Prevalence, Symptoms, and Prognosis of Intracerebral Abscess AAP Grand Rounds 2004;12;15

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://aapgrandrounds.aappublications.org/content/12/2/15.1

An erratum has been published regarding this article. Please see the attached page for: http://aapgrandrounds.aappublications.org/http://aapgrandrounds.aappublications.org/content/12/3/38.1.full.pd f

AAP Grand Rounds is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1999. AAP Grand Rounds is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2004 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1099-6605.

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6. American Academy of Pediatrics Committee on Drugs and Committee on Bioethics. Pediatrics. 1997;99:122-129.

Commentary by J. Gordon Millichap, MD, FAAP

Neurology, Childrens Memorial Hospital, Northwestern University Medical School, Chicago, IL

NEUROLOGY

Prevalence, Symptoms, and Prognosis of Intracerebral Abscess

Source: Goodkin HP , Harper MB, Pomeroy SL. Intracerebral abscess in children: historical trends at Childrens Hospital Boston. Pediatrics. 2004;113:1765-1770. f the 386 patients identied by databases as having been treated for intracerebral abscess at Childrens Hospital, Boston, Mass, between 1981 and 2000, 55 had the diagnosis conrmed by cranial imaging or autopsy reports. A retrospective review of the records of these 55 patients was performed. The age of patients ranged from 5 days to 34 years; 7 were younger than 8 weeks at presentation and 5 were younger than 1 month. Nine children were classied as immunosuppressed, 6 had organ transplantations, 2 were treated for acute lymphoblastic leukemia, and 1 had hyperimmunoglobulin M syndrome. Abscesses were single in 37 and multiple noncontiguous in 18. Cultures obtained by aspiration, resection, or biopsy on 42 occasions identied pathogens in 36 (86%), with 2 or more organisms in 14. Streptococcus milleri was the most frequent isolate. Of the 9 patients with fungal infections, 7 were immunosuppressed, and all died. Presenting symptoms included headache in 27 (50%), vomiting in 12 (22%), photophobia in 5 (9%), fever in 16 (29%), seizures in 15 (27%), changes in mental status (lethargy to coma) in 17 (31%), paresthesias in 4 (7%), hemiparesis in 4 (6%), and increasing head circumference in 3 (6%). All but 1 patient received antimicrobial therapy, either alone or in combination with surgery. Surgical treatment (aspiration in 39 and resection in 3) was performed in 42 (76%) cases, with 20 patients requiring 2 or more procedures. Thirteen (24%) patients died, with the most common cause of death being multisystem failure. Of the 24 patients followed after discharge (16 lost to follow-up), 7 recovered, 10 had developmental delay or learning disorders, 6 had epilepsy, and 3 developed hydrocephalus requiring a ventriculoperitoneal shunt. The 55 patients in this 1981-2000 series were compared to a similar study of the natural history of intracerebral abscess in 94 patients treated between 1945 and 1980.1 Congenital heart disease was the most common predisposing factor during both time periods, with the rate of cerebral abscess similar in both time periods (2.75 per year for 1981-2000 versus 2.68 per year for 1945-1980). When compared to the earlier era, the more recent case series revealed a decrease in the frequency of abscesses associated with sinus or otitic infection (11% in 1981-2000 versus 26% in 1945-1980), an increase in infants affected (18% versus 7%), an increased number associated with acute immunosuppressive diseases (16% versus 1%), an increase in cases treated with antibiotics alone (22% versus 1%), no signicant change in mortality (24% versus 27%), previously unrecognized Citrobacter causative organism (only in 3 neonatal cases), and fungus infection (predominantly in immunosuppressed patients) not encountered in the 1945-1980 era. Despite improvements in diagnosis due to neuroimaging, brain abscess continues to result in high rates of neurologic impairment and death. August 2004

A brain abscess consists of localized pus within the brain substance. Organisms enter the brain via the blood stream from a distant infection, such as a contiguous spread from the middle ear or paranasal sinuses, from a penetrating wound, or in association with cyanotic congenital heart disease with right-to-left shunt. Abscesses resulting from hematogenous spread may be localized in any part of the brain, most commonly at the junction of gray and white matter, whereas those arising from contiguous sources are usually supercial and close to the infected bone or dura. During the initial cerebritis (septic encephalitis) stage, the clinical picture is nonspecic. A patient with heart disease develops headache, vomiting, seizures, and fever. As the abscess forms, the neurologic signs become more apparent and lateralizing, with hemiparesis, hemianopia, papilledema, and localized percussion tenderness of the skull.2 The electrocardiogram shows focal slowing and computed tomography conrms the diagnosis. In the differential diagnosis, thromboses of arteries, veins, and dural sinuses are common in cyanotic infants and symptoms may mimic an abscess except that the onset is more abrupt. Thromboses are rare in infants older than 2 years of age. Hypoxic attacks occur in 12 to 15% of patients with cyanotic heart disease and are common during the rst 2 years of life. Meningitis may also mimic an abscess before symptoms and signs become lateralized.3 The diagnosis of brain abscess should be considered with new-onset headache and seizure, especially in a child with congenital heart disease or recent sinus or ear infection, or in an acutely immunosuppressed patient with fungal disease. References
1. Fischer EG, et al. Am J Dis Child. 1981;135:746-749. 2. Raimondi AJ, et al. J Neurosurg. 1965;23:588 (cited by Menkes, 1980). 3. Menkes JH. Textbook of Child Neurology. 2nd ed. Philadelphia, Pa: Lea & Febiger; 1980:345.

ALLERGY AND IMMUNOLOGY

Risk of Environmental Exposure to Peanut Allergen in Schools Appears to be Low

Source: Perry TT, Conover-Walker MK, Poms A, et al. Distribution of peanut allergen in the environment. J Allergy Clin Immunol. 2004;113:973-976.

ecause ingestion of even minute amounts of peanut by a sensitized child can cause anaphylaxis, parents fear their children will be inadvertently exposed to peanuts in schools, restaurants, and other public settings. Researchers at Johns Hopkins University, Baltimore, Md, measured the amount of major peanut allergen, Arachus hypogea allergen 1 (Ara h 1), present on cafeteria tables and other surfaces in schools, tested for airborne peanut allergen under a variety of simulated conditions, and examined the effectiveness of 15

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Prevalence, Symptoms, and Prognosis of Intracerebral Abscess AAP Grand Rounds 2004;12;15

Updated Information & Services References Subspecialty Collections

including high resolution figures, can be found at: http://aapgrandrounds.aappublications.org/content/12/2/15.1 This article cites 3 articles, 1 of which you can access for free at: http://aapgrandrounds.aappublications.org/content/12/2/15.1#BIBL This article, along with others on similar topics, appears in the following collection(s): Neurology http://aapgrandrounds.aappublications.org/cgi/collection/neurology Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: /site/misc/Permissions.xhtml Information about ordering reprints can be found online: /site/misc/reprints.xhtml

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economic status of these 2 neighborhoods were comparable. Surveys were conducted by trained interviewers at 6 hightrafc locations in each neighborhood at various times in order to maximize the likelihood of obtaining a representative sample of the target population of 15- to 30-year-olds. The nal sample consisted of 285 individuals, of whom 51% were female, 81% were African-American, and 13% were Hispanic. The average age of respondents was 20.3 years. The majority of respondents (65%) had computer access either at home, at school, or at a community organization. Younger members of the group (15 to 18 years of age) had more access (up to 91%), because of computer availability at schools, than older members of the sample (19 to 30 years of age). Two-thirds of all respondents used the Internet at least a few times a week. Across all age groups, 55% reported using the Internet to obtain health information. The second report, from the Center on Addiction and Substance Abuse (CASA), is derived from an ongoing study of how prescription drugs are diverted from legal distribution channels into illegal ones. During the week of January 15, 2004, researchers found 495 websites selling controlled drugs (Schedules II-V). Analysis of these sites revealed the following: 68% (338) were portal sitesconduits to other websites where drugs were offered and sold. 32% (157) were anchor siteswebsites where you could actually purchase drugs. Benzodiazepines were the most frequently offered drugs, followed by opioids. Of the anchor sites, 90% did not require a prescription. None of the sites had mechanisms to deter children from purchasing drugs. Commentary by Stanley I. Fisch, MD, FAAP
Private Practice, Harlingen, TX

new realm of information and communication. In the end, as with most things important to families and children, it will be up to parents to set controls and supervise their childrens use of the Internet, albeit a challenging task, particularly for older adolescents. We pediatricians can help by alerting parents to the potential dangers. References
1. Tam P . Fruitcake debutantes dened by O, and other spam tricks. The Wall Street Journal. May 28, 2004:B1. 2. Brodie M, et al. Health Aff. 2000;19:255-265. 3. Becker HJ. Future of Children. 2000;10:44-75.

Erratum

In the August 2004 issue of AAP Grand Rounds, page 15 in the commentary by J. Gordon Millichap on intracerebral access, the second sentence of the rst paragraph should read Organisms enter the brain via the blood stream from a distant infection, by continuous spread from the middle ear or paranasal sinuses, from a penetrating wound, or in association with cyanotic congenital heart disease with right-to-left shunt. The last line of the same paragraph should read The electroencephalogram shows focal slowing and computed tomography conrms the diagnosis. We regret the errors

CME Questions
The following continuing medical education questions cover the content of the September 2004 issue of AAP Grand Rounds. Please keep this issue. Each years material is worth up to 18 Category 1 credits toward the AMA Physicians Recognition Award.
CME Objectives: AAP Grand Rounds presents important new studies from the medical literature, selected by a panel of expert clinicians and editors. Selection criteria include clinical signicance, methodological quality, and the importance of the research question. The CME activity is designed to introduce new knowledge, reinforce the critical assessment of the evidence, and provide insights into the clinical application of new research. The activity is also designed to help clinicians hone their critical assessment skills, increase awareness of the current research environment, and stimulate further learning and investigation. Participants in this months activity should be able to, upon completion: Assess the impact of sugar-sweetened drinks on childhood obesity; Consider the benets of zinc supplementation in the treatment of severe pneumonia; and Discuss whether pulse oximetry is a reliable indicator for continued hospitalization of bronchiolitis patients.

Is there a problem? The Wall Street Journal reports that in April, 2004, 64% of all e-mail was spam.1 Combine this fact with these reports of pervasive access to the Internet and seemingly ready, direct access to prescription drugs, and you have to change your mental image of a drug pusher. Earlier reports about the digital divide highlighted disparities in access to such information because of class differences in Internet access.2,3 The rst report suggests the divide no longer exists, that Internet access is now pervasive, and emphasizes the positive aspects of Internet access: young people use the Internet to obtain health information. The CASA report points us to the dark side of these developments and is cause for great concern. Figure: Representation of an Internet ad received as spam 4/25/04*

*Content and format modied to mask the identity of the advertiser.

Federal and state regulations have not kept up with developments in cyberspace. Issues of privacy and free speech confound legislators attempts to impose controls on this 38

1. According to the study by James et al on a school-based intervention to reduce childhood obesity: a. school-based intervention studies have shown uniform effects on reducing obesity. b. school-based interventions are generally ineffective in published obesity prevention trials. c. their intervention had no impact on either carbonated drink intake or obesity. d. their intervention resulted in both lower carbonated drink intake and reduced percentage of overweight and obese children. e. their intervention resulted in less carbonated drink intake but no change in the percentage of overweight and obese children.

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2. Brooks et als study of young children with pneumonia in Bangladesh showed an association between which of the following? a. Decreased blood zinc levels and increased risk of severe pneumonia b. Decreased pulmonary zinc levels and increased risk of severe pneumonia c. Supplemental oral zinc and a decreased risk of recurrent pneumonia d. Supplemental oral zinc and more rapid recovery from severe pneumonia 3. According to the article by Schroeder et al, which of the following statements regarding pulse oximetry is true? a. Hospital discharge should be based solely on oxygen saturation. b. Over-reliance on pulse oximetry may prolong hospital stays. c. Pulse oximetry did not affect hospital discharge rates. d. Pulse oximetry is the most reliable measurement of oxygen saturation. 4. The study by Shultz et al shows that early intervention with video-assisted thoracic surgery (VATS) as adjunctive treatment of pleural empyema can: a. decrease the length of hospitalization and duration of fever. b. increase the morbidity of pleural empyema. c. increase the risk of infection with methicillin-resistant Staphylococcus aureus. d. obviate the need for antibiotics. 5. An 11-year-old girl is evaluated with a complaint of fever associated with a cough for a 5-day duration. Physical exam reveals a fever of 102.2F (39.0C), tachypnea, and focal crepitations. Which is the most likely cause of the patients pneumonia? a. Chlamydia pneumoniae b. Mycoplasma pneumoniae c. Parainuenza 1 d. Parainuenza 2 e. Streptococcus pneumoniae 6. The analysis of the Nationwide Inpatient Sample conducted by Barker and colleagues supports which of the following statements about the treatment of pediatric brain tumors? a. A child with a malignant brain tumor is more likely to be cured if that child gets care at a childrens hospital. b. Functional outcome after treatment for medulloblastoma is compromised by postponement of inpatient rehabilitation until radiation therapy has been completed. c. Surgeons who perform a high annual volume of craniotomy for adult brain tumor have outcomes equal to pediatric neurosurgeons in the performance of craniotomy for pediatric brain tumor. d. Surgeons who perform a high annual volume of craniotomy for adult brain tumor have outcomes inferior to pediatric neurosurgeons in the performance of craniotomy for pediatric brain tumor. e. The perioperative mortality rates for craniotomy for pediatric brain tumor are lower at busy childrens hospitals than at hospitals where children with this condition are seldom treated. 7. A 12-year-old child develops persistent cognitive and behavioral sequelae following cerebellar astrocytoma resection. Which of the following is included in the cerebellar cognitive affective syndrome? a. Dyscalculia b. Dysdiadochokinesia c. Impaired visual spatial skills d. Mutism

8. According to the study by Valent et al, the impact of the environment on child health: a. is negligible. b. is stable across all socioeconomic groups. c. may be largely alleviated by education of pediatricians and parents. d. requires government policy changes to be substantially improved. 9. During the well child exam of a 6-year-old boy and 8year-old girl, the parents volunteer that they will be going on a ski vacation next week. In providing anticipatory guidance for this trip, which of the following represents the best advice? a. Since most fatal injuries occur among girls, the daughter is at higher risk of a fatal injury from skiing. b. Since most fatal injuries occur in the evening, the children should not ski after 4 PM. c. Since most fatal injuries result from falls, the children should be accompanied by an adult on the ski lift. d. Since most fatal injuries result from head trauma, the children should wear ski helmets. e. Since most fatal injuries result from hypothermia, the children should wear warm clothing. 10. When performing computed tomography to evaluate abdominal injury in blunt trauma, what is a reasonable decision for bowel visualization? a. Barium provides good bowel contrast b. Hypaque must be used to visualize bowel c. No contrast is necessary d. Water is equally as effective as dilute Hypaque for visualization 11. Which of the following neurologic disorders is signicantly more prevalent with celiac disease compared to controls? a. Double vision b. Migraine headaches c. Obsessive compulsive disorder d. Stuttering e. Tics 12. The study by Benn et al of a Danish national birth cohort showed that: a. having 3 or more infections prior to age 6 months was associated with a decreased risk of atopic dermatitis. b. infants younger than 6 months who attended day care had an increased risk of atopic dermatitis. c. infections prior to age 6 months were not protective against atopic dermatitis. d. the majority of infants did not develop infections during the rst 6 months of life. e. the majority of infants eventually developed atopic dermatitis. 13. The Oketani method of breast massage was shown in a study by Foda et al to: a. have no effect on breast milk composition. b. increase the energy content of breast milk. c. increase the free water content of breast milk. d. increase the protein content of breast milk. e. increase the vitamin content of breast milk. 14. Which of the following statements about children in foster care is true? a. A small number of the children in foster care account for most of the mental health costs. b. Children less than 6 years of age at entry into foster care are at greater risk of requiring mental health services than children older than 6 years of age. c. Children with higher physical health care costs are less likely to receive mental health services. d. Children with multiple foster care placements are unlikely to receive mental health services.

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39

15. Which one of the following anatomic and physiologic abnormalities was most consistently identied in the study group of prepubertal children suspected of having sleep disordered breathing? a. Abnormal Respiratory Disturbance Index on polysomnography b. Hypertrophic tonsils and adenoids c. Increased vertical distance (overbite) between mandibular and maxillary incisors d. Long soft palate, with redundant tissue e. Nasal septal deviation 16. Which of the following is the most accurate method for diagnosing Helicobacter pylori infection in children? a. Antral biopsy b. H pylori serum immunoassay c. H pylori stool antigen test d. H pylori urinary IgG antibodies e. Urea breath test 17. A 3-year-old child is evaluated in the emergency department for a knee injury. The parent saw the child trip and fall down 3 steps, landing hard on his knee. Following the fall, he refused to bear weight. X-ray reveals a buckle fracture of the distal femur at the junction of diaphysis and metaphysis. Which of the following statements about the mechanism of this injury are correct? a. The injury results from axial loading and is consistent with the proposed history. b. The injury results from axial loading and is inconsistent with the proposed history. c. The injury results from complex loading and is consistent with the proposed history. d. The injury results from shearing forces and is consistent with the proposed history. e. The injury results from torsional forces and is inconsistent with the proposed history. 18. A website selling prescription drugs will probably: a. not require a doctors prescription. b. only sell drugs which are under consideration by the Food and Drug Administration for reclassication to over-the-counter status. c. reach fewer lower-income people since they have less access to the Internet than those with higher incomes. d. screen out most children from making purchases.

EDITORIAL BOARD
Editors-in-Chief Lewis R. First, Burlington, VT Edgar K. Marcuse, Seattle, WA Consulting Editors Joseph D. Dickerman, Burlington, VT Douglas Diekema, Seattle, WA Editorial Board M. Douglas Baker, Woodbridge, CT Leslie Barton, Tucson, AZ Robert H.A. Haslam, Toronto, ON Virginia Moyer, Houston, TX Gary Onady, Dayton, OH Richard A. Polin, New York, NY John Snyder, San Francisco, CA Bernhard Wiedermann, Washington, DC Contributing Section Editors Administration and Practice Management: Jerald L. Zarin, Houston, TX Adolescent Health: Richard R. Brookman, Glen Allen, VA Allergy and Immunology: Mitchell Lester, Westport, CT Anesthesiology and Pain Medicine: Thomas Mancuso, Boston, MA Bioethics: Brenda Jean Mears, Dallas, TX Breastfeeding: Wendelin Slusser, Los Angeles, CA Cardiology and Cardiac Surgery: David Danford, Omaha, NE Child Abuse and Neglect: Betty Spivack, Louisville, KY Children with Disabilities: Pasquale Accardo, Richmond, VA Clinical Pharmacology and Therapeutics: Ian M. Paul, Hershey, PA Community Pediatrics: Stanley I. Fisch, Harlingen, TX Critical Care: Susan L. Bratton, Ann Arbor, MI Dermatology: Albert C. Yan, Philadelphia, PA Developmental and Behavioral Pediatrics: Ronald L. Lindsay, Columbus, OH Emergency Medicine: Ronald L. Paul, Louisville, KY Endocrinology: Surendra Varma, Lubbock, TX Epidemiology: Daniel R. Neuspiel, New York, NY Gastroenterology and Nutrition: Neal LeLeiko, Providence, RI Genetics, Birth Defects: Lawrence R. Shapiro, New York, NY Hospital Care: Brian M. Pate, Kansas City, MO Infectious Diseases: Mobeen Rathore, Jacksonville, FL Injury and Poison Prevention: Murray L. Katcher, Madison, WI International Child Health: Brian Bramson, Raleigh, NC Medicine-Pediatrics: Brett Robbins, Rochester, NY Nephrology: Aaron Friedman, Madison, WI Neurological Surgery: Joseph H. Piatt, Jr., Philadelphia, PA Neurology: J. Gordon Millichap, Chicago, IL Ophthalmology: Walter M. Fierson, Pasadena, CA Orthopedics: Frederick Dietz, Iowa City, IA Otolaryngology: Daniel L. Wohl, Jacksonville, FL Pediatric Dentistry: John E. Nathan, Oak Brook, IL Perinatal Practice: Richard A. Polin, New York, NY Plastic Surgery: Fernando D. Burstein, Atlanta, GA Pulmonology: Jeffrey Wagener, Denver, CO Radiology: Beverly Wood, Los Angeles, CA Residents: Rick Focht, Crestview Hills, KY Rheumatology: Susan Ballinger, Indianapolis, IN School Health: Linda Grant, Boston, MA Senior Members: Donald W. Schiff, Littleton, CO Sports Medicine: E.F. Luckstead, Amarillo, TX Surgery: Clinton Cavett, Roanoke, VA Transport Medicine: Monica Kleinmann, Sharon, MA Uniformed Services: Michael Dubik, San Diego, CA Urology: Daniel McMahon, Akron, OH

CME INFORMATION
AAP Grand Rounds is an educational publication. The American Academy of Pediatrics is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. AAP Grand Rounds is planned and produced in accordance with ACCME Essentials. The American Academy of Pediatrics designates this educational activity for up to 18 Category 1 credits toward the AMA Physicians Recognition Award. Each physician should claim only those credits that he/she actually spent in the educational activity. The AMA has determined that nonUS licensed physicians who participate in this CME activity are eligible for AMA PRA Category 1 credit. A CME Quiz Sheet is included in the January issue of AAP Grand Rounds. The deadline for submitting the 2004 quiz sheet for 2004 credit is January 31, 2005. This is a scientic publication designed to present updates and opinion to health care professionals. It does not provide medical advice for any individual case, and is not intended for the layman.

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Answers: 1. d 2. d

3. b 4. a

5. e 6. e

7. c 8. d

9. d 10. d

11. b 12. c

13. b 14. a

15. a 16. a

17. a 18. a