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Table of Contents    
Year : 2019  |  Volume : 67  |  Issue : 3  |  Page : 875-879

Thalamic abscess caused by a rare pathogen - streptococcus sanguinis - A report and a review on thalamic abscess

Department of Neurosurgery, Chettinad Hosptital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Chennai, Tamil Nadu, India

Date of Web Publication23-Jul-2019

Correspondence Address:
Dr. Ramesh Vengalathur Ganesan
Department of Neurosurgery, Chettinad Hosptital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Chennai - 603 103, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.263201

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How to cite this article:
Ganesan RV, Veerasamy KK, Chittala M, Balasubramanian C. Thalamic abscess caused by a rare pathogen - streptococcus sanguinis - A report and a review on thalamic abscess. Neurol India 2019;67:875-9

How to cite this URL:
Ganesan RV, Veerasamy KK, Chittala M, Balasubramanian C. Thalamic abscess caused by a rare pathogen - streptococcus sanguinis - A report and a review on thalamic abscess. Neurol India [serial online] 2019 [cited 2020 Feb 25];67:875-9. Available from:


Thalamic location of a brain abscess is very unusual. Only 41 cases of thalamic abscess have been reported so far in the literature. The reported cases have been usually secondary to hematogenous spread from cyanotic heart disease, dental caries, etc. Streptococcus sanguinis is a normal oral commensal found in dental plaques and is a very unusual cause of intracranial infection. Only 7 cases of brain abscess caused by S. sanguinis have been reported so far. Thalamic abscess caused by S. sanguinis has not been reported so far.

A 42-year old man presented with headache, vomiting, and diminished sensation of right half of the body including face. He had no trauma to head, or any other source of infection elsewhere in the body including the oral cavity. Neurological examination was unremarkable except for the subjective sensory impairment of the right half of the body including face.

Computed tomographic (CT) scan and magnetic resonance imaging (MRI) of the brain showed a well-defined ring lesion with surrounding edema in the left thalamus, extending into the body and occipital horn of the left lateral ventricle, with mass effect and mild obstructive hydrocephalus [Figure 1] and [Figure 2]. The diagnosis of a high grade glioma and abscess were considered. Investigations did not reveal any immunocompromised state.
Figure 1: Contrast enhanced CT brain showing a thin-walled, ring enhancing lesion with perilesional edema in the left thalamus

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Figure 2: MRI brain (Axial DWI, ADC, T2, T2 FLAIR in the top row. Axial GRE, Coronal T2, Axial T1 contrast, MRA in the bottom row) showing the same lesion

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A left parietal craniotomy was performed. The cortical incision was made in the left posterior parietal cortex, and the occipital horn of lateral ventricle was entered. The lesion was found projecting into the lateral ventricle. Tapping revealed creamy yellow pus, suggesting an abscess. Taking adequate precautions to prevent spillage of pus into rest of the ventricular system, the abscess capsule, which was thin, was excised. The abscess bed and ventricle was thoroughly irrigated with antibiotic solution and the craniotomy was closed with external ventricular drain in the occipital horn [Figure 3].
Figure 3: Postoperative contrast CT brain showing complete excision of the abscess with external ventricular drain in situ

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The culture of the pus revealed Streptococcus sanguinis, which was confirmed by VITEK 2 system (Version: 06.01 MIC interpretation guideline. bioMérieux Inc.). The organism was sensitive to amipicillin, linezolid, ofloxacin, penicillin and vancomycin. The patient was treated with appropriate antibiotics with intravenous antibiotics for 3 weeks and oral antibiotics for another 3 weeks. The patient made an uneventful recovery. At the time of discharge and at a 2-month follow up, he was neurologically stable without any deficit.

The common sites of brain abscess are the temporal lobe, cerebellum, parietal lobe, frontal lobe, and occipital lobe, in this order. Ganglionic and thalamic location for an abscess are rare. Only a few sporadic case reports and small series are found in the literature. Ericus et al., (1982) reported a case of successful management of a thalamic abscess. In their study, they had cited only nine previous reports, starting from 1973.[1] After 1982, we found 32 more case reports of thalamic abscesses in the literature. These have been summarized in [Table 1].[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27]
Table 1: A review of literature on thalamic abscess

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An analysis of the previous reports of thalamic abscesses, in which some details of the cases were available, revealed the following. The age distribution was 7-70 years. The mean age was 36 years, and the median age was 38 years. 12 patients were males, 9 were females and the rest were not specified. Hemiparesis involving the contralateral limbs was the commonest symptom seen in 16 cases, and headache was the next common symptom seen in 13 cases. Fever was seen in 10, altered sensorium in 7, and meningism in 3 cases. 7 patients had a congenital heart disease. Surprisingly, sensory symptoms were seen in only 2 cases in the literature in the form of thalamic pain. The CT was the commonest mode of radiological diagnosis; MRI has been used only in 4 cases. A left-sided location was seen in 10 cases while the right thalamus was involved in 6 patients, and the rest were not specified. CT guided stereotactic aspiration was done for 11 cases. Burr hole aspiration (free hand) was done in 7 cases. The craniotomy (transcallosal transventricular approach) was used in 2 cases.[1],[12] Trans-ventricular endoscopic assisted drainage was used in 1 case.[15] Streptococcus of various species has been the commonest organism isolated, that was seen in 8 cases. Most of the patients with the thalamic abscess improved after treatment, with only three deaths reported so far.

In the present case, the patient had headache and contralateral hemi-sensory loss, which has not been reported so far. Since the diagnosis was uncertain in the absence of an infective focus and systemic signs, the patient was managed by an open craniotomy and excision of the abscess. S. sanguinis reported in the culture of the pus, has not been seen in previous reports of thalamic abscess.

Streptococcus sanguinis formerly was grouped under viridans streptococci. It is a normal commensal in the oral cavity founded in dental plaques and has a protective action against infection by other streptococci.[28] It is a gram positive coccus and a facultative anaerobe. It may enter bloodstream during dental cleaning and surgery, may colonize heart valves and can cause endocarditis. Central nervous system infection caused by S. sanguinis is very rare. Alba et al., (1994) while reporting a case of S. sanguinis recurrent meningitis secondary to shunt surgery, had cited 4 previous reports of S. sanguinis meningitis.[29] Kassis et al., (2010) while reporting a case of   S.sanguinis Scientific Name Search  Scientific Name Search  brain abscess in a 19-year old boy secondary to bacterial endocarditis, had cited 6 previous reports of S. sanguinis brain abscesses, most of which were secondary to dental procedures and maxillofacial trauma.[30] Dhawan et al., (2003) have reported left frontal lobe abscess caused by S. sanguinis infection secondary to skull base and maxillofacial trauma.[31] There have been no previous instances of S. sanguinis thalamic abscess reported in the literature. Our patient did not have any source of infection, including intra-oral sepsis.

Solitary thalamic abscess is an uncommon condition with only about 41 cases reported in the literature so far. S. Sanguinis is a very rare cause of intracranial infection, with only about 5 cases of meningitis and 7 cases of brain abscess caused by this organism. This is the first instance of a thalamic abscess caused by S. sanguinis.

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  References Top

Ercius MS, Dempsey R, Chandler WF. Successful treatment of solitary thalamic abscess Case report. J Neurosurg 1982;56:865-7.  Back to cited text no. 1
Black PM, Levine BW, Picard EH, Nirmel K. Asymmetrical hydrocephalus following ventriculitis from rupture of a thalamic abscess Surg Neurol 1983;19:524-7.  Back to cited text no. 2
Hollander D, Villemure JG, Leblanc R. Thalamic abscess: A stereotactically treatable lesion. Appl Neurophysiol 1987;50:168-71.  Back to cited text no. 3
Venger BH, Landon G, Rose JE. Solitary histoplasmoma of the thalamus: Case report and literature review. Neurosurgery 1987;20;784-7.  Back to cited text no. 4
Naidu MR. Solitary thalamic abscess. Clin Neurol Neurosurg 1988;90:245-7.  Back to cited text no. 5
Yoritaka A, Sugiura K, Hiramatu M, Baba M. A case of solitary thalamic abscess treated by sterotactic aspiration. No To Shinkei 1990;42:749-53.  Back to cited text no. 6
Bergen GA, Wallach PM, Adelman HM. Pyogenic thalamic brain abscess in the setting of a ventricular septal defect. J Neuroimaging 1991;1:151-3.  Back to cited text no. 7
Megens J, van Loon J, Goffin J, Gybels J. Subcortical aphasia from a thalamic abscess. J Neurol Neurosurg Psychiatry 1992;55:319-21.  Back to cited text no. 8
Gonzales GR, Herskovitz S, Rosenblum M, Foley KM, Kanner R, Brown A, et al. Central pain from cerebral abscess. Neurology 1992;42:1107.  Back to cited text no. 9
Yamamoto M, Hagiwara S, Umebara Y, Tanaka N, Ide M, Jimbo M. Solitary pyogenic thalamic abscess--two case reports. Neurol Med Chir (Tokyo) 1993;33:630-3.  Back to cited text no. 10
Sohn IT, Bae HG, Doh JW, Lee KS, Yun IG, Byun BJ. A case of thalamic abscess: Case report. J Korean Neurosurg Soc 1996;25:2127-30.  Back to cited text no. 11
Cheong JH, Kim JM, Bak KH, Shin HS, Oh SH, Kim KM, et al. Pyogenic thalamic brain abscess: A case report. J Korean Neurosurg Soc 1996;25:1286-91.  Back to cited text no. 12
Takada Y, Ohno K, Wakimoto H, Hirakawa K. Treatment of intracranial abscess in the era of neuroimaging: An analysis of 13 consecutive cases. J Med Dent Sci 1998;45:69-76.  Back to cited text no. 13
Singh P, Singh A. Thalamic and ganglionic abscesses: A report of two cases. Neurol India 2002;50:225.  Back to cited text no. 14
Gajdhar M, Yadav YR. A case of thalamic abscess treated by endoscopic surgery. Neurol India 2005;53:345-6.  Back to cited text no. 15
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Tonon E, Scotton PG, Gallucci M, Vaglia A. Brain abscess: Clinical aspects of 100 patients. Int J Infect Dis 2006;10:103-9.  Back to cited text no. 16
Peker S, Isik U, Akgun Y, Ozek M. Deep brain stimulation for Holmes' tremor related to a thalamic abscess. Childs Nerv Syst 2008;2:1057-62.  Back to cited text no. 17
Callovini GM, Bolognini A, Gammone V, Petrella G. First-line stereotactic treatment of thalamic abscesses: Report of three cases and review of the literature. Cent Eur Neurosurg 2009;70:143-8.  Back to cited text no. 18
Agrawal A, Rafael C. Spontaneous thalamic abscess in a nonimmunocompromised patient. Infect Dis Clin Pract 2010;18:83-4.  Back to cited text no. 19
Sangwan P, Saikia B, Sharma PK, Sharma R, Khilnani P. Ventriculo-peritoneal shunt: A rare cause of basal ganglia and thalamic abscess. J Pediatr Neurosci 2013;8:132-4.  Back to cited text no. 20
[PUBMED]  [Full text]  
Chakravarthy H, Manjunath YC. A pyogenic thalamic abscess treated using CT guided free hand aspiration of abscess at a centre in rural India. J Neurol Stroke 2014;1:00013.  Back to cited text no. 21
Fabbri G, Guardigni V, Sarubbo S, Cultrera R, Contini C. Brain abscess sustained by actinomyces meyeri in an immunocompetent patient. J Neurol Neurophysiol 2014;5:184.  Back to cited text no. 22
Koka A, Sachdev A, Yazbeck MF, Bell RD, Farrellc C. Novel partial anomalous pulmonary venous connection associated with brain abscess. J Clin Neurol (Seoul, Korea) 2014;10:55-8.  Back to cited text no. 23
Subramani P, Raja V, Lingaiah BB, Madappa BP, Chakravarthy H. Group G streptococci in association with brain abscess: A rare occurrence. J Infect Dev Ctries 2014;8:1488-90.  Back to cited text no. 24
Basyuni S, Sharma V, Santhanam V, Ferro A. Fatal thalamic abscess secondary to dental infection. BMJ Case Reports 2015;bcr-2015-212589. doi: 10.1136/bcr-2015-212589.  Back to cited text no. 25
Şenol O, Süslü HT, Tatarlı N, Tiryaki M, Güçlü B. Thalamic abscess caused by a rare pathogen: Streptococcus constellatus. Brain Nerve 2011;63:891-6.  Back to cited text no. 26
Tsuang FY, Lin YT, Yen DHT, Teng LJ, Tsai JC. Rapid identification of Streptococcus intermedius by multiplex polymerase chain reaction 1 week before culture positivity in a patient with antibiotic-treated thalamic brain abscess. J Microbiol Immunol Infec 2017;50:549-51.  Back to cited text no. 27
Paik S, Senty L, Das S, Noe JC, Munro CL, Kitten T. Identification of virulence determinants for endocarditis in Streptococcus sanguinis by signature-tagged mutagenesis. Infect Immun 2005;73:6064-74.  Back to cited text no. 28
Alba D, Zapater P, Torres E. Recurrent Streptococcus sanguis meningitis in a patient with a ventriculoperitoneal shunt. Clin Infect Dis 1994;19:808.  Back to cited text no. 29
Kassis H, Marnejon T, Gemmel D, Cutrona A, Gottimukkula R. Streptococcus sanguinis brain abscess as complication of subclinical endocarditis: Emphasizing the importance of prompt diagnosis. South Med J 2010;103:559-62.  Back to cited text no. 30
Dhawan B, Lyngdoh V, Mehta VS, Chaudhry R. Brain abscess due to Streptococcus sanguis. Neurol India 2003;51:131-2.  Back to cited text no. 31
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  [Figure 1], [Figure 2], [Figure 3]

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