bacteria, brain abscess, Clostridium perfringens, craniotomy.
as-containing brain abscesses are very rare and the majority are caused by Clostridium perfringens [6]. A recent review of the literature
G
Address reprint requests to: Dr. Jose´ E. Cohen, Dorrego 851-2000 Rosario, Argentina. Received June 23, 1997; accepted August 12, 1997. 0090-3019/99/$–see front matter PII S0090-3019(97)00498-9
revealed only 21 cases of clostridial brain abscesses since 1963 [2,4,6 –9]. In most cases (84%) the source of the infection was a penetrating head injury involving military practice and civilian cases, resulting from seemingly trivial injuries [4,8]. Craniotomy was considered to be the cause in only three cases [1,8]. We report a case of gas-containing brain abscess attributable to C. perfringens that required urgent surgery after a craniotomy for a brain tumor.
Case Report A 53-year-old male was admitted to the Neurosurgery Department for a cerebral neoplasm. Two months before admission he had experienced a generalized tonic-clonic seizure. Neurological exam was normal except for an abnormal left plantar response. A computed tomography (CT) scan revealed a hypodense lesion in the right frontotemporal area. Magnetic resonance images showed the infiltrating frontotemporal tumor and the diagnosis of low-grade glioma was suspected. A temporal lobectomy was performed and the diagnosis was confirmed. Although the surgery was uneventful, the postoperative course was complicated and the patient remained confused and agitated. A CT scan was performed but no abnormal findings were seen. On the second postoperative day the patient continued to be agitated and became febrile with moderate stiffness of his neck. A lumbar puncture was done and the cerebrospinal fluid (CSF) findings were consistent with bacterial meningitis. The CSF results were as follows: xanthochromia was present; white cell © 1999 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
Postcraniotomy Gas-Containing Brain Abscess
Surg Neurol 569 1999;51:568 –70
cle, bone, and brain tissue were sent for cultures and C. perfringens sensitive to penicillin G, anaerobic streptococci, anaerobic corynebacteria and Staphylococcus aureus were isolated. Penicillin and ornidazol were started and after 3 days the patient’s condition improved markedly. He was awake and alert, followed commands adequately and was extubated. There was no fever, papilledema or meningismus, and spinal fluid pleocytosis was now predominantly lymphocytic. However, after a week of antibiotic therapy he developed severe gastrointestinal bleeding and died unexpectedly. Autopsy was not performed.
Discussion
CT scan demonstrating gas within the right temporal fossa as well as the brain parenchyma. Note the gas underneath the scalp and the swelling of the galea and temporalis muscle.
1
count was 1140 cells/mm3 (predominantly polymorphonuclear leukocytes); glucose was 60 mg/dl (blood glucose was 230 mg/dl); protein was 2.3 g/l. Gram stains failed to show any bacteria; however, vancomycin and ceftazidime were empirically started. Unexpectedly, on the third postoperative day, the patient became deeply comatose. The right pupil was dilated (6 mm) and the left was small (2 mm), and neither reacted to light. His limbs were held in a flexed position, with decerebrate posturing on the left side in response to painful stimuli. The patient was intubated, ventilated, and intravenous mannitol was given. A CT scan demonstrated gas under the swollen scalp as well as in the temporal fossa at the lobectomy site, producing mass effect and moderate surrounding edema (Figure 1). Urgent surgical debridement and drainage was performed and the necrotic tissue and fetid pus were radically removed. The gram stain from the draining fluid revealed Gram-positive bacilli and Gram-negative bacilli. Additional specimens of mus-
Gas within a brain abscess was seen only once in almost 300 cases of brain abscess [3,5,6]. Recently, a review of the literature confirmed the rarity of this condition [8]. C. perfringens is usually the organism responsible for brain abscesses; however, any of the pathogenic clostridial organisms in the gas gangrene group are perfectly capable of infecting the brain and producing gas [6,8]. The presenting symptoms began early in the postoperative course, mimicking an acute and severe meningoencephalitis with disturbance of consciousness. The radiological finding of intracranial air requires differentiating between a gas-containing abscess cavity and a postoperative pneumocephalus. An early complicated postoperative course, evidence of a swelling wound, the pattern of air distribution in soft tissues and intracranially, the increasing intracranial gas with no history of a sinus lesion, and the finding of associated brain edema and/or pus collection are valuable clues that suggest the diagnosis of a gas-containing abscess. Early recognition of this entity is of great importance to immediately start the appropriate treatment for this infectious emergency. Considering the seriousness of clostridial wound infections outside the central nervous system, it is surprising that brain abscesses caused by these organisms are not uniformly fatal [6]. Among the reviewed patients only 10.5% died, most of them before antibiotics became available [8]. In our case, the microbiological finding of mixed flora is consistent with previous reports. Almost half of the cases of clostridial brain abscesses are in fact polymicrobial [8]. Gram-negative bacilli, including Klebsiella, Escherichia coli, and Proteus contribute frequently to the suppurative process, and less often, Gram-positive cocci such as S. aureus, Strep-
570 Surg Neurol 1999;51:568 –70
Cohen et al
tococcus hemolyticus, and Streptococcus fecalis are involved in the infectious process [2,4,6 – 8]. Therefore, the spectrum of chemotherapy should be broad enough to cover the Gram-negative bacilli in particular [8]. Young and Frazee [9] considered gas within intracranial abscesses to be an indication for surgical excision. We consider surgical debridement and excision of the necrotic tissue a major component of the treatment of clostridial abscess, radically changing the ominous prognosis of the presented case. Surgery contributed to evacuation of the infectious process as well as the mass effect produced by the pus, necrotic tissue, and entrapped gas. Although lobectomy gave the clostridial infection extra room for gas accumulation, the gas volume surpassed the available space and was directly responsible for a considerable mass effect, adding an extra factor to this life-threatening infectious condition. REFERENCES 1. Ariza J, Casanova A, Viladrich PF, Linares J, Pallares R, Rufi G, Verdaguer R, Gudiol F. Etiological agent and primary source of infection in 42 cases of focal intracranial suppuration. J Clin Microbiol 1986;24:899 –902. 2. Domingo Z. Clostridial brain abscess. Br J Neurosurg 1994;8:691– 4. 3. Garfield J. Management of supratentorial intracranial abscess: review of 200 cases. Brit M J 1969;2:7–11. 4. Heineman HS, Braude AI. Anaerobic infection of the brain: Observations on eighteen consecutive cases of brain abscess. Am J Med 1963;35:682–97. 5. Loeser E, Scheimberg L. Brain abscesses: review of ninety-nine cases. Neurology 1957;7:601–9. 6. Norrell H, Howieson J. Gas-containing brain abscess. AJR Am J Roentgenol 1970;109:273– 6.
7. Russell JA, Taylor JC. Circumscribed gas-gangrene abscess of the brain: Case report together with an account of the literature. Br J Surg 1963;50:434 –7. 8. Tekko ¨ k IH, Higgins MJ, Ventureyra ECG. Posttraumatic gas-containing brain abscess caused by Clostridium perfringens with unique simultaneous fungal suppuration by Myceliophthora thermophila: Case report. Neurosurgery 1997;39:1247–51. 9. Young RF, Frazee J. Gas within intracranial abscess cavities: an indication for surgical excision. Ann Neurol 1984;16:35–9.
COMMENTARY
Infection by Clostridium perfringens carries a high mortality, particularly when combined with other bacteria, as was the case reported by Cohen et al. Despite the rarity of this agent in the general etiological picture of brain abscesses, its diagnosis must be strongly suspected whenever a gascontaining brain abscess is seen on neuroimaging studies, particularly after penetrating wounds or surgical procedures. It must be remembered that C. perfringens is by far the most frequent cause of gas-containing brain abscesses; thus, the lesson from the case reported by Cohen et al could be to immediately begin aggressive antimicrobial therapy against a potential infection by C. perfringens when a gas-containing abscess is revealed on neuroimaging studies after brain surgery or open trauma, even before the actual demonstration of the bacteria by microbiological methods. Julio Sotelo, M.D. Instituto Nacional de Neurologia y Neurocirugia Mexico City, Mexico
reatment of depression can improve a patient’s overall quality of life in several ways. It may enhance the ability to follow the treatment regimen for the co-occurring medical condition, decreasing complications and improving the eventual outcome. In addition, effective management of depression can lessen the degree to which the patient is irritable, demanding, or experiences overall problems in functioning, any of which may contribute to slower or more difficult recovery, and greater stress and disability from the medical condition. Finally, controlling the depression will often improve the cognitive symptoms that are a part of some illnesses.
T
—Depression Fact Sheet National Institute of Mental Health