P3.M245: Brain Abscess Positive for Streptococcus pneumoniae in an 11-Year-Old Female Attributable to Inadequate Treatment of Otitis Media

Introduction: Infection with Streptococcus pneumoniae is a rare cause of brain abscesses in pediatric patients. Brain abscesses in these patients are a neurosurgical emergency and must be considered in the differential diagnosis of a patient with headache, vomiting, fever, change in consciousness, or focal neurological deficits. The clinical presentation of a brain abscess is often nonspecific, and the classic triad of headache, fever, and focal neurological deficits is not often present, which makes diagnosis particularly challenging. Intracranial infections, including brain abscesses, are also more commonly found in immunocompromised patients due to decreased immunological function.

Case Description: An 11-year-old African-American female with no significant past medical history presented to the pediatric clinic with vomiting and headache increasing in frequency and severity for approximately one month. Imaging revealed a lesion with peripheral ring enhancement in the right frontal lobe with midline shift, suggestive of brain abscess. Aspiration and culture of the abscess fluid revealed infection with Streptococcus pneumoniae. The patient was treated with ceftriaxone and metronidazole in the pediatric intensive care unit and was able to be discharged home once her condition was improved. No obvious source of primary infection was identified based on the patient’s history.

Discussion: Further chart review revealed an emergency department visit approximately one month prior to the onset of symptoms, which resulted in a diagnosis of tympanic membrane perforation and acute otitis media in the right ear that was treated with combined neomycin, polymyxin B, and hydrocortisone otic solution drops. The topical otic solution that was used does not cover for S. pneumoniae infection, and the proposed mechanism of infection was the contiguous spread of the infection from the right perforated tympanic membrane, through the sinuses, and into the right anterior frontal lobe, supported by imaging findings. Due to the patient’s age, sex, and severity of the disease, additional immunologic evaluation was recommended for the outpatient setting. The prevalence of acute otitis media in the United States is increasing, and healthcare providers can help reduce the risk of complications from otitis media by ensuring adequate antibiotic coverage for common infectious organisms likely to cause otitis media, whether patients present to primary care, urgent care, or the emergency department. Bacterial organisms are believed to be the main causes of acute otitis media, with Streptococcus pneumoniae being the most common cause of otitis media in all ages.

Conclusion: The purpose of this case is to highlight the warning signs of brain abscess in pediatric patients, persuade healthcare providers to consider infection with Streptococcus pneumoniae in their differential, and ensure that antibiotic treatment of otitis media, a common pediatric infection, fully covers for the more common causative bacterial agents with the goal of reducing the risk of complications such as brain abscess.