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|LETTERS TO EDITOR
|Year : 2019 | Volume
| Issue : 3 | Page : 875-879
Thalamic abscess caused by a rare pathogen - streptococcus sanguinis - A report and a review on thalamic abscess
Ramesh Vengalathur Ganesan, Karthikeyan K Veerasamy, Madhulika Chittala, Chandramouli Balasubramanian
Department of Neurosurgery, Chettinad Hosptital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Chennai, Tamil Nadu, India
|Date of Web Publication||23-Jul-2019|
Dr. Ramesh Vengalathur Ganesan
Department of Neurosurgery, Chettinad Hosptital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Chennai - 603 103, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|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 2019 Aug 21];67:875-9. Available from: http://www.neurologyindia.com/text.asp?2019/67/3/875/263201
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. After 1982, we found 32 more case reports of thalamic abscesses in the literature. These have been summarized in [Table 1].,,,,,,,,,,,,,,,,,,,,,,,,,,
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., Trans-ventricular endoscopic assisted drainage was used in 1 case. 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. 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. Kassis et al., (2010) while reporting a case of S.sanguinis 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. Dhawan et al., (2003) have reported left frontal lobe abscess caused by S. sanguinis infection secondary to skull base and maxillofacial trauma. 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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[Figure 1], [Figure 2], [Figure 3]