Pediatric brainstem abscess with hemorrhage mimicking diffuse intrinsic pontine glioma: a case report

Multiple Abscesses in the Frontal, Temporal and Brainstem regions in a 4.5-year-Old Girl- An Illustrative Case Report

Background

Brainstem located abscesses are rare in the pediatric population. Diagnosis of brain abscess can be challenging as patients may present with nonspecific symptoms and the classical triad of headache, fever, and focal neurological deficit is not always present. Treatment can be conservative or a combination of surgical intervention with antimicrobial therapy.

Case Description

We present the first case of a 4.5-year-old girl with acute lymphoblastic leukemia that developed infective endocarditis (IE) and subsequently developed 3 suppurative collections (frontal, temporal, and brainstem). The patient had negative cerebrospinal, blood, and pus culture growth and subsequently underwent burr-hole drainage of the frontal and temporal abscesses with a 6-week course of intravenous antibiotic therapy with an uneventful postoperative course. At 1 year, the patient is left with minor right lower limb hemiplegia and no cognitive sequelae.

Conclusion

The decision to surgically intervene for brainstem abscesses is dependent on surgeon and patient factors including the presence of multiple collections, midline shift, the aim of source identification in sterile cultures, and the patient's neurological condition. Patients with hematological malignancies should be monitored closely for IE which is a risk factor for hematogenous spread of brainstem located abscesses.

Clinical features, microbiology, and management of pediatric brainstem abscess

PURPOSE

Brainstem abscess is a rare condition accounting for merely 1% of brain abscesses incidence in the pediatric population. This study aimed to present a single patient with a pontine abscess and review the literature to highlight clinical features, diagnosis, and management of brainstem abscess.

METHODS

The PubMed database was screened for English-language articles concerning pediatric brainstem abscess. We, therefore, identified 22 publications, which concisely depict 23 cases. Our study reports on the 24th pediatric patient diagnosed with that entity. All included reports were analyzed in terms of clinical presentation, diagnosis, management, and outcomes of described patients.

RESULTS

There was slight women predominance (15:9), with a mean age of occurrence 6.4 years, ranging from 7 months to 16 years. Pons was the most common location of brainstem abscess, occurring in 75% of patients. Clinically, they mostly presented with cranial nerves palsy (79.2%), hemiparesis (66.7%), and pyramidal signs (45.8%). The classic triad of symptoms, including fever, headache, and the focal neurologic deficit was present in 20.8% of patients. Positive pus cultures were obtained in 61.1%. Streptococci and Staphylococci were the most frequently identified pus microorganisms. Outcomes were satisfactory, with a 79.2% rate of general improvement.

CONCLUSIONS

Neurosurgical aspiration is a safe and beneficial therapeutic method. It should always be considered and should promptly be performed when the conservative treatment is not successful and clinical deterioration occurs. Prognosis in pediatric brainstem abscess is generally favorable. Most patients recover with minor neurologic deficits or improve completely.