Transcript PCC C4Case4: Brain Abscess

General Data
•
•
•
•
•
•
•
•
•
•
A.J.C.
12 years old, M
Birthdate: February 18, 2000
Filipino
Roman Catholic
Currently lives in Navotas
Grade 3 student
Date of Admission: January 13, 2012
Date of Interview: February 22, 2012
Informants:
– Edwin Condeno (father, 38yo, college graduate)
– Nelia Condeno (mother, 41yo, hs graduate)
– Both are close to patients; but patient is more close to grandmother esp
when parents are not around
• Reliability: 88%
Chief Complaint:
“MASAKIT ANG ULO AT TENGA.
NAGSUSUKA DIN SIYA.”
History of Present Illness
10 years PTA
16 days PTA
15 days PTA
11 days PTA
 Developed chronic ear infection after coming from a beach
 Regularly medicated with unrecalled name of ear drops
applied 3x daily
 Severe R auricular pain extending to postauricular area after
coming from Tagaytay
 aural discharge (white and purulent)
 Applied regular ear drops, no relief
 No consult done
 Ear pain & discharge accompanied with fever (unrecorded
grade)
 Paracetamol (unknown dose) , relieved after 4 days
 No consult done
 Consulted (at MCU)  discovered that the R eardrum has
already been affected
 Rx Cotrimoxazole, ear pain persisted
History of Present Illness
9 days PTA
 R ear cleaned (at MCU), provided slight relief
 Later developed severe headache (extending to entire head)
esp upon movement
 Vomiting, preferred lying
6 days PTA
 Patient brought to hospital (in Tondo) mainly due to
headache & vomiting
 Clinical impression: gastrointestinal problem, no meds given
5 days PTA
 Patient brought to his pediatrician (in Navotas)  Rx
unrecalled name of antibiotic for 14 days
ADMIT
 Patient was not improving
 Parents decided to d/c medication and admit the patient to
UST Hospital
Review of Systems
•
•
•
•
•
•
•
•
•
•
•
General: (+) weight loss; (+) low activity level; (+) low appetite; (-) delay in growth
Cutaneous: (-) rash, hair loss, pruritus
Head: (-) visual difficulties, lacrimation, hearing, nasal discharge, epistaxis, sore
throat
Cardiovascular: (-) cyanosis, easy fatigability, fainting spells
Respiratory: (-) chest pain, cough, difficulty of breathing
Gastrointestinal: (+) epigastric pain; (+) food intolerance; (-) diarrhea, constipation,
jaundice
Genitourinary: (-) burning sensation, frequency, discharge, edema of hands & feet
Endocrine: (-) palpitations, cold/heat intolerance, polyuria, polydipsia, polyphagia
Nervous/Behavioral: (+) weakness; (+) eating problems; (-) sleep problems,
convulsions, (-) memory loss, mental deterioration
Musculoskeletal: (+) limitation of motion; (-) pain/swelling in bone, joint or muscle
Hematopoiesis: (-) pallor, bleeding, easy bruisability
Past Medical History
•
•
•
•
•
Dengue – 2010
Frequent cough and colds
R ear infection – 2002
Immunizations: 1 shot of BCG vaccine
No allergies, previous injuries
Personal History
Home
•
•
•
Only child
Lives with parents and
grandmother
Playful, spoiled and shy
but close to all his family
members; closest to
grandmother
Education
• Previously studied in
Cavite (failed grade 3
due to not doing his
homeworks)
• Transferred to Manila
and repeated grade 3
Eating Behavior
• Good appetite
• Likes: Chickenjoy,
hotdog anggs, soda
• Dislikes: vegetables
except squash
• Doesn’t take vitamins
Activities
• Likes playing psp &
computer games;
Chinese garter
Sexual
• Not sexually
active
Suicidal Ideations
• No suicidal
ideations
Safety
• Parents take good
care of him
Tanner Staging
• Patient refused
Family History
• Parents: The patient’s mother is 41 years old
and works in a studio. His father is 38 years
old and works as a videographer.
• Familial illness: Both of his parents have a
family history of diabetes mellitus. There
was no family history of tuberculosis.
Socioeconomic & Environmental
History
• Lives with his parents and grandmother in
Navotas
• House: clean and well-protected
• Both parents work; earnings serve as their
source of income
• Not exposed to cigarettes or other air pollution
(no one in his family smokes & their house kept
clean always)
• Garbage collected daily
• Water source: Maynilad Water Services
February 22, 2012
PHYSICAL EXAMINATION
General Survey
•
•
•
•
•
•
Conscious, coherent
Ambulatory, moderate level of activity
No presence of cardiopulmonary distress
Brown complexion
Looked undernourished but well-hydrated
Not ill-looking
Vital Signs & Anthropometric Data
•
•
•
•
•
•
•
36.6°C (axillary)
98bpm
22breaths/min
100/60mmHg
25kg
136.5cm
BMI: 13
Skin
• Brown complexion
• Good skin turgor
• 2 vesicles along the wrist measuring 0.5cm in
diameter each
• No edema, no jaundice
HEENT
Head
•
•
•
Normal contour, no swelling
Hair normally distributed
except in areas around the
surgical scars
Hair: black and fine in
texture, no lice/nits
Ears
•
•
Eyes
•
•
•
Eyelids not swollen, pink
conjunctivae, anicteric
sclerae
UO 20/25, normal pupillary
light reflex, normal corneal
light reflex
Normal EOM, (-) cross-cover
test
•
External ear: normal
size&shape, no swellings, no
lesions, no tenderness, no
discharge
Ext. auditory canals filled with
minimal cerumen, wounds
along the lateral wall of R
auditory canal
(N) L tympanic membrane,
perforated R tympanic
membrane
Nose
•
Symmetrical, no alar flaring,
patent nares, no discharge,
nasal septum in midline, no
sinus tenderness
Throat
•
•
•
•
•
•
Moist lips, no
excoriations
Buccal mucosa were
pink and moist
Uvula in midline
Tonsils not swollen
No swellings around
the neck
No
lymphadenopathy
Chest & Lungs
Heart and Vascular System
• Symmetrical chest, transverse diameter > AP diameter, no chest
retractions, symmetrical chest expansion, equal tactile & vocal
fremiti, resonant lungs, no adventitious breath sounds
• Adynamic precordium, apex beat at 5th LICS MCL, no thrills,
S1>S2 at apex, S2>S1 at base, no murmurs, JVP 3cm at 30°C
angle, equal (2+) peripheral pulses
Abdomen, Kidneys, GU, Anal &
Rectum
• Flat abdomen, no visible pulsations, (N) bowel sounds, no
direct or indirect tenderness; liver span & edge and
palpation of kidneys and spleen not done due to
uncooperativeness of patient, no CVA tenderness
• Genitalia not examined and DRE not done (patient refused)
Musculoskeletal & Neurological
•
•
•
•
(N) posture but slow in walking
MMT: 5 in L UE≤ 4 in R UE&LE
Cerebrum: Normal stream of talk,
uncooperative, irritable, conscious
Intact CN
– Fundoscopy: no papilledema, (N) color of
optik disc
– Normal visual fields, no nystagmus &
ptosis
– Normal sensation on face
– Rubbing fingers NOT heard at R ear
– Weber test: lateralized to R ear
– Rinne test: BC>AC on R ear; (N) on L ear
– Uvula in midline, (N) palatal movements
– can turn head against resistance & can
shrug shoulders
– No tongue lesions, not deviated
•
Cerebellar:
– Finger-to-nose test: past pointing
and intention tremors (R UE)
– Heel-to-shin test: (N)
– Rapid alternating movement test:
Slow in execution
•
•
•
•
•
Gait & Posture: L shoulder is higher
than R shoulder; assumes a wide
based gait; slow upon walking
Sensory: Normal
DTR: weak (+1)
No pathological reflexes
(-) Kernig’s & Brudzinski signs
APPROACH TO DIAGNOSIS
Approach to sign/symptom whose mechanism is
well understood.
Salient Features
Subjective (+)
 12yo M
 Hx of chronic R ear infection
 R auricular pain (extending to postauricular area)
with aural discharge
 Fever
 Severe headache
 Vomiting
 Generalized weakness
Objective (+)




Perforated R tympanic membrane
Rubbing of fingers: not hear at R ear
Weber test: Lateralized to R ear
Finger-to-nose test: Past pointing and intention
tremors (R UE)
 Slow upon doing rapid alternating movement
test
 MMT: 4 – R UE&LE
 L shoulder higher than R; assumes wide-based
gait; slow upon walking
Subjective (-)
 (-) nuchal rigidity
 (-) hearing loss
Objective (-)
 (-) Kernig’s and Brudzinski’s signs
Presenting Manifestation
 Chronic R ear infection
Symptoms: R auricular & postauricular pain with
discharge
PE findings (R ear): rubbing fingers not heard, Weber
test lateralized to R ear, Rinne test BC>AC
 Fever
 Headache & Vomiting
 Slow upon doing rapid alternating movements; Finger-tonose test: intention tremors and past-pointing; MMT: 4 –
R UE&LE (weak); Gait and Posture: L shoulder higher
than R, wide-based gait, slow upon walking
Weakness
Clinical Diagnosis
• Right cerebellar abscess due to chronic
otitis media
• Differential Diagnosis:
– Extradural abscess
– Subdural abscess / empyema
– Otitic hydrocephalus / pseudotumor cerebri
– Bacterial Meningitis
Subdural
Abscess
Otitic
Hydrocephalus
Bacterial
Meningitis
Embolization due to
CHD w/ RL shunt
Chronic OM and
mastoiditis
Chronic Otitis
Media
Chronic OM or
chronic sinusitis
Acute or chronic
ear infection,
drugs, head
injury
Most common
intracranial
complication of
suppurative OM
Headache, fever,
vomiting, lethargic
state
Cerebellar abscess:
ataxia,
dysdiachokinesia,
intention tremor, past
pointing
Temporal abscess: focal
seizures or aphasia
Severe earache,
headache,
fever,
Localizing
neurologic signs
are usually
absent
Fever, headache
Coma, seizures,
hemiplegia,
hemiparesis,
aphasia, (+)
Kernig’s sign
*RAPID
progression of
symptoms
Persistent
headache,
diplopia,
blurring of
vision, nausea
and vomiting,
papilledema,
most patient
lack
constitutional
symptoms
Neck stiffness,
fever, nausea
and vomiting,
headache,
altered mental
status
Resistance neck
flexion and (+)
Kernig’s sign
MRI / CECT Scan –
enhancing lesion
(N) / WBC,
(N)/protein, glucose
may be 
CSF – usually
clear, (N)
pressure, may
contain
lymphocytes &
neutrophils,
slight protein
MRI/CECT –
enhancing
lesion bet. dura
& tegmen
CSF - pressure,
pleocytosis
predominantly
PMN, protein,
(N) glucose
MRI / CECT Scan
– enhancing
lesion in the
subdural space
ICP w/ (N) CSF
findings, (N)
ventricular size
CSF - sugar,
protein
Diagnosis / Labs
Etiology
Extradural
Abscess
Presentation / PE findings
Brain Abscess
Confirmatory Tests
• MRI / CECT Scan – most reliable methods of
localizing and demonstrating abscesses
• *Examination of CSF – should NOT BE DONE
in children suspected to have brain abscess
EPIDEMIOLOGY, ETIOLOGY &
PATHOPHYSIOLOGY
Brain abscess
• Focal, suppurative infection within the
brain parenchyma
• Most common: 4-8 years old and
neonates
• Causes:
•
•
•
•
•
•
Congenital Heart Disease (TOF)
Meningitis
Chronic otitis media
Mastoiditis
Sinusitis
Others
Brain abscess
Otitis media- inflammatory condition of
the middle ear that results from the
dysfunction of eustachian tube.
 Associated with: Upper Respiratory Infection
Risk Factors:
Bacterial pathogens:
-Early age of first diagnosis
-Male
-Not breastfed
-Genetics
-Tobacco exposure
-Low socioeconomic status
-Native Americans, white
-Congenital anomalies
-*Streptococcus
pneumoniae
-Haemophilus influenzae
-Streptococcus Group A
-Branhamella catarrhalis
-Staphylococcus aureus
-Staphylococcus
epidermidis
Otitis media
Clinical Manifestations:
– red, sore, thickened bulging immobile
eardrum
– severe ear pain, discomfort, fullness in
ear
– irritable, change in eating and sleeping
habits
– fever (<25%)
– hearing loss (esp for chronic otitis media)
Complications of Otitis media
• Intratemporal
Dermatitis
Tympanic
membrane
perforation
Mastoiditis
Facial nerve
paralysis,
• Intracranial
Meningitis
Focal
encephalitis,
Brain abscess
Otitic
hydrocephalus
each
Brain abscess
• Usually single but 30% are multiple
• 80% - frontal, parietal, temporal lobes
• 20% - occipital lobe, cerebellum,
brainstem
• Frontal lobe - sinusitis or orbital
cellulitis
• Temporal lobe or cerebellum - chronic
otitis media and mastoiditis.
Brain abscess
• Etiology:
– Streptococci (S. pyogenes group A or B, S.
pneumoniae)
– Anaerobic organisms (gram-positive
cocci, Bacteroides spp., Fusobacterium
spp., Prevotella spp., Actinomyces spp.)
– Gram-negative aerobic bacilli
(Haemophilus aphrophilus, H.
parainfluenzae, H. influenzae,
Enterobacter, E. coli, Proteus spp.)
Brain abscess
Clinical Manifestations:
• Early stages:
-low-grade fever, headache, lethargy
• Vomiting, severe headache, seizures,
papilledema, focal neurologic signs
(hemiparesis), coma
• Cerebellar abscess :
-nystagmus, ipsilateral ataxia and
dysmetria, vomiting, headache
Cerebellar Functions
 Vermis – influences movements of long axis of
the body
 Intermediate zone – control muscles of the distal
parts of the limbs, esp the hands and feet
 Lateral zone – planning of sequential
movements of the entire body and involved with
conscious assessment of movement errors
Signs of Cerebellar Dysfunction
• Hypotonia
• Postural changes and alteration of gait: shoulder on the
side of the lesion is lower than on the normal side; wide
base when standing and often stiff legged; lurches and
staggers toward affected side
• Disturbances in voluntary movement (ataxia): tremor,
decomposition of movement
• Dysdiadochokinesia
• Disturbances of reflexes: pendular knee jerk
• Disturbances of ocular movement: nystagmus
• Disorders of speech: dysarthria (articulation is jerky and
the syllables often are separated from one another)
TREATMENT AND PROGNOSIS
Treatment
• The initial management of a brain abscess
includes prompt diagnosis and institution of
an antibiotic regimen that is based on the
probable pathogenesis and the most likely
organism.
• Brain abscess
•
– Antibiotics without surgery:
• if the abscess is <2 cm in
diameter
• the illness is of short duration
(<2 wk)
• no signs of increased
•
intracranial pressure
• child is neurologically intact
– If the decision is made to
treat with antibiotics alone,
the child should have weekly
neuroimaging studies to
ensure the abscess is
decreasing in size.
Otitis media
– staphylococci, Proteus vulgaris, and Pseudomonas
aeruginosa, and numerous anaerobic bacteria
– combination of vancomycin, a 3rd-generation
cephalosporin (ceftazidime), and metronidazole
Meropenem
– good activity against gram-negative bacilli,
anaerobes, staphylococci, and streptococci,
including most antibiotic-resistant pneumococci
– may be used alone to replace the combination of
metronidazole and a β-lactam
– However, it does not provide activity against
methicillin-resistant S. aureus and may have
decreased activity against penicillin-resistant
strains of S. pneumoniae, indicating that
vancomycin should remain a part of the initial
regimen when these organisms are suspected.
• An encapsulated abscess, particularly if the
lesion is causing a mass effect or increased
intracranial pressure, should be treated with
a combination of antibiotics and aspiration.
• Surgical excision
– rarely required, because the procedure
may be associated with greater
morbidity compared with aspiration of a
cavity.
– Associated infectious processes such as
mastoiditis, sinusitis, or a periorbital
abscess, may require surgical drainage.
– Indications for Surgery:
• Abscess is >2.5 cm in diameter
• Presence of gas
• Multiloculated
• Located in the posterior fossa
• Fungus is identified.
•
The duration of antibiotic therapy
depends on the organism and response to
treatment, but is usually 4–6 wks
• Mastoidectomy
– For chronic otitis media w/
complications
– to eradicate infected tissue,
creating a safe, dry ear
– considered at any age
• Tympanoplasty
– for the preservation and
restoration of hearing
– less commonly performed in
children less than 5 years old
who have not yet achieved
adequate eustachian tube
function.
Prognosis
• Mortality rate associated with brain abscess has
decreased significantly to ≈15–20 % with the use of CT or
MRI and prompt antibiotic and surgical management.
• Factors associated with high mortality rate at the time of
admission:
–
–
–
–
Age <1 yr
multiple abscesses
Coma
lack of CT facilities.
• Long-term sequelae occur in at least 50% of survivors and
include hemiparesis, seizures, hydrocephalus, cranial
nerve abnormalities, and behavior and learning
problems.
THANK YOU! =)
References:
Nelson Textbook 18th edition
Boies Fundamentals of Otolaryngology 6th edition
Adams and Victor’s Principles of Neurology 9th edition
Clinical Neuroanatomy 7th edition