Brain abscess caused by Salmonella typhi Case report
YASUO SUZUKI, M.D., YOSHIAKI SUGIYAMA, M.D., RYOJI I s m I , M.D., AND ISAMI SATO, M.D.
Department of Neurosurgery, Toyama Prefectural Central Hospital, Toyama, Japan The authors report a rare case of a brain abscess associated with osteomyelitis caused by Salmonella typhi that remained in contact with human tissues for 33 years without losing its virulence. KEY WORDS
9 brain abscess
A
NY Or the pyogenic bacteria may cause brain abscess. Staphylococci, streptococci, and pneumococci are common, a-5 but brain abscesses caused by the Salmonella group are extremely rare. We describe a brain abscess caused by S a l m o n e l l a typhi that was successfully treated by aspiration, drainage, and injection of antibiotics into the abscess, and systemic antibiotic therapy.
9 Salmonella typhi
9 typhoid abscess
A 45-year-old w o m a n was admitted to our clinic on May 26, 1975, because of progressive headache of 1 month's duration without nausea and vomiting, and i n t e r m i t t e n t numbness and convulsion involving the angle of the left side of the mouth for 1 week. She had suffered typhoid fever at the age of 12 years, but there was no history o f otitis media or high fever. Examination. N o abnormal findings were noted on the systemic physical examination. Her temperature was 97 ~ F and the pulse 92. She was alert and well oriented but dysarthric. Examination of the cranial nerves
revealed no abnormalities other than a central facial palsy on the left side. The optic fundi were normal. The patient had n o r m a l reflexes, and no sensory abnormalities were present. There was weakness of the left fingers. The white cell count was 8500/cu m m with 2% eosinophils. Blood sedimentation rate was 24 m m in the first hour. N o other abnormality was found on routine hematological or biochemical examinations. L u m b a r puncture revealed an opening pressure o f 140 mm H20, protein content 60 mg%, glucose 76 rag%, and 94-white blood cells. Plain skull films and t o m o g r a p h y showed irregular bone destruction with an island o f high density in the right parietal region (Fig. 1). An electroencephalogram was normal. A brain scan showed abnormal accumulation of 99mTc in the parietal region (Fig. 2). Right carotid angiography confirmed the presence of a large mass in the same area, without hypervascularity or ring-like shadow. Within 4 days, the patient's left arm became paralyzed and weakness developed in the left leg. Operation. On June 5, 1975, a right front o p a r i e t o t e m p o r a l c r a n i o t o m y was per-
J. Neurosurg. / Volume 45 / December, 1976
709
Case Report
Y. Suzuki, Y. Sugiyama, R. Ishii and I. Sato
FIG. 1. Anteroposterior tomogram (left) and lateral skull film (right) show irregular bone destruction with an island of high density in the right parietal region.
Postoperative Course. After operation, antibiotic therapy was continued. The patient received 8 gm of cephalothin and 2 gm of chloramphenicol daily for 21 days, and penicillin was injected into the abscess for 7 days. On the fourth postoperative day, she began to move her arm. Her neurological disabilities improved steadily, and when she was discharged 44 days postoperatively, her neurological examination was normal except for residual weakness of the left side of the face. Her temperature was normal. Cultures obtained from stool, urine, blood, bile, and cerebrospinal fluid were negative on several occasions. Postoperative angiograms showed satisfactory shrinkage of the abscess cavity.
formed. When the scalp was reflected, a focus of osteomyelitis was seen in the center of the bone flap, and continuing into the brain parenchyma through the dura mater (Fig. 3). The dura mater was incised in a circular fashion. A brain cannula was inserted into the abscess cavity, which was at a depth of 3 cm and contained 10 ml of yellowish, muddy fluid. The contents were aspirated and penicillin was injected into the abscess cavity. A drain was left in the space and the bone flap was not replaced. Pathological Examination. Purulent material from the abscess cavity was planted in cultures, which grew Salmonella typhi with the phage type D2 characterized biochemically by failure to ferment lactose, inability to produce indole and positive sugar fermentation without the formation of gas, and immunologically by the presence of Vi antigen. This was sensitive to a number of antibiotics.
A variety of complications of Salmonella infection may occur, such as laryngeal ulcer, gallbladder infection, or cystitis. Suppurative
FIG. 2. Risht lateral scan shows abnormal uptake in the right parietal region,
FIG. 3. Operative photograph shows bone destruction in the center of the bone flap.
710
J. Neurosurg. / Volume 45 / December, 1976
Discussion
Salmonella brain abscess processes m a y a p p e a r in other parts of the body. Although Salmonella meningitis is not very unusual, brain abscess is not a frequent c o m p l i c a t i o n . B r a i n abscesses due to Salmonella typhi were reported by Melchior 6 in 1911 and by Burrows 2 in 1959. Since then, Paniker and G e o r g e 7 reported an otogenic brain abscess c a u s e d by Salmonella typhimurium, and Brzezinski, et al.,1 reported a cerebral abscess during Salmonella enteritidis infection. In our case, a brain abscess was caused by Salmonella typhi associated with osteomyelitis of the skull. It was presumed that the typhoid bacillus remained in contact with h u m a n tissues for 33 years without losing its virulence and caused osteomyelitis. Acknowledgment
References
1. Brzezinski J, Planeta-Malecka I, Zierski J, et al: ]Cerebral abscess during Salmonella enteritidis infection in an 8-month-old infant.] Pediatr Pol 44:223-226, 1969 (Pol) 2. Burrows W: Textbook of Microbiology, ed 17. Philadelphia: WB Saunders, 1959, p 484 3. Krayenbiihl HA: Abscess of the brain. Ciin Nenrosurg 14:25--44, 1967 4. Loeser E Jr, Scheinberg L: Brain abscesses. A review of 99 cases. Neurology 7:601-609, 1957 5. McFarlan AM: The bacteriology of brain abscess. Br Med J 2:643-644, 1943 6. Melchior E: l~lber Hirnabscesse und sonstige umschriebene intrakranielle Eiterungen im Verlauf und Gefolge des Typhus abdominalis. Zbl Grenzgeb Med Chir 14:49-56, 1911 7. Paniker CKJ, George K: Otogenic brain abscess caused by Salmonella typhimurium. J Indian Med Assoc 45:451-452, 1965
We would like to thank Professor K. Ueki, Department of Neurosurgery, Brain Research Institute, Niigata University, for his encouragement and advice.
Address reprint requests to: Yasuo Suzuki, M.D., Department of Neurosurgery, Brain Research Institute, Niigata University, 1 Asahimachi, Niigata City, 951 Japan.
J. Neurosurg. / Volume 45 / December, 1976
711
YASUO SUZUKI, M.D., YOSHIAKI SUGIYAMA, M.D., RYOJI I s m I , M.D., AND ISAMI SATO, M.D.
Department of Neurosurgery, Toyama Prefectural Central Hospital, Toyama, Japan The authors report a rare case of a brain abscess associated with osteomyelitis caused by Salmonella typhi that remained in contact with human tissues for 33 years without losing its virulence. KEY WORDS
9 brain abscess
A
NY Or the pyogenic bacteria may cause brain abscess. Staphylococci, streptococci, and pneumococci are common, a-5 but brain abscesses caused by the Salmonella group are extremely rare. We describe a brain abscess caused by S a l m o n e l l a typhi that was successfully treated by aspiration, drainage, and injection of antibiotics into the abscess, and systemic antibiotic therapy.
9 Salmonella typhi
9 typhoid abscess
A 45-year-old w o m a n was admitted to our clinic on May 26, 1975, because of progressive headache of 1 month's duration without nausea and vomiting, and i n t e r m i t t e n t numbness and convulsion involving the angle of the left side of the mouth for 1 week. She had suffered typhoid fever at the age of 12 years, but there was no history o f otitis media or high fever. Examination. N o abnormal findings were noted on the systemic physical examination. Her temperature was 97 ~ F and the pulse 92. She was alert and well oriented but dysarthric. Examination of the cranial nerves
revealed no abnormalities other than a central facial palsy on the left side. The optic fundi were normal. The patient had n o r m a l reflexes, and no sensory abnormalities were present. There was weakness of the left fingers. The white cell count was 8500/cu m m with 2% eosinophils. Blood sedimentation rate was 24 m m in the first hour. N o other abnormality was found on routine hematological or biochemical examinations. L u m b a r puncture revealed an opening pressure o f 140 mm H20, protein content 60 mg%, glucose 76 rag%, and 94-white blood cells. Plain skull films and t o m o g r a p h y showed irregular bone destruction with an island o f high density in the right parietal region (Fig. 1). An electroencephalogram was normal. A brain scan showed abnormal accumulation of 99mTc in the parietal region (Fig. 2). Right carotid angiography confirmed the presence of a large mass in the same area, without hypervascularity or ring-like shadow. Within 4 days, the patient's left arm became paralyzed and weakness developed in the left leg. Operation. On June 5, 1975, a right front o p a r i e t o t e m p o r a l c r a n i o t o m y was per-
J. Neurosurg. / Volume 45 / December, 1976
709
Case Report
Y. Suzuki, Y. Sugiyama, R. Ishii and I. Sato
FIG. 1. Anteroposterior tomogram (left) and lateral skull film (right) show irregular bone destruction with an island of high density in the right parietal region.
Postoperative Course. After operation, antibiotic therapy was continued. The patient received 8 gm of cephalothin and 2 gm of chloramphenicol daily for 21 days, and penicillin was injected into the abscess for 7 days. On the fourth postoperative day, she began to move her arm. Her neurological disabilities improved steadily, and when she was discharged 44 days postoperatively, her neurological examination was normal except for residual weakness of the left side of the face. Her temperature was normal. Cultures obtained from stool, urine, blood, bile, and cerebrospinal fluid were negative on several occasions. Postoperative angiograms showed satisfactory shrinkage of the abscess cavity.
formed. When the scalp was reflected, a focus of osteomyelitis was seen in the center of the bone flap, and continuing into the brain parenchyma through the dura mater (Fig. 3). The dura mater was incised in a circular fashion. A brain cannula was inserted into the abscess cavity, which was at a depth of 3 cm and contained 10 ml of yellowish, muddy fluid. The contents were aspirated and penicillin was injected into the abscess cavity. A drain was left in the space and the bone flap was not replaced. Pathological Examination. Purulent material from the abscess cavity was planted in cultures, which grew Salmonella typhi with the phage type D2 characterized biochemically by failure to ferment lactose, inability to produce indole and positive sugar fermentation without the formation of gas, and immunologically by the presence of Vi antigen. This was sensitive to a number of antibiotics.
A variety of complications of Salmonella infection may occur, such as laryngeal ulcer, gallbladder infection, or cystitis. Suppurative
FIG. 2. Risht lateral scan shows abnormal uptake in the right parietal region,
FIG. 3. Operative photograph shows bone destruction in the center of the bone flap.
710
J. Neurosurg. / Volume 45 / December, 1976
Discussion
Salmonella brain abscess processes m a y a p p e a r in other parts of the body. Although Salmonella meningitis is not very unusual, brain abscess is not a frequent c o m p l i c a t i o n . B r a i n abscesses due to Salmonella typhi were reported by Melchior 6 in 1911 and by Burrows 2 in 1959. Since then, Paniker and G e o r g e 7 reported an otogenic brain abscess c a u s e d by Salmonella typhimurium, and Brzezinski, et al.,1 reported a cerebral abscess during Salmonella enteritidis infection. In our case, a brain abscess was caused by Salmonella typhi associated with osteomyelitis of the skull. It was presumed that the typhoid bacillus remained in contact with h u m a n tissues for 33 years without losing its virulence and caused osteomyelitis. Acknowledgment
References
1. Brzezinski J, Planeta-Malecka I, Zierski J, et al: ]Cerebral abscess during Salmonella enteritidis infection in an 8-month-old infant.] Pediatr Pol 44:223-226, 1969 (Pol) 2. Burrows W: Textbook of Microbiology, ed 17. Philadelphia: WB Saunders, 1959, p 484 3. Krayenbiihl HA: Abscess of the brain. Ciin Nenrosurg 14:25--44, 1967 4. Loeser E Jr, Scheinberg L: Brain abscesses. A review of 99 cases. Neurology 7:601-609, 1957 5. McFarlan AM: The bacteriology of brain abscess. Br Med J 2:643-644, 1943 6. Melchior E: l~lber Hirnabscesse und sonstige umschriebene intrakranielle Eiterungen im Verlauf und Gefolge des Typhus abdominalis. Zbl Grenzgeb Med Chir 14:49-56, 1911 7. Paniker CKJ, George K: Otogenic brain abscess caused by Salmonella typhimurium. J Indian Med Assoc 45:451-452, 1965
We would like to thank Professor K. Ueki, Department of Neurosurgery, Brain Research Institute, Niigata University, for his encouragement and advice.
Address reprint requests to: Yasuo Suzuki, M.D., Department of Neurosurgery, Brain Research Institute, Niigata University, 1 Asahimachi, Niigata City, 951 Japan.
J. Neurosurg. / Volume 45 / December, 1976
711
