Actinomycosis of the Brain: Case Report and Review of the Literature

The available world literature (since Friedman''s and Levy''s comprehensive report in 1937) regarding actinomycosis of the central nervous system is reviewed. Only cases proved by culture were included in this analysis. A total of 17 cases was collected and an additional patient with this entity is described.The important differences between actinomycosis and nocardiosis are discussed. A definite diagnosis of actinomycosis was possible only when anaerobic cultures of cerebrospinal fluid or material obtained from a brain abscess yielded colonies of typical Actinomyces organisms. The characteristic result of infection of the brain by this fungus was abscess formation, and this occurred in all except one of the cases reviewed. Penicillin appears to be the drug of choice in treatment and, where possible, surgical excision of the cerebral abscess should be undertaken.     

High levels of sFas and PBMC apoptosis before and after excision of malignant melanoma--case report

In our study we investigated the level of apoptosis in PBMCs and the serological level of sFas (CD95/APO-1) in 22 patients with malignant melanoma (12 patients with unique cutaneous primary tumour and 10 patients with unique brain metastasis). The first determination was performed before tumour excision and the second at 6-7 months after excision. Results in patients with primary tumour in the first determination: 6 patients with over normal values in PBMCs apoptosis and 5 patients with increased values of sFas. In the second determination: apoptosis was increased in 5 patients and sFas level was increased in 4 cases. In patients with metastases in the first determination apoptosis of PBMC was increased in 7 cases and sFas in 5 cases. In the second determination apoptosis was increased in 4 cases and sFas was increased in 4 cases. Our results show that half of the investigated patients presented elevated values of PBMCs apoptosis and Fas receptor both before and 6-7 months after tumour excision. Apoptosis values for PBMCs and sFas values were with 1/4 higher than normals. There was no difference in clinical evolution of the patients with normal or increased values for studied parameters. Clinical evolution was performed for 1 year. The presence of increased values for PBMCs and sFas after tumour excision, primary or metastasis is surprising and hard to explain. It is possible that tumoral evolution induces a disregulation at PBMCs level or other cells level that persists unexpectedly, after tumour excision or apoptotic processes, in a certain level to be independent and anterior to tumour development.     

Abscesses of the breast; recurring lesions in the areolar area

Subareolar abscesses beginning either in infected skin glands or in breast ducts have an extraordinary tendency to recur and to be resistant to treatment. About three-fourths of 64 patients observed had from one to many recurrences of abscess after either spontaneous or surgical drainage, and many even after wide excision of scar in an interval of quiescence.The most successful of a number of methods of treatment used was wide removal of scar and underlying chronic abscess cavity combined with removal of the ampulla and mouth of a connecting duct. In a substantial number, after either drainage or unsuccessful excision, the process gradually subsided over a period of months or years. Cancer has not been observed in any of the 64 patients.     

Management of Supratentorial Intracranial Abscess: A Review of 200 Cases

Two hundred cases of intracranial supratentorial abscess have been reviewed: 100 spanned the years 1951 to 1957, and 100 the years 1962 to 1967. The mortality rate of 40% was the same in both series, chiefly owing to continuing inaccurate localization of the abscess and inadequate use of antibiotics. The hazards of lumbar puncture are real, and this procedure is contra-indicated when convulsions, signs of a hemisphere disturbance, or papilloedema are present. Of the methods for localizing intracranial abscess the site of E.N.T. sepsis, ventriculography, and brain scanning were found to be the most valuable. Penicillin in high dosage continues to be the most important antibiotic. The results of assiduously repeated burrhole aspiration compare favourably with those of later excision.     

ABSCESSES OF THE BREAST—Recurring Lesions in the Areolar Area

Subareolar abscesses beginning either in infected skin glands or in breast ducts have an extraordinary tendency to recur and to be resistant to treatment. About three-fourths of 64 patients observed had from one to many recurrences of abscess after either spontaneous or surgical drainage, and many even after wide excision of scar in an interval of quiescence.The most successful of a number of methods of treatment used was wide removal of scar and underlying chronic abscess cavity combined with removal of the ampulla and mouth of a connecting duct.In a substantial number, after either drainage or unsuccessful excision, the process gradually subsided over a period of months or years.Cancer has not been observed in any of the 64 patients.     

The efficacy of trovafloxacin versus ceftriaxone in the treatment of experimental brain abscess/cerebritis in the rat

Current estimates of the mortality associated with brain abscesses range from 0-24%, with neurological sequellae in 30-55% of survivors. Although the incidence of brain abscess appears to be increasing, likely due to an increase in the population of immunosuppressed patients, the condition is still sufficiently uncommon to make human clinical trials of therapy problematic. An animal model to study the efficacy of new treatment regimens, specifically, new antimicrobial agents is therefore necessary. This study uses a well-defined experimental paradigm as an inexpensive method of inducing and studying the efficacy of antibiotics in brain abscess. The rat model of brain abscess/cerebritis developed at this institution was used to determine the relative efficacy of trovafloxacin as compared to ceftriaxone in animals infected with Staphylococcus aureus. S. aureus ( approximately 10(5) CFU in 1 microliter) was injected with a Hamilton syringe, very slowly, over the course of 70 minutes after a two mm burr hole was created with a spherical carbide drill just posterior to the coronal suture and four mm lateral to the midline. Eighteen hours later treatment was begun; every 8 hours the rats were dosed with subcutaneous ceftriaxone (n = 10), trovafloxacin (n = 11) or 0.9% sterile pyogen-free saline (n = 10). After four days of treatment the brains were removed and sectioned with a scalpel. The entire injected hemisphere was homogenized and quantitative cultures performed. The mean +/- SEM log(10) colony forming units/ml S. aureus recovered from homogenized brain were as follows: controls 6.10 +/- 0.28; ceftriaxone 3.43 +/- 0.33; trovafloxacin 3.65 +/- 0.3. There was no significant difference in bacterial clearance between ceftriaxone versus trovafloxacin (p = 0.39). Trovafloxacin or other quinolones may provide a viable alternative to intravenous antibiotics in patients with brain abscess/cerebritis.     

S. aureus-dependent microglial activation is selectively attenuated by the cyclopentenone prostaglandin 15-deoxy-Delta12,14- prostaglandin J2 (15d-PGJ2)

Microglial activation is a hallmark of brain abscess. The continual release of proinflammatory mediators by microglia following bacterial challenge may contribute, in part, to the destruction of surrounding normal tissue characteristic of brain abscess. Therefore, attenuating chronic microglial activation during the course of CNS bacterial infections may have therapeutic benefits. The purpose of this study was to evaluate the ability of the natural peroxisome proliferator-activated receptor (PPAR)-gamma agonist 15-deoxy-Delta12,14- prostaglandin J2 (15d-PGJ2) to modulate microglial activation in response to Staphylococcus aureus, one of the main etiologic agents of brain abscess in humans. 15d-PGJ2 was a potent inhibitor of proinflammatory cytokine (IL-1beta, TNF-alpha, IL-12 p40) and CC chemokine (MIP-1beta, MCP-1) production in primary microglia, but had no effect upon the expression of select CXC chemokines (MIP-2, KC). 15d-PGJ2 also selectively inhibited the S. aureus-dependent increase in microglial TLR2, CD14, MHC class II, and CD40 expression, whereas it had no effect on the co-stimulatory molecules CD80 and CD86. Microarray analysis revealed additional inflammatory mediators modulated by 15d-PGJ2 in primary microglia following S. aureus exposure, the majority of which were chemokines. These results suggest that suppressing microglial activation through the use of 15d-PGJ2 may lead to the sparing of damage to normal brain parenchyma that often results from brain abscess.     

CXC chemokine receptor-2 ligands are required for neutrophil-mediated host defense in experimental brain abscesses

We have developed a mouse brain abscess model by using Staphylococcus aureus, one of the main etiologic agents of brain abscesses in humans. Direct damage to the blood-brain barrier was observed from 24 h to 7 days after S. aureus exposure as demonstrated by the accumulation of serum IgG in the brain parenchyma. Evaluation of brain abscesses by immunohistochemistry and flow cytometry revealed a prominent neutrophil infiltrate. To address the importance of neutrophils in the early containment of S. aureus infection in the brain, mice were transiently depleted of neutrophils before implantation of bacteria-laden beads. Neutrophil-depleted animals consistently demonstrated more severe brain abscesses and higher CNS bacterial burdens compared with control animals. S. aureus led to the induction of numerous chemokines in the brain, including macrophage-inflammatory protein (MIP)-1alpha/CCL3, MIP-1beta/CCL4, MIP-2/CXCL1, monocyte chemoattractant protein-1/CCL2, and TCA-3/CCL1, within 6 h after bacterial exposure. These chemokines also were expressed by both primary cultures of neonatal mouse microglia and astrocytes exposed to heat-inactivated S. aureus in vitro. Because neutrophils constitute the majority of the cellular infiltrate in early brain abscess development, subsequent analysis focused on MIP-2 and KC/CXCL1, two neutrophil-attracting CXC chemokines. Both MIP-2 and KC protein levels were significantly elevated in the brain after S. aureus exposure. Neutrophil extravasation into the brain parenchyma was impaired in CXCR2 knockout mice and was associated with increased bacterial burdens. These studies demonstrate the importance of the CXCR2 ligands MIP-2 and KC and neutrophils in the acute host response to S. aureus in the brain.     

Brain abscess due to Nocardia

Cerebral Nocardiosis is a rare disease, usually occurring in immunocompromised hosts. We report here two cases of brain abscess due to Nocardia species-one due to usual N. asteroides and other by uncommon N. caviae. N. asteroides affected the brain in a post renal transplant patient, whereas N. caviae caused infection of brain in an apparently healthy individual. To the best of our knowledge, all the previous cases of brain abscess due to Nocardia caviae have been reported in compromised hosts. Agar dilution antimicrobial testing showed relatively higher resistant pattern in N. asteroides. In spite of antimicrobial therapy, both the patients succumbed, one within 4 days and other after an initial improvement for four weeks due to drainage of abscess.The technical assistance of Mr. R.K. Sapra and Mr. Pawan Kumar is greatfully acknowledged.     

Fungal cerebral abscess in a diabetic patient successfully treated with surgery followed by prolonged antifungal therapy

BackgroundIntracranial fungal masses are uncommon diseases, but their incidence is increasing, most often due to the prolonged survival of patients with different immunodeficiencies. The management of patients with intracranial fungal masses included stereotactic biopsy for diagnosis, partial or radical surgery excision and prolonged antifungal therapy.AimsWe report the case of a 51-year-old diabetic man with a history of psoas abscess due to Candida albicans 1 year before the onset of neurological symptoms, including headache and generalized tonoclonic seizures.MethodsMagnetic resonance imaging showed a single lesion located in the right parietal lobe with mass effect, surrounding edema and enhancement after injection of gadolinium. The material was purulent.ResultsDirect microscopic examination showed hyaline, branched and septate hyphae compatible with fungal elements.ConclusionsFungal infections, especially due to Candida species, should be considered in diabetic patients with parenchymal brain abscesses. Radical excision followed by prolonged antifungal therapy based on fluconazole or amphotericin B is necessary to improve the prognosis of this type of patients.     

Safety and efficacy of human amniotic membrane in primary pterygium surgery

Grafts made from human amniotic membrane are used to prevent recurrence of pterygium after excision. The success of the procedure can be affected by the quality of preparation and preservation of the grafts. We prospectively evaluated the safety and efficacy of cryopreserved amniotic membrane prepared at the research tissue bank of the Biotechnology Research Center in Tripoli, Libya, and used as adjunct therapy in primary pterygium excision. Twenty-six patients (15 males and 11 females) aged 21–78 years and indicated for primary pterygium excision were transplanted at the Tripoli Eye Hospital with the amniotic membrane grafts. Sixteen patients (62 %) were available for all three follow-up visits scheduled at 1, 3 and 6 months post-surgery. By the third visit, two patients (12.5 %) developed granuloma and three (18.8 %) had pterygium recurrence. The grafts were used after cryopreservation for ≤180 days or >180 days, but statistical analysis showed that the complications were not associated with the length of storage. Moreover, the high rate of complications in this study was not caused by use of cryopreserved AM. In conclusion, locally produced cryopreserved AM is safe as an adjunct therapy for treatment of primary pterygium excision.     

细菌性脑脓肿的抗感染治疗进展

细菌性脑脓肿指细菌引起的颅内脓腔性感染,虽然发病率不高,但可导致严重后果。导致细菌性脑脓肿的病原体中,以链球菌、葡萄球菌最多,在我国及亚洲地区,革兰阴性杆菌也是重要病原体。第3代头孢菌素联合甲硝唑是最常用的经验性用药方案,能覆盖细菌性脑脓肿的最常见病原体。细菌性脑脓肿抗感染治疗的疗程一般长于6周,且须密切监测患者临床表现和头颅影像学改变。目前多采用手术联合内科药物的治疗方案,可明显缩短疗程,预后也大大改善。单纯保守治疗在脓肿较小、病情轻等情况下可考虑,以避免手术等有创操作的风险。但总体来说,细菌性脑脓肿的药物治疗方案仍缺乏足够的循证医学证据。     

Isolation of Propionibacterium acnes from central nervous system infections

Propionibacterium acnes is a common skin colonizer and its involvement in central nervous system (CNS) infections may be related with previous neurosurgical procedures. P. acnes was isolated in pure or mixed cultures from ten patients with CNS infections during a 5-year period. The clinical presentation, treatment and outcome were retrospectively reviewed. Nine out of 11 patients had CNS infections after a neurosurgical procedure. The clinical presentation was: brain abscess (five patients), subdural or epidural empyema (four patients) and shunt meningitis (one patient). Three patients had also secondary meningitis. All patients received antibiotic therapy and all abscesses and empyemas were drained. The patient with shunt meningitis cured without catheter removal. Only one patient with a brain abscess by P. acnes died, but several months thereafter and as a consequence of a Gram-negative superinfection. P. acnes is a pathogen for the CNS and infections must be surgically managed under adequate antibiotic treatment.     

Bilophila wadsworthiain brain abscess: case report

A case of a patient with a 20-year history of chronic otitis media complicated by cholesteatoma and brain abscess is described. A CT scan with contrast material showed three abscess cavities in the right cerebellar hemisphere. A culture from a specimen of the cholesteatoma yielded a significant amount of growth of Bilophila wadsworthia, Bacteroides fragilis and Prevotella oris and a moderate growth of alpha-streptococci and Staphylococcus simulans. From the pus of the brain abscess we also isolated numerous Bilophila wadsworthia, Bacteroides fragilis and Prevotella oris and some Prevotella buccae and Peptostreptococcus anaerobius. No aerobes were present. The patient underwent a craniotomy and the biggest abscess was removed together with the capsule. The antimicrobial therapy included penicillin plus metronidazole and later augmentin. The result of the treatment was a complete cure and total recovery of the patient. This is the first documentation of isolation of B. wadsworthia in chronic otitis media and in brain abscess.     

Liver abscess as the presenting manifestation of chronic granulomatous disease

Chronic granulomatous disease (CGD) is a rare primary immunodeficiency disease, affecting phagocytic blood cells, which predispose patients to recurrent infectious complications. Herein, an 11-year-old girl is described who presented with liver abscess at the age of 9 years. Positive dihydrorhodamine (DHR) and nitrobluetetrazolium (NBT) tests confirmed the diagnosis of CGD for the patient. Anti-tuberculosis drugs and parenteral antibiotic therapy were started. Unusual visceral abscess and recurrent infections should be considered as an alarm for primary immunodeficiency diseases, while early diagnosis and appropriate treatment could prevent severe complications and even death in this group of patients.     

Hook of hamate fractures: critical evaluation of different therapeutic procedures

The treatment of choice in nondisplaced hook of hamate fractures is conservative, with lower arm splinting. Displaced fractures should be treated operatively, whereby excision of the fragment or open reduction and internal fixation are described. A hamulus ossis hamati fracture was verified in 14 patients (mean age, 42 years; range, 21 to 73 years) including 11 men and three women. In six patients (42.9 percent), conservative treatment was initiated immediately after trauma with a lower arm cast for 6 weeks, and eight patients (57.1 percent) were operated on primarily. In five patients (35.7 percent), the fragment was excised, and in three patients (21.4 percent), an open reduction and internal fixation was performed using a screw. In five of six patients treated conservatively, nonunion of the fracture with persisting clinical symptoms developed. All of those patients were treated operatively, whereby three patients underwent excision and two patients underwent screw fixation, which led to elimination of the symptoms. One patient was asymptomatic despite nonunion of the fracture and rejected surgery. All of the eight patients operated on primarily were asymptomatic 3 months after surgery. Therefore, the success rate of primary surgical treatment (eight of eight) was significantly higher compared with conservative treatment(one of six). Finally, all 14 patients were asymptomatic at late postoperative follow-up. The clinical outcome of patients with hook of hamate fractures treated conservatively was disappointing. Therefore, primary surgical treatment is recommended. In our patients, excision and open reduction and internal fixation led to comparable results.     

Anaerobic axillary abscess.

Fifty-two patients with axillary abscesses were seen during two years. Staphylococcus aureus was isolated from 34, anaerobic bacteria from 12, and skin flora from five; in one case the pus was sterile. Seven patients with hidradenitis suppurativa had recurrent infection with abscess formation, which was bilateral in three. Anaerobes were isolated in five of these cases and skin flora alone in two. Anaerobes are secondary invaders in this condition, and histological examination shows that the primary abnormality is obstruction of pilosebaceous follicles and apocrine glands, associated with keratin plugging of the follicles. Chemotherapy offers little hope of cure, although metronidazole removes the offensive smell of the discharge. Radical surgery is usually indicated.     

Treatment of acute abscesses in the casualty department.

In the treatment of acute pyogenic soft-tissue abscess incision, curettage, and primary suture was compared with incision and drainage alone in a randomised prospective trial. Operations were performed under antibiotic cover by casualty officers, and patients were reviewed by an independent observer in a septic dressing clinic. Altogether 114 patients were studied, of whom 54 were treated by curettage and primary suture and 60 by simple drainage. The mean healing time was 8.9 days in those treated by primary suture and 7.8 days in those treated by simple drainage (p less than 0.05). Primary healing failed to occur in 19 (35%) of the sutured wounds, but there were no other complications in either group. It is concluded that incision and drainage alone is adequate treatment for acute soft-tissue abscess.     

A Case of Primary Localized Cutaneous Infection Due to <Emphasis Type="Italic">Fusarium oxysporum</Emphasis>

Fusarium is a ubiquitous hyalohyphomycete isolated from food, widespread in the environment (plants, soil) and present at all latitudes. Fusarium oxysporum and Fusarium solani are the most frequent pathogenic species, followed by F. moniliforme and F. chlamydosporum. Infections due to this mold may be disseminated or localized. Localized forms include cutaneous and subcutaneous infection, onychomycosis, endophtalmitis, otitis, sinusitis, arthritis, osteomyelitis, and brain abscess. Disseminated forms are those in which two or more noncontiguous sites may be involved. These latter are observed in patients with severe neutropenia. Wounds, digital ulcers, onychomycosis, and paronychia are the typical cutaneous portal of entry. We report a case of primary localized cutaneous infection due to Fusarium in a 29-year-old woman presenting with a nodular lesion, partially ulcerated, asymptomatic on the first finger of the left hand, appeared 4 months earlier. Histological examination showed spongiosis and acanthosis in the stratum corneum, ulceration and inflammation with prevalently mononucleate cells and septate and branched fungal structures in the epidermis and in dermis. The fungus was identified as Fusarium oxysporum by culture of biopsy fragments on Sabouraud dextrose agar with chloramphenicol. The culture was deposited in the culture collection of the mycology section of IHEM, Brussels (IHEM21984 col no. 125). The patient had normal immune status and was successfully treated with surgical excision. Recovery was confirmed at follow-up 8 months later.     

Amebic liver abscess: report of three cases

Amebic abscess is a common manifestation of extraintestinal amebiasis and it is associated with relatively high morbidity and mortality. We present three cases seen in Bari, Southern Italy, one of which was autochthonous and the other two were not. Diagnosis was performed by elevated antibody titre for E. histolytica through immunofluorescence assay and positive antigen determination by ELISA in stools and in abscess aspirate. Fever often accompanied by chills, abdominal pain, weight loss and hepatomegaly were present. Laboratory findings also revealed leukocytosis with neutrophilia. Pleural effusion was observed in two patients. In all our patients multiple abscesses were observed. All the patients were treated with metronidazole and two of them also underwent the aspiration of the amoebic abscess. In all of them there was improvement of the clinical picture, as demonstrated by computerized tomography.