DOI: 10.33962/roneuro-2021-031 Paediatric brain abscesses in tribal region of India. A single centre experience Sachin Kumar Jain, Gaurav Jaiswal, Tarun Kumar Gupta, Krishna Govind Lodha, Vishnu Kumar Lohar, Kaushal Yadav Romanian Neurosurgery (2021) XXXV (2): pp. 199-203 DOI: 10.33962/roneuro-2021-031 www.journals.lapub.co.uk/index.php/roneurosurgery Paediatric brain abscesses in tribal region of India. A single centre experience Sachin Kumar Jain, Gaurav Jaiswal, Tarun Kumar Gupta, Krishna Govind Lodha, Vishnu Kumar Lohar, Kaushal Yadav Department of Neurosurgery, R.N.T. Medical College, Udaipur, INDIA ABSTRACT Introduction: Brain parenchymal abscesses are relatively infrequent but potentially serious infections in the paediatric population. Surgical intervention in addition to a prolonged administration of antibiotics is generally appropriate management. Aims and objective: We performed this study to assess the clinical profile, aetiology and outcome of paediatric brain abscess which are treated surgically only by aspiration in the tribal region of Rajasthan. Material and method: A single-centre retrospective study was conducted over a 5 year period (2014–2019) in the department of neurosurgery in RNT medical college, Udaipur, Rajasthan. We treated approx. 60 patients of which 25 patients treated conservatively and 5 patient treated by craniotomy and abscess excision. So only 30 patient included in our study in which abscess treated by aspiration only. Patients<18 years of age with a confirmed intra-parenchymal abscess were included. Patient records were reviewed for abscess location, microbiology results, Clinical features, Surgical intervention, and outcome using the Glasgow Outcome Score at 3 months. Result: 11 patients had an abscess in the temporal lobe and Streptococcus was the most common causative micro-organism (n¼15). 25 patients (80%) had an identifiable source which included: ENT infections, congenital cardiac malformations, recent dental surgery and meningitis. The most common symptom is fever f/b headache, seizure and vomiting. But despite previous studies seizure (10/30) presentation is comparatively more. All 30 patients underwent aspiration. Conclusion: In tribal regions of India ENT infections are a more common source of brain abscess because of poor hygiene and illiteracy and their ignorance of ENT infections and also not taking seriously to fever, headache and other health issues. But at present, there are also decreasing trends of brain abscess by ENT infections and rising trends by congenital heart disease which is a good sign that the health and educational infrastructure is strengthening in the tribal region also. INTRODUCTION A brain abscess is an intra-parenchymal collection of pus in the brain. The incidence of brain abscess among intracranial masses varies from 1-2% in western countries, to about 8% in developing countries1. It is still a life threatening and fatal entity and often leads to serious disability and even death if misdiagnosed or treated improperly2. Brain abscesses are relatively less common in the paediatric population compared to adults; however, they remain a serious, life-threatening infection3. Keywords abscess, aspiration, paediatrics, ENT Corresponding author: Gaurav Jaiswal Department of Neurosurgery, R.N.T. Medical College, Udaipur, India drsachinj6184@gmail.com Copyright and usage. This is an Open Access article, distributed under the terms of the Creative Commons Attribution Non–Commercial No Derivatives License (https://creativecommons .org/licenses/by-nc-nd/4.0/) which permits non- commercial re-use, distribution, and reproduction in any medium, provided the original work is unaltered and is properly cited. The written permission of the Romanian Society of Neurosurgery must be obtained for commercial re-use or in order to create a derivative work. ISSN online 2344-4959 © Romanian Society of Neurosurgery First published June 2021 by London Academic Publishing www.lapub.co.uk http://www.lapub.co.uk/ 200 Sachin Kumar Jain, Gaurav Jaiswal, Tarun Kumar Gupta et al. The causes of brain abscesses are highly variable in children. The major predisposing conditions in children are: an adjacent focus of infection, trauma, haematogenous seeding, neurosurgical procedures, cyanotic heart disease and immunocompromised states4,5,6. Associated sites of infection commonly include sinusitis, mastoiditis, dental infections and chronic otitis media where aerobic bacterial infections such as Streptococci and Staphylococci predominate4,7 The gold standard treatment of brain abscesses continues to be aspiration or excision combined with antibiotic therapy.5 However the outcome has improved dramatically in recent decades due to improvements in diagnostic techniques and broad- spectrum antibiotics8. Magnetic Resonance Imaging is more sensitive at diagnosing early cerebritis9 and has increased the prognosis of brain abscess by improving the speed of diagnosis. Despite all of these advances abscesses are still a significant cause of morbidity and mortality10. In addition, abscess growth can result in rupture of the abscess into the ventricular system. This life- threatening event will result in an acute decompensation and symptoms of a purulent meningitis11. We performed this study to assess the clinical profile, aetiology, and outcome of paediatric brain abscess in the tribal region of Rajasthan. MATERIAL AND METHOD A single-centre retrospective study was conducted over a 5-year period (2014–2019) in department of neurosurgery in RNT medical college, Udaipur, Rajasthan. We treated approx. 60 patients in which 25 patients treated conservatively and 5 patients treated by craniotomy and abscess excision. So only 30 patients included in our study in which abscess treated by aspiration only. The final cohort of 30 patients comprised 20 male patients (45.8%) and 10 female patient and had a mean age of 6.5 ± 4 years Patients < 18 years of age with radiological confirmed intra-parenchymal abscess were included. Patient records were reviewed for abscess aetiology, location, size, microbiology results, surgical intervention, and outcome using the Glasgow Outcome Score at 3 months. We include the patients in which abscess treated only by aspiration and then antibiotics. Aspiration of abscess may be single or multiple times. Size of abscess is more than 2.5 cm. The total antibiotic duration was discernible from the medical notes for all patients and the mean time was 5.8 ± 2.0weeks. This comprised a mean of 2.9 ± 1.5 weeks intravenous and3.0 ± 1.8 weeks oral antibiotics. White cell count >11109/L and/or C-Reactive Protein >5mg/L was classed as raised inflammatory markers. Functional outcome was measured using the Glasgow Outcome Score (GOS) at 3 months from discharge. Those with isolated subdural empyema, extradural abscess, or an unknown abscess location were excluded from the study. RESULT Most common symptom is fever followed by headache, seizure and vomitting. (Table-3). The classic triad of headache, fever and focal neurological deficit was seen in two patients (8.6%). Drowsiness or reduced level of consciousness on presentation was recorded in 6 patients (34.8%). Age of patients are mostly 5-10 years. (Table-1) The Temporal lobe was the most common abscess location (11). The remainder of the abscesses were in the parietal lobe (8), frontal lobe (7), cerebellum (2), thalamus (1), pons (1) (Table 4) .22 patients had a solitary lesion at presentation and rest 8 has more than one lesion. The patient with aspergilloma had two lesions in the same location. Figure 1. Pre-operative scan of 10-month male child left temporo-parietal brain abcess (original pics). S. N. Age Number Percentage 1 2 3 <5 year 5-10 yr 10-18 yr 6 15 9 20% 50% 30% Table 1. 25 patients (80 %) had an identifiable source which include post meningitic (4), congenital cardiac malformations (7), Otogenic and mastoditis (11), Post 201 Paediatric brain abscesses in tribal region of India traumatic (3). Rest 5 has other non-identifiable sources (Table-2). Streptococcus was the most common organism cultured from the abscesses (18). Other microorganisms include Staphylococcus aureus (5), Coliforms (1), Propriobacterium (1), Mycobacterium tuberculosis (2), Gram negative rods (1) and mixed anaerobes (2). All 30 patients underwent surgery. All 30 patients had Burr hole aspirations (Figure 1 and 2) (17 patients had single aspiration). More than 2.5 cm size of abscess aspirated or treated surgically, rest were treated conservatively. Pre-operative imaging was available for all 30 patients and volumetric analysis showed an average pre-operative volume of 16.3ml. Figure 2. Post-operative scan of this 10-month male child after single burr hole aspiration (original pics). S. N. Predisposing Factor No. Percentage 1 2 3 4 5 Otitis Media and mastoditis Congenital heart disease Meningitis Posttraumatic Others 11 7 4 3 5 36.66% 23.33% 13.33% 10% 16.66% Table 2. According to size 2.5- 3.5 cm total 16 cases in which 4 cases require single re aspiration (28.57%) , but in 3.5-4.5 cm size total 10 cases in which we require 6 re aspiration (60%) , in which 4 cases require single reaspiration and 2 require two reaspiration. More than 4.5 cm total 4 cases in which 3 patients requires re aspiration. (75%), in which 1 case require two re aspiration and rest 2 cases required three re- aspiration (Figure-3). But the good thing is that all treated with aspiration and antibiotics. Location dose not significantly co-relate with re –aspiration. Figure 3. Huge abscess in left temporoparietal region in 2.5month old child (Original Pics). GOS score at 3-month -22 patient has 5, 3 patients has score 4 and 3 patient had score 3 or less. 2 patients expired – 1 due to some cardiac problem in congenital heart disease, second is due to severe sepsis in otitis media patient. Rest 28 patients survived. According to symptoms fever resolved in all patients. Seizure resolved in 6/8 patients in 3 months follow up. Motor deficit corrected in 6/8 patients in 3 months follow up. S.N. Symptoms and Signs Number Percentage 1 2 3 4 5 6 7 8 Fever Headache Seizure Altered Sensorium Vomitting Meningism Motor deficit Sensory deficit 14 11 10 6 5 5 8 4 46.66% 36.66% 33.33% 20% 16.66% 16.66% 26.66% 13.33% Table 3. S.N. Site of abscess Number Percentage 1 2 3 4 5 Temporal Frontal Parietal Cerebellum Others(pons,thalamus) 11 7 8 2 2 36.66% 23.33% 26.66% 6.66% 6.66% Table 4. 202 Sachin Kumar Jain, Gaurav Jaiswal, Tarun Kumar Gupta et al. DISCUSSION The change in practice towards early prescription of antibiotics for oto-sinogenic infections has resulted in a change in the infective etiologies associated with brain abscess12. In studies from the pre-CT era ENT infections were the cause in 38-76% of brain abscesses in children; however this has fallen to 8- 36% .In the modern era with congenital heart disease and immunosuppression becoming a more commonly recognized causative factor11,12,13,14.But in the present study, Temporal lobe abscess following middle ear infection and mastoiditis was the commonest finding15,16. Temporal lobe abscess following otogenic infection has been found in previous studies22. In tribal area due to poor hygine and others late responding to fever and ignorance of ear infection or maltreatment of ear infection develop a simple meningitis and ear infection into a brain abscess15,16. In our study, males are more affected than females. Males are more exposed to outdoor activities with greater chance of ear infection and predisposing to brain abscess 17. Regardless of the changes in etiology, Streptococcus remains the most commonly reported causative microbe both in this series and those published in the literature17,18. The presentation of brain abscesses is non-specific but most commonly includes, headache, fever, altered mental status, meningism and seizures5,.According to Samull et al nowadays suggest that headache and fever is the most common symptoms and seizures is not so common in abscess but in this study seizure is also common complain (10/30-30%) because involvement of temporal lobe is more . Those who present with altered mental status and rapid neurological deterioration are more likely to have an increased mortality rate19. 2 patient expired in this study had low GCS and altered mental status. So preoperative GCS is important for prognosis. Multiple aspirations were associated with a larger initial abscess volume. These will leave a larger cavity that is slower to involute and thus leave a nidus of infection that can re-accumulate. Half of the patients in this series required more than one aspiration and thus patients should be counselled accordingly.12 Modern series report lower mortality rates than the pre-CT era ranging from 8 to 25%20 and the large series by Tekkok and Erbengi21 even managed 0% mortality at the end of their study period. Neuroimaging was done in all cases. CT scan was done in 25 cases and MRI was done 5 cases. The only added advantages of MRI over CT Scan are: better differentiation of edema from necrosis, more sensitivity in detection of early cerebritis, greater sensitivity for early satellite lesion23. Most common neuroimaging finding was ring enhancing lesion. This has been reported in previous studies from India and abroad24,25. One reason for a low mortality rate may be an aggressive approach towards abscess drainage and also sepsis source control. Poor Glasgow coma scale (GCS) at time presentation has been associated with poor outcome. Previous studies in India, Nepal and Pakistan have also reported poor GCS as negative prognostic factor in their studies24,25 CONCLUSION This study demonstrates that in the modern era with ready access to CT imaging and broad-spectrum antibiotics, low rates of morbidity and mortality can be achieved. Drainage of paediatric abscesses remain the mainstay of treatment both to relieve mass effect and provide a microbiological diagnosis. Patients and their families should be counselled to expect multiple procedures. But in this study most common predisposing factor for abscess is otitis media than congenital heart disease. Because in tribal region exposed to outdoor activities with greater chance of ear infection and predisposing to brain abscess. Also, illiteracy and poor hygiene leads to more chances of chronic ear discharge and brain abscess formation in future. So we need to educate the people of tribal region for proper hygine and also early consult to doctor for any ear infection. We have to educate them about their proper health checkup and consult if child had fever, seizure, headache and vomitting. If infant and less than 3 yr age child had excessive irritability then also take consultation. We can also promote pneumococcal vaccination. But at present there are also decreasing trends of brain abscess by ENT infections (11/30 -36.66%) and rising trends by congenital heart disease (7/30- 23.33%) which is a good sign that the health and educational infrastructure is strengthening in tribal region also. 203 Paediatric brain abscesses in tribal region of India CONFLICT OF INTEREST There is no conflict of interest to disclose. INFORMED CONSENT Informed consent was obtained from all individual participants included in this study. REFERENCES 1. Sharma BS, Gupta SK, Khosla VK. Current concepts in the management of pyogenic brain abscess. 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